Sesamoid Fracture & Excision 2026 | DPM

Diagnosis	X-ray Finding	Bone Scan / MRI	Clinical Feature
Acute Sesamoid Fracture	Irregular fracture line; jagged edges; acute onset	Bone scan: hot; MRI: marrow edema + fracture line	Sudden onset after direct trauma or forceful toe dorsiflexion
Sesamoid Stress Fracture	May be normal early; delayed: sclerosis/fragmentation	MRI essential — earliest detection; edema without clear fracture	Gradual onset in dancers, runners; localized plantar big toe pain
Sesamoiditis (inflammation, no fracture)	Normal	MRI: bone marrow edema only; no fracture line	Chronic plantar forefoot pain; dancers; high-heel wearers
Bipartite Sesamoid (normal variant)	Smooth, rounded edges; bilateral in 85%	Bone scan: cold (no uptake); MRI: no edema if asymptomatic	Incidental finding; becomes symptomatic only if acutely injured
Avascular Necrosis (AVN)	Fragmentation; sclerosis; irregular density	MRI: subchondral collapse; dark on T1	After corticosteroid injection or traumatic disruption of blood supply

Duration / Recovery

Treatment	Indication	Notes
NWB boot + dancer pad (sesamoid cutout)	Acute fracture; stress fracture; sesamoiditis	6–8 weeks NWB; gradual return 3–4 months	First-line for all; dancer pad offloads sesamoid from plantar pressure
Bone stimulator (ultrasound or electrical)	Delayed union; stress fracture >3 months no healing	Adjunct 3–6 months	May improve healing rate in delayed union; non-invasive
Cortisone injection	Sesamoiditis; acute inflammation; NOT fracture AVN	Short-term relief 2–4 months	Avoid injection into fractured or AVN sesamoid — worsens AVN risk
Partial or total sesamoid excision	Chronic non-union >6 months; AVN; painful bipartite	WB in surgical shoe 3–4 weeks; full activity 3–4 months	Preserve FHB function; avoid total excision if possible — hallux valgus risk; partial preferred
Custom orthotics (long-term)	All sesamoid conditions post-acute phase	Long-term	Metatarsal bar or sesamoid cutout; protects against recurrence

Quick answer: Sesamoid Fracture Excision Michigan Podiatrist is a common foot/ankle topic that affects many patients. The 2026 evidence-based approach combines proper diagnosis, conservative-first treatment, and escalation only when needed. We treat this regularly at our Howell and Bloomfield Hills practices. Call (810) 206-1402.

The sesamoid bones of the great toe — two small, pea-sized bones embedded within the flexor hallucis brevis (FHB) tendon at the plantar surface of the first metatarsophalangeal joint — are among the most mechanically loaded small bones in the body. They transmit an estimated 50-60% of body weight at the toe-off phase of gait and serve as a pulley mechanism that dramatically increases the mechanical advantage of the FHB tendon. This extreme functional loading makes the sesamoids vulnerable to both acute fracture from direct trauma and stress fracture from repetitive athletic loading. Dr. Tom Biernacki at Balance Foot & Ankle evaluates sesamoid pathology with precision and provides definitive management — conservative and surgical — for Michigan patients.

Sesamoid Anatomy and Function

Two sesamoids are located at the plantar first MTP joint: the tibial (medial) sesamoid and the fibular (lateral) sesamoid. They are embedded within the medial and lateral slips of the FHB tendon and are connected to each other and the plantar structures by the intersesamoid ligament. Both sesamoids articulate with the plantar surface of the first metatarsal head — each has a dedicated articular facet. This joint surface can develop articular cartilage injury (sesamoid chondromalacia) distinct from fracture. The tibial sesamoid is larger, bears more load, and is fractured or inflamed approximately twice as frequently as the fibular sesamoid.

The sesamoids reduce friction under the first MTP joint, absorb impact loading, and increase FHB mechanical advantage for powerful hallux plantarflexion — the critical final push-off movement of gait. Any condition compromising sesamoid integrity directly impairs toe-off power and produces pain specifically at the plantar ball of the foot beneath the great toe base.

