Quick answer: Sesamoid Surgery Excision Tibial 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 Township practices. Call (810) 206-1402.
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When Do Sesamoids Require Surgery?
Medically Reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists, Michigan. Last updated April 2026.
The sesamoid bones — the two small round bones embedded within the flexor hallucis brevis tendons beneath the first metatarsal head — are essential structures for great toe push-off mechanics. When sesamoids become painful from fracture, stress fracture non-union, avascular necrosis (AVN), or chronic sesamoiditis, conservative treatment resolves most cases with time and appropriate offloading. However, a subset of patients — typically those with AVN, fracture non-union, or chronically painful sesamoids unresponsive to 6-12 months of conservative management — ultimately require surgical intervention.
Sesamoid surgery is not entered into lightly. The sesamoids play an important biomechanical role, and their removal or modification carries functional implications that must be understood preoperatively. The decision for surgery requires careful clinical and imaging evaluation and a thorough discussion of realistic outcomes and alternatives.
Indications for Sesamoid Surgery
Sesamoid fracture non-union: A sesamoid fracture that fails to heal despite adequate immobilization (typically 6-8 weeks in a non-weight-bearing cast or boot) and has been present for 3-6 months or longer. Non-union is confirmed by CT or MRI showing persistent fracture gap with surrounding sclerosis and absence of bridging bone callus.
Avascular necrosis: Disruption of the sesamoid blood supply produces bone death that can progress to fragmentation and collapse, causing chronic intractable pain. AVN is diagnosed by MRI (decreased T1 signal with T2 edema pattern) and may occur following stress fracture, repetitive trauma, or corticosteroid injection. Once AVN is established and symptomatic, conservative measures have limited efficacy and surgical excision is often the only reliable option.
Chronic sesamoiditis unresponsive to conservative care: Sesamoiditis — inflammation of the sesamoid-metatarsal articulation without fracture — typically responds to offloading, custom orthotics, and activity modification within 3-6 months. When pain persists beyond 6-12 months despite appropriate conservative management, surgical intervention may be considered.
Surgical Options
Tibial sesamoid excision (partial or complete): The tibial (medial) sesamoid is more commonly affected and more commonly excised. Complete tibial sesamoid excision removes the entire sesamoid, while partial excision (sesamoid shaving) removes only the diseased or fragmented portion. Complete excision is appropriate for AVN with significant collapse or for non-union with extensively fragmented bone. Partial excision is preferred when viable sesamoid tissue can be preserved.
Fibular sesamoid excision: The fibular (lateral) sesamoid is less commonly excised because its removal creates a more significant hallux valgus deformity tendency (loss of the lateral support that normally counters the hallux valgus pull). When fibular sesamoidectomy is required, concurrent surgical correction of any existing or developing hallux valgus deformity is often planned simultaneously.
Surgical approach: Access to the tibial sesamoid is typically through a plantar medial incision that carefully protects the adjacent plantar medial digital nerve. The sesamoid-metatarsal joint is identified, the diseased sesamoid or fragment is excised, and the flexor hallucis brevis tendon is repaired around the excision site to maintain tendon integrity.
Postoperative Expectations and Functional Outcomes
Recovery from sesamoidectomy requires several weeks in a surgical shoe with protected weight-bearing, followed by gradual return to regular footwear and activity. Most patients notice a “different feel” under the first metatarsal head after sesamoidectomy — slightly less cushioned push-off due to the altered first ray mechanics. This is generally well-tolerated, particularly when the other sesamoid remains intact.
Hallux cock-up deformity — upward pulling of the great toe from the flexor hallucis brevis imbalance created by sesamoidectomy — is a potential long-term complication that occurs in a minority of patients and may require secondary correction. Maintaining the tendon repair and ensuring residual sesamoid tissue when possible reduces this risk.
Athletes undergoing tibial sesamoidectomy can generally return to running sports at 3-4 months postoperatively. Ballet dancers and other athletes requiring extreme first MTP joint dorsiflexion may experience prolonged recovery due to altered sesamoid mechanics.
