Initial Management of Bipartite Medial Great Sesamoid
The initial management for a bipartite medial great sesamoid is conservative treatment with rest, activity modification, footwear changes with sesamoid padding, and NSAIDs for 6-12 weeks, as imaging alone cannot distinguish between a normal anatomical variant and pathology without clinical correlation. 1
Diagnostic Confirmation First
The critical first step is determining whether the bipartite sesamoid is symptomatic or an incidental finding, as bipartite sesamoids are common anatomical variants that are frequently asymptomatic. 2
Key imaging distinction:
- Negative bone scintigraphy with an indeterminate linear lucency on radiographs suggests sesamoid bipartition (normal variant) rather than fracture. 2
- If bone scintigraphy shows increased uptake, this indicates pathology (sesamoiditis, stress fracture, or other inflammatory process) requiring treatment. 2, 3
Conservative Management Protocol (0-12 Weeks)
Initial phase (0-6 weeks): 1
- Complete rest from aggravating activities, particularly running, jumping, and push-off movements
- Activity modification to eliminate weight-bearing pressure on the affected sesamoid 4
- Footwear modifications: 4
- Sesamoid pad or orthotic inlay to offload pressure from the medial sesamoid
- Stiff-soled shoes to limit first metatarsophalangeal joint motion
- Shock-absorbing insoles
- NSAIDs for pain and inflammation 4
- Ice massage to the affected area 4
- Running surface modification to softer terrain if athlete 4
Intermediate phase (6-12 weeks): 1
- Continue conservative measures if improving
- Consider immobilization boot if symptoms persist despite initial measures 5
- Advanced imaging (MRI) should be obtained if diagnosis remains uncertain or symptoms worsen, to detect bone marrow edema, stress fractures, avascular necrosis, or nonunion 1
When Conservative Treatment Fails
After 12 weeks of appropriate conservative management without improvement, consider: 4
- Local corticosteroid injections (lidocaine-methylprednisolone) at the site of pain, into the metatarsophalangeal joint, or at the fracture line if present 4
- MRI evaluation to rule out osteonecrosis or nonunion, which would explain treatment failure 4
- Investigate systemic causes if bilateral involvement or atypical presentation, particularly gout in patients with positive family history 5
Critical Pitfalls to Avoid
Do not assume all bipartite sesamoids are pathologic - many are asymptomatic anatomical variants that require no treatment. 2 The presence of a bipartite sesamoid on imaging without clinical symptoms or positive bone scan does not warrant intervention.
Do not rush to surgery - almost all sesamoid conditions improve with conservative treatment in the long run. 4 Surgical intervention (screw fixation for fractures or sesamoidectomy) should be reserved as a last resort for persistent pain after exhaustive conservative measures, confirmed osteonecrosis, or symptomatic nonunion. 4, 6
Recognize acute diastasis - if comparing current radiographs to prior imaging shows widening between bipartite fragments, this represents acute injury (turf toe with plantar capsular disruption) rather than a stable anatomical variant. 7, 8 This requires either early protection with possible surgical repair of the retinaculum, or resection of the distal fragment with capsular repair if conservative treatment fails. 8
Do not overlook bilateral presentation - bilateral sesamoiditis should prompt investigation for systemic disease, particularly gout, even in young athletes. 5