When Do Sesamoids Require Surgery?

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 comprehensive evaluation and a transparent discussion of all treatment options. Call (810) 206-1402 or book online.

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon 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 reached over one million views.