Alternatives to Excision
Before proceeding to sesamoidectomy, less invasive alternatives should be considered. Bone marrow stimulation (drilling the sclerotic sesamoid) attempts to reactivate the healing response. Platelet-rich plasma or other biologic injections may support healing in non-union scenarios. For partial AVN, a custom orthotic with precise sesamoid offloading (dancer’s pad modification) can provide durable symptom relief without surgery.
If you have persistent sesamoid pain or a diagnosed sesamoid fracture non-union or AVN, our podiatric surgeons at Balance Foot & Ankle in Howell and Bloomfield Township, Michigan provide hands-on exam plus imaging when needed and a transparent discussion of all treatment options. Call (810) 206-1402 or book online.
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4330 E Grand River Ave
Howell, MI 48843
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43494 Woodward Ave, Suite 208
Bloomfield Township, MI 48302
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More Podiatrist-Recommended Surgery Essentials
Post-Op Walking Boot
Protected weight-bearing immobilization through the first healing weeks.
Surgical-Scar Healing Lotion
Reduces scar thickness and tenderness as the incision matures.
Return-to-Activity Insole
Supports the reconstructed foot during the first months back on your feet.
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Watch: BEST Sesamoiditis Treatment [Sesamoid Bone Pain & Fracture FIX] — MichiganFootDoctors YouTube
When to See a Podiatrist
Foot and ankle surgery in 2026 is dramatically different than a decade ago — most procedures are now minimally-invasive, outpatient, and allow weight-bearing within days. Balance Foot & Ankle surgeons have performed 3,000+ foot/ankle surgeries with modern techniques. If another surgeon has recommended a traditional open procedure, a second opinion may reveal a faster, less-invasive option.
Call Balance Foot & Ankle: (810) 206-1402 · Book online · Offices in Howell & Bloomfield Township
Differential Diagnosis: What Else Could It Be?
Not every case of sesamoiditis is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.
| Condition | How It Differs |
|---|---|
| Sesamoid stress fracture | Acute or gradually worsening sharp pain, tender directly over one sesamoid, positive findings on MRI. |
| Hallux rigidus | Stiff, painful big toe joint with limited dorsiflexion — pain is AT the joint, not UNDER the ball. |
| Turf toe (plantar plate injury) | Acute hyperextension mechanism, diffuse swelling of the 1st MTP, positive 1st MTP drawer test. |
Red Flags — When to See a Podiatrist Now
Seek same-day evaluation at Balance Foot & Ankle if you notice any of the following:
- Sudden sharp onset (possible fracture)
- Bruising or swelling under the big toe
- Pain at rest or at night
- Inability to push off during gait
Call (810) 206-1402 or request an appointment. Our Howell and Bloomfield Township offices reserve same-day slots for urgent foot and ankle issues.
In Our Clinic: What We See
Clinical perspective from Dr. Tom Biernacki, DPM — Balance Foot & Ankle, Howell & Bloomfield Township, MI:
In our Balance Foot & Ankle clinic, sesamoiditis patients are usually dancers, runners, or women who have spent significant time in heels. They describe pain directly UNDER the big toe joint — not at the joint (that’s hallux rigidus) — which worsens with push-off. On exam we palpate each sesamoid separately (tibial and fibular) and assess for sensitivity. We always get X-rays to look for sesamoid fracture or bipartite sesamoid (a normal variant). Treatment uses a dancer’s pad to offload the sesamoid, stiff-soled footwear to reduce push-off stress, and activity modification.
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.
Same-day appointments available. (810) 206-1402
Doctor Hoy’s Natural Pain Relief Gel
Natural topical pain relief I use in our clinic. Arnica + camphor formula — apply directly to the area 3–4x daily. ($20–25)
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 Sesamoiditis?
Sesamoiditis 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 sesamoiditis 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 sesamoiditis 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 sesamoiditis 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.
Ready to feel better?
Same-week appointments available in Howell and Bloomfield Township, Michigan.
Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.