What is the treatment for sesamoiditis?

Treatment of Sesamoiditis

The treatment of sesamoiditis should begin with conservative measures including rest, activity modification, padding, orthotic devices, and NSAIDs, with corticosteroid injections reserved for cases that don't respond to initial treatment, and surgical intervention (sesamoidectomy) considered only after failure of conservative management. 1

Initial Conservative Management

• Rest and activity modification: Reduce weight-bearing pressure on the affected sesamoid by limiting activities that aggravate symptoms, particularly those involving pushing off the forefoot 2

• Footwear modifications:

  • Use shoes with adequate cushioning and a stiff sole to reduce pressure on the sesamoids 2
  • Consider shoes with a wider toe box to reduce compression 1
  • Avoid high heels which increase forefoot pressure 1

• Padding and strapping:

  • Apply temporary padding under the affected area to offload the sesamoid 1
  • Use a sesamoid pad or J-shaped pad to redistribute pressure away from the painful sesamoid 2

• Orthotic devices:

  • Custom foot orthoses with specific modifications to offload the sesamoids 1
  • Metatarsal pads or bars positioned proximal to the sesamoids 2

• Pain management:

  • NSAIDs for pain and inflammation control 2
  • Ice massage to reduce local inflammation 2

Second-Line Treatment

• Corticosteroid injections:

  • Local injections of lidocaine-methylprednisolone at the site of pain can provide significant relief 2
  • Steroid injections into the subsesamoid joint have shown long-lasting results in patients who don't respond to initial conservative measures 3
  • Consider a second injection if the first one provides only partial relief 3

• Immobilization:

  • Short-term immobilization with a walking boot or cast for severe cases to allow for healing 1
  • Gradual return to activities following immobilization 1

Advanced Imaging for Persistent Cases

• MRI evaluation is recommended for cases that don't respond to conservative treatment to:

  • Detect bone marrow edema, stress fractures, or avascular necrosis 4
  • Evaluate for plantar plate tears or other soft tissue pathology 5

• CT scan may be useful to:

  • Distinguish between stress fractures and bipartite sesamoids 4
  • Evaluate for nonunion in cases of previous fracture 5

Surgical Management

• Indications for surgery:

  • Persistent symptoms (pain score ≥3) after two steroid injections 3
  • Failed conservative management for 6 months or longer 6
  • Evidence of osteonecrosis or nonunion on imaging 2

• Surgical options:

  • Sesamoidectomy (removal of the affected sesamoid) is the most common surgical intervention 3
  • Fracture fixation with screws for acute fractures with displacement 2

Treatment Algorithm

1. Initial phase (0-6 weeks):

   • Rest, activity modification, footwear changes
   • NSAIDs and ice therapy
   • Padding and orthotic devices

2. Intermediate phase (6-12 weeks):

   • If symptoms persist, consider corticosteroid injection
   • Advanced imaging (MRI or CT) if diagnosis is uncertain or symptoms worsen

3. Persistent phase (>12 weeks):

   • Second corticosteroid injection if first provided partial relief
   • Consider surgical consultation if symptoms remain significant after conservative measures

Common Pitfalls and Caveats

• Failure to distinguish between sesamoiditis and bipartite sesamoid (a normal anatomical variant) can lead to unnecessary treatment 7
• Overlooking contributing biomechanical factors (such as hallux valgus or pes cavus) may result in treatment failure 1
• Persistent symptoms despite appropriate conservative management may indicate underlying pathology requiring advanced imaging 4
• Sesamoidectomy should be considered a last resort as it can alter foot biomechanics 3