Management of Refractory Sesamoiditis
For sesamoiditis that fails conservative treatment, obtain advanced imaging (MRI or CT) to identify underlying pathology, followed by corticosteroid injection if imaging shows inflammation without structural damage, or proceed to fibular sesamoidectomy if conservative measures including injections fail after 6-12 weeks. 1, 2, 3
Diagnostic Evaluation After Conservative Failure
When initial conservative treatment (rest, activity modification, footwear changes, padding) fails after 6-12 weeks, advanced imaging is essential to guide further management 1:
- MRI is the preferred imaging modality to detect bone marrow edema, stress fractures, avascular necrosis, or plantar plate tears that may be driving persistent symptoms 1, 4
- CT scanning should be obtained to distinguish stress fractures from bipartite sesamoids or to evaluate for nonunion in cases of previous fracture 1, 4
- Persistent symptoms despite appropriate conservative management typically indicate underlying structural pathology requiring this advanced imaging workup 1
Treatment Algorithm Based on Imaging Findings
If Imaging Shows Inflammation Without Structural Damage
Corticosteroid injection into the affected area is the next appropriate step 3:
- A single steroid injection achieved long-term symptom resolution in 44% of patients (8/18 thumbs) with chronic sesamoiditis 3
- An additional 28% (5/18) improved with a second injection if the first failed 3
- At 9-year follow-up, steroid injections provided durable results in 72% of patients who received them 3
- Reserve sesamoidectomy only for patients with visual analog pain scores ≥3 after 2 steroid injections 3
If Conservative Treatment Plus Injections Fail
Fibular sesamoidectomy via plantar approach is a safe and effective option for refractory cases 2, 5:
- All 12 patients in one series achieved complete pain resolution following fibular sesamoidectomy at average 35-month follow-up 2
- Complication rates are acceptable: transient neuritis (17%), superficial infection (8%), and painful scarring (8%) 2
- Hallux varus deformity, a theoretical concern, was not observed in any patients 2
- Almost all sesamoid conditions improve with conservative treatment in the long run, making surgery truly a last resort 6
Critical Pitfalls to Avoid
Do not proceed to surgery without advanced imaging, as you may miss fractures, nonunion, or osteonecrosis that require different surgical approaches than simple sesamoidectomy 1, 6:
- Insufficient therapeutic results from conservative treatment may indicate osteonecrosis or nonunion requiring screw fixation rather than sesamoidectomy 6
- Plain radiographs are normal in 65% of chronic sesamoiditis cases, making advanced imaging essential 3
Ensure adequate conservative treatment duration before escalating 7: