Sesamoiditis

Sesamoiditis is an inflammatory condition of the sesamoid bones which are located on the plantar (bottom) aspect of the first metatarsal phalangeal joint (1st MPJ or big toe joint).

Treatment of Sesamoiditis

Conservative treatment of sesamoiditis consists of limiting activities and padding or 'off loading' of the joint. Off loading refers to taking the weight bearing load off of a particular area by use of a sleeping pad. In the case of sesamoiditis, the mat ought to be approximately 1/4" thick with a cut out for the bottom of the first MPJ. Should padding help, a prescription orthotic with a similar pad would be helpful.

Surgical treatment of sesamoiditis usually consists of removal of the entire sesamoid bone. Occasionally planing of the bone, or removing the bottom half of the bone may be a useful surgical procedure. Planing is employed less often than overall excision due to the fact that planing may weaken the sesamoid and lead to fractures of the sesamoid.

Removal of the tibial or fibular sesamoids does not generally effect the normal function of the joint. If a patient has a family history of bunions or currently has a bunion, there will be a tendency to increase the rate that a bunion will form with isolated removal of the tibial sesamoid. By removing the tibial sesamoid, the pull of the FHB muscle will become slightly stronger through the remaining fibular sesamoid. As a result, this may accelerate the formation of a bunion. If there is no history of bunions in the family, this may not even become a factor in choosing to excise the tibial sesamoid.

Nomenclature:

First metatarsal phalangeal joint - the big toe joint. Often referred to as the very first MPJ.

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Itis - Used as a Suffix and Refers to Any Structure that is Inflamed.

Plantarflex - to move down in the direction of the plantar surface (or floor).

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• Sesamoid is derived from Greek and refers to a sesame seed.
• TheGreeks apparently related the shape of the sesamoid bone to a sesame seed.

Anatomy:

The two sesamoid bones are located on the bottom top of the first metatarsal phalangeal joint. The sesamoids are actually a working part of the First MPJ and articulate with the plantar top of the first metatarsal. The sesamoid bones are usually an extension of the flexor hallucis brevis (FHB) muscle and give the FHB a greater range of motion and improved lever action at the level of the 1st MPJ.

• Sesamoid bones are referred to by their location and are classified as the tibial sesamoid (medial) and the fibular sesamoid (lateral).
• Tibial and fibular make reference to the bones of the lower leg.

Sesamoid bones are most common to be able to the first MPJ but may also be found at other tendon/joint floors where a tendon changes direction. Although they're discovered with much less frequency, other locations range from the smaller MPJ's and also even the metacarpal phalangeal joint (the thumb).

Biomechanics:

The flexor hallucis brevis muscle (FHB) originates on the plantar surface of the calcaneus (heel bone). When the FHBfires, its' function is to plantarflex the great toe. The primary function of the FHB is to help in balance and assist the calf with the toe off portion of gait. As the FHB fires, the load generated by the body of the muscle is sent through the sesamoid to an expansion of the FHB that attaches to the plantar facet of the great toe. The net result is that the great bottom plantarflexes using the sesamoid bones to glide around the plantar surface of the 1st MPJ.

Symptoms:

The onset of sesamoiditis may be insidious or even abrupt. An insidious onset would suggest a great inflammatory condition of the joint between the articular top of the sesamoid and the articular surface of the First metatarsal. An abrupt onset would suggest a fracture of the sesamoid. Regardless of onset, pain is typical specific to the bottom of the 1st MPJ. Occasionally the entire 1st MPJ may enlarge and become stiff. Pain is aggravated by long periods of standing, squatting as well as the use of higher heeled shoes.

X-ray conclusions in cases of sesamoiditis usually show an elevated density of the affected sesamoid bone. Whenever viewing anAP x-ray, the physical appearance of the bone would light up brighter suggesting increased density of the bone consistent with inflammation.

Differential Diagnosis:

Arthritis.

Bunion

Fractured sesamoid.

Gout as Well as Pseudogout

Hallux limitus and hallux rigidus.

Infection of the Joint (Septic Joint)

About the author:Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Doctor. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and it is in active practice in Granville, Ohio.

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