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Sesamoiditis of the Foot

- Discussion:
    - inflammation and swelling around the sesamoid (tibial > fibular) and FHB can be secondary to trauma, infection, AVN, stress fractures, or a systemic disorder;
           - sesamoiditis may also be precipitated by a cavus foot w/ excessive wt bearing under the first metatarsal;
           - sesamoid shape may vary and in some cases may be especially thick or pointed;
           - a sharp pointed sesamoid might cause a deep seated callus to form under it, and extra-articular shaving or partial excision of the plantar half may afford relief;

- Clinical Findings:
    - symptoms include pain on wt bearing and with dorsiflexion of the great toe and pain with direct palplation;
    - determine whether the medial or the lateral sesamoid is involved;    
    - first MTP joint may show swelling;

- Non-Operative Treatment:
    - non operative treatment may start with extra-soft shoe inserts and shoe modification;
    - if simple inserts do not work, then consider insertion of a semi-rigid fiberglass insert placed below a soft inset (this limits great toe dorsiflexion and therefore takes the stress off of the sesamoids);

- Operative Treatment:
    - best indication for surgical treatment is a tibial sesamoid non union (or bipartite sesamoid) which has remained symptomatic despite non op treatment;
    - in this case the smaller sesamoid fragment is removed (cutting thru the synchondrosis), and FHB tendon is then re-secured to the remaining sesamoid;
    - complications:
           - excision of both sesamoids is always avoided since it will lead to a "cock up" deformity;
           - removal of only the fibular sesamoid can lead to hallux varus;
           - removal of the tibial sesamoid can result in hallux valgus;
           - nerve injury:
                  - plantar-medial cutaneous nerve is at risk with the surgical approach to the medial sesamoid;
                  - it is located underlying an incision made at  the junction of the glabrous skin of the hallux and needs to be identified before approach can proceed
    - reference:
           - Sesamoid disorders and treatment. An update.
           - Tibial sesamoid shaving for treatment of intractable plantar keratosis.  

Injuries to the hallucal sesamoids in the athlete.    

Anatomic variations in the first ray: Part II. Disorders of the sesamoids.