What are the treatment options for sesamoiditis?

Treatment Options for Sesamoiditis

Conservative management is the first-line treatment for sesamoiditis, with most cases responding to a combination of activity modification, proper footwear, padding, NSAIDs, and physical therapy before considering more invasive interventions. 1, 2

Initial Conservative Management

Activity Modification

• Reduce weight-bearing activities that exacerbate pain
• Temporary rest from high-impact activities (running, dancing, jumping)
• Modify training surface to softer options when returning to activity 3

Pain Management

• NSAIDs for pain and inflammation control 3
• Ice massage to reduce inflammation 3
• Avoid corticosteroid injections initially as they may mask symptoms and allow further damage

Biomechanical Interventions

1. Footwear Modifications:

   • Shoes with stiff soles to reduce flexion at the MTP joint 3, 2
   • Adequate shock absorption properties
   • Low heel-to-toe drop to reduce pressure on the forefoot

2. Orthotic Devices:

   • Custom orthoses with specific sesamoid accommodations 2
   • Sesamoid pad placement to offload the affected sesamoid 3
   • Temporary padding/strapping techniques to reduce pressure 2

Advanced Conservative Interventions

If initial conservative measures fail after 4-6 weeks:

Therapeutic Injections

• Local lidocaine-methylprednisolone injections at the site of pain 3
• Consider fluoroscopic guidance for precise placement 4
• Limit injections to avoid potential complications of repeated steroid use

Immobilization

• Short-term immobilization with walking boot or stiff-soled shoe
• Gradual return to activity following immobilization period

Imaging for Treatment Planning

• Radiographs (including skyline view) to differentiate between fracture and bipartite sesamoid 3
• MRI is the recommended imaging modality for accurate diagnosis of sesamoid pathology 1, 4
• Bone scintigraphy may help differentiate between stress fracture and other conditions 1

Surgical Management

Consider surgical intervention only after failed conservative treatment (typically 3-6 months):

Indications for Surgery

• Persistent pain despite adequate conservative management
• Evidence of osteonecrosis or non-union 3
• Functional limitations affecting quality of life

Surgical Options

• Sesamoidectomy (removal of the affected sesamoid) 3, 5
• Screw fixation for acute fractures with displacement 3

Expected Recovery Timeline

• Recovery from sesamoiditis can be prolonged, with an average of 161.4 days reported in young athletes 6
• Conservative treatment resolves most cases (89.8%) without need for surgery 6
• Return to sports is possible in the majority of cases (84.7%) 6

Common Pitfalls and Caveats

1. Misdiagnosis: Sesamoiditis can mimic other forefoot pathologies. Ensure accurate diagnosis with appropriate imaging before initiating treatment 4.

2. Premature Return to Activity: Returning to high-impact activities too soon can lead to symptom recurrence or worsening.

3. Overlooking Biomechanical Factors: Failure to address underlying biomechanical issues (foot posture, gait abnormalities) may result in persistent symptoms 2.

4. Inadequate Conservative Trial: Rushing to surgical intervention before an adequate trial of conservative measures (minimum 3 months) may lead to unnecessary procedures.

5. Underestimating Recovery Time: Patients should be counseled that recovery from sesamoiditis can be prolonged, often taking 3-6 months for complete resolution 6.

The management of sesamoiditis should follow a stepwise approach, starting with conservative measures and progressing to more invasive interventions only when necessary. With appropriate treatment, most patients can expect good long-term outcomes and return to previous activity levels.