What is the treatment for sesamoiditis?

Treatment of Sesamoiditis

Conservative management is the cornerstone of sesamoiditis treatment, with initial therapy consisting of rest, activity modification, footwear changes, and offloading devices for 0-6 weeks, reserving advanced imaging and surgical intervention only for refractory cases. 1

Initial Conservative Management (0-6 weeks)

The first-line approach focuses on mechanical offloading and symptom control:

• Rest and activity modification to reduce weight-bearing pressure on the affected sesamoid 1, 2
• Footwear modifications including inlays, sesamoid pads, shock-absorbing insoles, and stiff soles to limit metatarsophalangeal joint motion 2
• NSAIDs and ice massage for pain control and inflammation reduction 2
• Running surface modification to softer terrain for athletes 2
• Orthotics and immobilization devices to offload the sesamoid complex 3

Intermediate Phase (6-12 weeks)

If symptoms persist beyond the initial conservative period:

• Corticosteroid injections into the subsesamoid joint can provide effective long-term relief 4

  • A single steroid injection was successful in 8 of 20 thumbs (40%) with chronic sesamoiditis 4
  • A second injection provided relief in an additional 5 thumbs (25%) 4
  • Long-term follow-up at 9 years showed sustained improvement in most patients treated with injections alone 4

• Advanced imaging should be obtained if diagnosis is uncertain or symptoms worsen 1

  • MRI is recommended to detect bone marrow edema, stress fractures, avascular necrosis, or plantar plate tears 5, 1
  • CT scan helps distinguish stress fractures from bipartite sesamoids and evaluate for nonunion 5, 1

Refractory Cases and Surgical Intervention

Sesamoidectomy should be reserved as a last resort for patients who remain symptomatic (pain score ≥3) after 2 steroid injections and appropriate conservative management 4:

• Surgical options include fracture/nonunion fixation with screw fixation or various approaches for sesamoidectomy 3, 2
• In one series, 6 of 20 thumbs (30%) required sesamoidectomy, with only 1 requiring secondary surgery for recurrent symptoms 4
• Persistent symptoms despite conservative management may indicate underlying pathology such as osteonecrosis, nonunion, or chondromalacia requiring surgical intervention 3, 2

Important Clinical Pitfalls

Do not overlook systemic causes: Sesamoiditis can be the first manifestation of gout, particularly in cases with bilateral involvement or poor response to standard treatment 6. Consider dual-energy CT if gout is suspected, especially with positive family history 6.

Distinguish bipartite sesamoids from fractures: Skyline X-rays are essential to differentiate congenital bipartite sesamoids from acute fractures 2, 7. This distinction is critical as treatment approaches differ.

Address postural deformities: Special attention must be paid to underlying foot deformities that may contribute to abnormal mechanical stress on the sesamoid complex 2.