What is the treatment for sesamoiditis?

Treatment of Sesamoiditis

The initial treatment for sesamoiditis should focus on conservative measures including rest, padding, orthotic devices, and anti-inflammatory medications, with surgical intervention reserved only for cases that fail to respond to conservative management after 3-6 months. 1

Diagnosis and Assessment

• Pain characteristics typically include localized tenderness under the first metatarsophalangeal joint, worsening with weight-bearing activities and push-off phase of gait 1
• Physical examination reveals direct tenderness over the sesamoid bones, pain with dorsiflexion of the great toe, and possible swelling 2
• Imaging studies may include:
  • Standard radiographs (including axial sesamoid view) to rule out fracture or bipartite sesamoid 3
  • MRI for cases with persistent symptoms to evaluate for bone marrow edema, stress fractures, or avascular necrosis 4
  • CT may be useful to distinguish between stress fractures and bipartite sesamoids 4

Conservative Management (First-Line)

• Immediate activity modification with reduction of weight-bearing pressure on the affected sesamoid 3
• Temporary padding/strapping to offload the sesamoid area 1
• Footwear modifications:
  • Shoes with stiff soles to limit dorsiflexion of the first metatarsophalangeal joint 3
  • Adequate shock absorption properties 3
  • Low heel height to reduce pressure on the forefoot 1
• Orthotic devices:
  • Custom foot orthoses with sesamoid cutout or relief 1
  • Sesamoid pad placement to redistribute pressure away from the affected area 3
• Anti-inflammatory measures:
  • NSAIDs for pain control and inflammation reduction 3
  • Ice massage to reduce local inflammation 3
• Corticosteroid injections may be considered for persistent symptoms:
  • Local injection of lidocaine-methylprednisolone at the site of pain 3
  • Steroid injections into the subsesamoid joint for chronic cases 5

Advanced Conservative Management

• Immobilization with walking boot or cast for 4-6 weeks may be necessary for severe cases or those with stress fractures 6
• Physical therapy focusing on:
  • Intrinsic foot muscle strengthening 1
  • Gait retraining to reduce forefoot loading 1
  • Gradual return to activity protocols 1
• Ultrasound or other physical modalities may provide symptomatic relief 1

Surgical Management (For Refractory Cases)

• Surgical intervention should only be considered after failure of conservative treatment for 3-6 months 2
• Surgical options include:
  • Sesamoidectomy (partial or complete excision of the affected sesamoid) 5
  • Bone grafting for non-unions 2
  • Internal fixation for acute fractures 2
  • Curettage or shaving procedures for chondromalacia 2

Treatment Algorithm

1. Initial Phase (0-6 weeks):

   • Rest and activity modification
   • Padding/strapping and appropriate footwear
   • NSAIDs and ice therapy
   • Custom orthoses with sesamoid relief

2. Intermediate Phase (6-12 weeks):

   • If symptoms persist, consider:
   • Corticosteroid injection
   • Immobilization with walking boot
   • Physical therapy

3. Advanced Phase (3-6 months):

   • Second corticosteroid injection if first was partially effective 5
   • Continued orthotic management with possible modifications
   • Gradual return to activities with modified techniques

4. Surgical Consideration (>6 months):

   • Consider surgical intervention only after failed conservative management
   • Sesamoidectomy has shown good long-term outcomes for refractory cases 5

Common Pitfalls and Caveats

• Bipartite sesamoids (congenital anatomical variant) may be mistaken for fractures on imaging 3
• Failure to address underlying biomechanical factors (hallux valgus, pes cavus) may lead to treatment failure 1
• Sesamoidectomy carries risks including hallux valgus deformity, cock-up deformity, and decreased push-off strength 2
• The sesamoid complex transmits up to 50% of body weight during normal gait and up to 300% during push-off, making complete healing challenging without proper offloading 2
• Return to high-impact activities should be gradual and only after complete resolution of symptoms to prevent recurrence 1