Sesamoid Injuries in the Foot
Sesamoid injuries in the foot refer to damage or inflammation of the small, oval-shaped bones embedded within the tendons of the foot, known as sesamoids. These bones play a vital role in foot mechanics, especially in providing leverage during walking, running, and jumping. Most commonly located beneath the first metatarsal head, the sesamoids help with the propulsion of the foot during the push-off phase. However, these bones are susceptible to injury, particularly in athletes and those who put increased pressure on the ball of their feet.
How Common It Is and Who Gets It? (Epidemiology)
Sesamoid injuries are common in active individuals, especially athletes who engage in high-impact activities like running, basketball, soccer, and ballet.
- Runners and dancers are especially prone to overuse injuries.
- Football players and those in sports requiring sudden stops, pivots, or direction changes also see high rates of injury.
- Women are at higher risk due to wearing high heels, which places excessive stress on the forefoot and sesamoids.
Why It Happens – Causes (Etiology and Pathophysiology)
Sesamoid injuries may result from acute trauma, overuse, or chronic repetitive stress:
- Turf toe (soft tissue injury): A hyperextension injury of the big toe joint causing soft tissue damage around the sesamoid.
- Fractures: Direct impact or excessive pressure can cause stress fractures or fractures from trauma.
- Sesamoiditis: Overuse and repetitive loading can cause inflammation of the sesamoids, leading to chronic pain.
- Biomechanical factors: High arches, flat feet, or improper footwear can predispose individuals to excessive pressure on the sesamoids.
How the Body Part Normally Works? (Relevant Anatomy)
The sesamoid bones are embedded within the tendons of the flexor hallucis brevis muscle beneath the first metatarsal head.
- These sesamoids function as pulleys, helping the tendons transmit force and reducing friction during foot push-off.
- The medial (tibial) and lateral (fibular) sesamoids assist in levering the big toe, enabling smooth propulsion while walking or running.
- These bones also bear the weight during push-off, absorbing pressure on the ball of the foot.
Injuries to these bones or surrounding tissues can impair the natural motion of the big toe, leading to pain and limited mobility.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of sesamoid injuries typically include:
- Pain beneath the first metatarsal head, often exacerbated by walking, running, or activities that involve push-off.
- Swelling and bruising around the sesamoid bones.
- Limited range of motion in the big toe, often with pain on dorsiflexion.
- Tenderness or localized pain when palpating the sesamoid area.
- In chronic cases, calluses or corns may form over pressure points due to altered gait mechanics.
- A clicking sensation or locking may occur when the sesamoid is involved in motion.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a physical examination and may include:
- X-rays: To assess for fractures, stress fractures, or bipartite sesamoid differentiation.
- MRI: Provides detailed images of soft tissue injuries, such as inflammation or avascular necrosis.
- CT scans: Useful in identifying fracture patterns and nonunion of the sesamoid bones.
- Ultrasound: May help identify soft tissue inflammation or tendon pathology associated with sesamoiditis.
Classification
Sesamoid injuries are classified by the type and severity of the injury:
- Turf Toe: Soft tissue injury around the sesamoid due to forced dorsiflexion.
- Fracture: Either acute trauma or stress fractures (caused by repetitive loading).
- Sesamoiditis: Chronic inflammation of the sesamoid bones and surrounding tendons from overuse.
Severity ranges from mild inflammation to complete fractures or non-union.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may mimic sesamoid injuries include:
- Metatarsalgia: General forefoot pain often mistaken for sesamoid-related pain.
- Tendonitis or plantar fasciitis: Causing pain around the ball of the foot.
- Hallux rigidus: Arthritis in the first MTP joint presenting with pain near the sesamoid region.
- Stress fractures in the metatarsals or toes.
- Plantar plate injury: Can present with similar pain patterns.
Treatment Options
Non-Surgical Care
Most sesamoid injuries can be treated conservatively:
- Padding and strapping: A pad may be placed in the shoe to cushion the inflamed sesamoid area, or the toe may be taped or strapped to relieve that area of tension.
- Immobilization: The foot may be placed in a cast or removable walking cast. Crutches may be needed to prevent placing weight on the foot.
- NSAIDs: Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are often helpful in reducing the pain and inflammation.
- Physical therapy: Exercises (range of motion, strengthening, and conditioning) and ultrasound therapy can aid in rehabilitation after immobilization.
- Corticosteroid injections: In some cases, cortisone is injected into the joint to reduce pain and inflammation.
- Orthotics: Custom orthotic devices that fit into the shoe may be prescribed for long-term treatment of sesamoiditis to balance the pressure placed on the ball of the foot.