Sesamoid Fracture vs. Bipartite Sesamoid

A critical diagnostic challenge in sesamoid evaluation is distinguishing a true fracture from a bipartite sesamoid — a normal anatomic variant present in approximately 25% of the population where the sesamoid develops from two ossification centers that fail to fuse, resulting in a sesamoid with a smooth fibrocartilaginous partition through its center. Bipartite sesamoids are typically bilateral, have smooth rounded margins at the partition, and are asymptomatic unless subjected to injury. True fractures are typically unilateral, have irregular jagged fracture margins, and have a clear traumatic or overuse history.

MRI is the most sensitive diagnostic modality, showing bone marrow edema (T2 hypersignal) in acute fractures — absent in the normal bipartite variant. Bone scan demonstrates increased uptake in acute fractures. Comparative bilateral X-rays help identify bipartite morphology when present on both sides.

Who Gets Sesamoid Fractures?

Sesamoid stress fractures are disproportionately common in dancers (particularly ballet and contemporary dancers who spend prolonged periods in demi-pointe), long-distance runners with high weekly mileage, court sport athletes (tennis, basketball, volleyball) with repetitive toe-off demands, and cavus foot (high arch) patients in whom excess pressure is concentrated under the first metatarsal head. Acute fractures occur from direct plantar impact — falling from height onto the ball of the foot, a forceful stumble on stairs, or a direct blow. Soccer players can fracture sesamoids from ball impact or ground contact during powerful kicks.

Conservative Treatment

The primary goal of conservative management is complete mechanical offloading of the fractured sesamoid to allow bone healing. Dr. Biernacki’s conservative protocol includes: strict non-weight-bearing in a non-walking cast or CAM boot for 4-6 weeks for acute fractures; dancer’s pad — a U-shaped or donut-shaped padding with a cutout over the sesamoid — that redirects plantar pressure away from the fracture; custom orthotics with a sesamoid accommodation (a sesamoid cutout in the rearfoot posting material) for long-term pressure redistribution; and LIPUS bone stimulation (EXOGEN) as an adjunct for fractures with delayed healing. Activity restriction from high-impact loading is maintained until radiographic healing is confirmed.

Conservative management achieves union in approximately 50-70% of acute sesamoid fractures at 4-6 months. Chronic non-union sesamoids with sclerotic margins and failed healing have substantially lower union rates with continued conservative management — typically less than 30%.

Sesamoidectomy Surgery

Sesamoidectomy — surgical removal of the fractured, avascular, or chronically painful sesamoid — is indicated for: confirmed non-union at 6-9 months with persistent pain, avascular necrosis (identified on MRI as T1 hypointensity without marrow signal), and refractory sesamoiditis with articular cartilage destruction that has failed 6 months of conservative management. The procedure is performed through a 3-4 cm plantar or medial incision under local anesthesia as an outpatient procedure.

The critical technical consideration in sesamoidectomy is preservation of the FHB tendon function. The sesamoid is enucleated from within the FHB tendon — the tendon is split longitudinally, the sesamoid is excised, and the tendon is meticulously repaired. Failure to repair the FHB tendon results in hallux valgus (tibial sesamoid excision) or hallux varus (fibular sesamoid excision) deformity. Bilateral sesamoidectomy is avoided because removing both sesamoids eliminates all FHB mechanical advantage and produces severe hallux weakness and cock-up deformity. Overall outcomes for sesamoidectomy show good to excellent pain relief in approximately 80-85% of patients.

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Frequently Asked Questions

When should I see a podiatrist?

If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).

What does treatment cost?

Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.

How quickly can I get an appointment?

Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.

What is Stress fracture?

Stress fracture is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.

Symptoms and warning signs

Common signs of stress fracture include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.

Conservative treatment options

Most cases of stress fracture respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.

When is surgery considered?

Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.

Recovery timeline and prevention

Recovery from stress fracture varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your sesamoiditis, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.