What is the treatment for sesamoiditis?

Treatment of Sesamoiditis

The primary treatment for sesamoiditis involves conservative measures including rest, activity modification, proper footwear with cushioning, and anti-inflammatory medications, with surgical intervention reserved only for cases that fail conservative management after 6 months. 1, 2

Conservative Management (First-Line Treatment)

Immediate Pain Relief Measures

• Rest and activity modification to reduce weight-bearing pressure on the affected sesamoid 2
• Ice massage to reduce inflammation 2
• NSAIDs for pain control and inflammation reduction 2

Footwear Modifications

• Specialized footwear with stiff soles to limit motion at the first metatarsophalangeal joint 2
• Custom orthotic devices with sesamoid padding to offload pressure 1, 2
• Avoiding high-impact activities and running on soft surfaces rather than hard surfaces 2

Immobilization

• Short-term immobilization with a walking boot for acute cases to allow healing 1, 2
• Taping techniques to limit first metatarsophalangeal joint extension 1

Intermediate Interventions

• Corticosteroid injections into the affected area when initial conservative measures fail 2, 3
  • Studies have shown that steroid injections can provide long-lasting relief for many patients 3
  • A treatment algorithm involving up to two steroid injections before considering surgery has shown good long-term results 3

Surgical Management (Reserved for Treatment Failures)

• Surgical intervention should only be considered after failure of conservative management for at least 6 months 1, 2
• Surgical options include:
  • Sesamoidectomy (removal of the affected sesamoid) 1, 3
  • Fracture fixation with screws in cases of acute fractures or non-unions 2

Special Considerations

Differential Diagnosis

• It's important to rule out other causes of sesamoid pain, including:
  • Stress fractures or acute fractures 1, 2
  • Osteonecrosis 1
  • Bipartite sesamoid (normal anatomical variant that can become symptomatic) 2, 4
  • Chondromalacia 1
  • Gout affecting the sesamoid (rare but important to identify as it requires specific treatment) 4, 5

Diagnostic Approach

• Sesamoid provocation test can help confirm the diagnosis 3
• Radiographs including specialized skyline views to evaluate sesamoid integrity 2
• Advanced imaging (MRI, CT) may be needed for cases that don't respond to initial treatment 4

Treatment Algorithm

1. Initial 4-6 weeks: Rest, NSAIDs, ice, footwear modifications with sesamoid padding 1, 2
2. Persistent symptoms: Immobilization with walking boot for 2-4 weeks 2
3. Continued pain: First corticosteroid injection 3
4. Recurrent pain after injection: Consider second corticosteroid injection 3
5. Failure after two injections and 6+ months of conservative care: Consider surgical consultation for possible sesamoidectomy 1, 3

Prognosis

• Most cases of sesamoiditis improve with conservative management given adequate time 2
• Long-term follow-up studies show good outcomes with a structured approach of injections before considering surgery 3
• Persistent pain may indicate osteonecrosis or non-union requiring surgical intervention 2