Surgical Care
Surgery is needed when non-surgical treatment fails, or if the injury is severe or involves nonunion or osteonecrosis of the sesamoid:
- Sesamoidectomy: Surgical removal of one or both sesamoids, typically when conservative treatments fail or in cases of fracture nonunion.
- Osteotomy: Used in cases of sesamoid fractures with poor healing potential.
- Tendon transfer: In cases where tendon function is compromised, a tendon transfer may be required to restore mobility.
Recovery and What to Expect After Treatment
- Non-surgical recovery: Most mild injuries recover within 4–6 weeks with rest and appropriate footwear.
- Surgical recovery: Post-surgical recovery includes 7–10 days in a post-operative shoe or boot. Gradual transition to weight-bearing as tolerated occurs over 4–6 weeks.
- Physical therapy helps restore range of motion, strength, and gait.
Full recovery typically takes 8–12 weeks, depending on the severity and surgical approach.
Possible Risks or Side Effects (Complications)
- Hallux valgus (bunion) may develop after medial sesamoidectomy due to the loss of medial stabilizing structures.
- Metatarsalgia: Altered forefoot loading following sesamoid removal.
- Stiffness or decreased range of motion at the first MTP joint.
- Persistent pain from incomplete resection or tendon imbalance.
- Recurrence of symptoms in cases of tendon imbalance or non-union.
Long-Term Outlook (Prognosis)
The prognosis is generally excellent after sesamoidectomy, with significant reduction in pain and restoration of activity.
- Early biomechanical correction and adherence to rehabilitation minimize recurrence.
- Patients typically resume full activities within 3 months, though high-impact sports may require additional recovery time.
Out-of-Pocket Costs
Medicare
CPT Code 28315 – Tibial Sesamoidectomy: $109.30
Medicare Part B covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover the remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These supplemental plans work alongside Medicare to cover any costs left after the primary coverage.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will serve as a secondary payer. These plans typically cover any remaining balance, including coinsurance or deductibles, which usually range from $100 to $300 depending on your coverage and provider network.
Workers’ Compensation
If your tibial sesamoidectomy is required due to a work-related injury, Workers’ Compensation will cover all related medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays for all approved services directly.
No-Fault Insurance
If your foot condition or tibial sesamoidectomy is related to an automobile accident, No-Fault Insurance will generally cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on your policy.
Example
Carlos Martinez developed chronic pain and inflammation in his tibial sesamoid, requiring sesamoidectomy (CPT 28315). His estimated Medicare out-of-pocket cost was $109.30. Since Carlos had supplemental insurance through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What are tibial sesamoids?
A. Tibial sesamoids are small, oval-shaped bones located beneath the first metatarsal in the foot, specifically within the flexor hallucis brevis tendon. They act as pulleys, assisting in the movement of the big toe and improving the efficiency of foot movement.
Q. Why is the position of the tibial sesamoid important?
A. Proper alignment of the tibial sesamoid is crucial for normal foot function. Misalignment can lead to pain, inflammation, and conditions like sesamoiditis or fractures, which can disrupt walking and cause difficulty in activities like running or jumping.
Q. What conditions are associated with misalignment of the tibial sesamoid?
A. Conditions include sesamoiditis (inflammation), sesamoid fractures, and misalignment leading to abnormal pressure on the foot, causing pain during physical activities or while walking.
Q. How is tibial sesamoid misalignment diagnosed?
A. Diagnosis is typically made through physical examination, X-rays, or MRI scans to determine the exact position of the sesamoid and assess the extent of any misalignment or damage.
Q. What treatments are available for tibial sesamoid misalignment?
A. Treatment options include conservative methods like rest, ice therapy, anti-inflammatory medications, and custom orthotics. In severe cases, surgical options such as sesamoidectomy may be recommended to remove the problematic bone.
Q. What is sesamoidectomy, and when is it needed?
A. Sesamoidectomy is a surgical procedure where the sesamoid bone is removed. It is typically performed when conservative treatments fail, and the pain caused by the sesamoid is persistent, especially in athletes or active individuals.
Q. How can tibial sesamoid issues be prevented?
A. Prevention includes wearing appropriate footwear with adequate arch support, stretching and strengthening exercises for the foot and ankle, and avoiding excessive strain on the foot through high-impact activities.
Q. How long does recovery take after sesamoidectomy surgery?
A. Recovery time varies, but most patients can expect to return to normal activities within a few months, with physical therapy helping to restore foot function and strength. Full recovery may take 3 to 6 months, depending on the individual.
Q. Can tibial sesamoid misalignment cause long-term foot problems?
A. Yes, if left untreated, tibial sesamoid misalignment can lead to chronic pain, deformities, and problems with foot function. Over time, this can result in conditions like arthritis or joint instability in the big toe.
Q. Can tibial sesamoid misalignment be treated without surgery?
A. Yes, mild cases of misalignment can often be managed with non-surgical treatments such as rest, custom orthotics, anti-inflammatory medications, physical therapy, and appropriate footwear modifications.
Q. What role do sesamoids play in walking and running?
A. Sesamoids act as pulleys for the tendons that control toe movement, which helps with push-off during walking and running. Misalignment can affect these movements, causing pain and instability during these activities.
Q. Are there any non-invasive treatments for tibial sesamoid issues?
A. Non-invasive treatments include the use of custom orthotics to redistribute pressure, padding to protect the sesamoids, ice therapy, rest, and modifying physical activities to reduce stress on the sesamoid area.
Q. Is surgery the only option if the tibial sesamoid is misaligned?
A. No, surgery is typically considered a last resort after conservative treatments fail. Surgery is usually recommended if the condition causes persistent pain or significantly affects foot function, such as during walking or sports.
Q. How can physical therapy help with tibial sesamoid issues?
A. Physical therapy can help strengthen the muscles around the foot and ankle, improve mobility, and correct abnormal gait patterns. It also aids in rehabilitation after surgery to restore full foot function.
Q. What can I do to reduce the risk of tibial sesamoid injury or misalignment?
A. To reduce the risk, wear supportive shoes with proper arch support, avoid overuse of the feet, engage in strengthening and flexibility exercises, and avoid high-impact activities without proper foot support.
Q. What causes sesamoid injuries?
A. These injuries are often caused by overuse, trauma, or repetitive stress, particularly in athletes.
Q. What are the symptoms of sesamoiditis?
A. Symptoms include pain and swelling beneath the first metatarsal head, aggravated by walking or running.
Q. How is sesamoiditis treated?
A. Treatment includes rest, orthotics, NSAIDs, and corticosteroid injections for pain and inflammation.
Q. When is surgery needed for sesamoid injuries?
A. Surgery is necessary when there is nonunion of fractures, osteonecrosis, or when pain persists despite conservative treatments.
Q. How long is recovery after sesamoidectomy?
A. Recovery typically takes 8–12 weeks, with gradual weight-bearing and physical therapy.
Summary and Takeaway
Sesamoid injuries in the foot, including sesamoiditis and fractures, can lead to significant pain and functional limitation. Early intervention with non-surgical treatments like orthotics and activity modification can often provide relief. For persistent or severe cases, sesamoidectomy offers long-term pain relief and functional improvement.
Clinical Insight & Recent Findings
A recent study in Foot & Ankle Orthopaedics examined how degenerative changes at the tibial sesamoid–metatarsal joint affect recovery after hallux valgus surgery using the modified Lapidus procedure. Researchers reviewed weightbearing CT scans and patient-reported outcome data from 57 patients.
They found that after surgery, the space between the tibial sesamoid and the first metatarsal increased, indicating improved alignment. However, patients who already had advanced degenerative changes (a narrower joint space before surgery) tended to have worse physical function scores one year later, even when the sesamoids were successfully realigned.
This suggests that pre-existing arthritic wear at the tibial sesamoid joint can limit postoperative improvement despite technically successful correction. (“Study on degenerative changes of the tibial sesamoid joint and outcomes after hallux valgus surgery – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Sesamoid injuries are treated by orthopedic foot and ankle surgeons, podiatric surgeons, and rehabilitation specialists. Postoperative care and physical therapy are essential to optimize recovery.
When to See a Specialist?
Consult a specialist if you experience pain under the ball of the foot beneath the big toe, especially if it worsens with activity or shoe wear.
When to Go to the Emergency Room?
Go to the emergency room if you experience severe foot pain, swelling, or bruising following a traumatic injury, or if a bone is visible through the skin.
What Recovery Really Looks Like?
Recovery depends on the severity of the injury. For non-surgical cases, pain relief can be achieved in 4–6 weeks. Post-surgical recovery requires 8–12 weeks of careful rehabilitation and physical therapy to restore mobility and strength.
What Happens If You Ignore It?
Ignoring sesamoid injuries may result in chronic pain, gait abnormalities, and long-term disability, including arthritis and permanent joint damage.
How to Prevent It?
- Wear shoes that offer adequate arch support and cushioning
- Avoid repetitive stress on the forefoot
- Stretch and strengthen foot muscles regularly
- Correct any foot deformities early, and use orthotics to redistribute pressure.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and omega-3 fatty acids supports bone and joint healing, while staying hydrated helps with tissue regeneration.
Activity and Lifestyle Modifications
After healing, focus on strengthening and balancing exercises to prevent reinjury. Avoid high-impact activities until full recovery and mobility are restored.
Dr. Mo Athar
