Sesamoid Surgery: Sesamoidectomy and Treatment for Intractable Sesamoid Pain

Quick answer: Sesamoid Surgery Sesamoidectomy Foot 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.

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Township, MI. Last updated April 2026.

Understanding the Sesamoid Bones

The two sesamoid bones—tibial (medial) and fibular (lateral)—sit within the flexor hallucis brevis tendons beneath the first metatarsal head. These pea-sized bones function as pulleys that increase the mechanical advantage of the big toe flexors, absorb weight-bearing forces during push-off, and protect the underlying tendon from compression against the metatarsal head.

Each sesamoid bears up to 50% of body weight during the toe-off phase of walking and up to three times body weight during running. This extraordinary loading explains why sesamoid injuries are common in athletes and dancers. The tibial sesamoid is injured more frequently because it bears greater load during the medial weight transfer of normal gait.

Blood supply to the sesamoids is tenuous, entering primarily through the proximal pole. This limited vascularity makes sesamoid fractures slow to heal and predisposes them to avascular necrosis—a condition where the bone dies due to interrupted blood flow. Understanding this anatomy is essential for appreciating why some sesamoid injuries require surgical intervention.

When Conservative Treatment Fails: Surgical Indications

Surgery is considered after 3-6 months of failed conservative treatment including immobilization in a walking boot, activity modification, custom orthotics with sesamoid offloading, and anti-inflammatory measures. Persistent pain that limits daily walking or prevents return to desired activities despite these measures warrants surgical evaluation.

Specific surgical indications include nonunion sesamoid fractures confirmed on MRI or CT with persistent pain, avascular necrosis with bone collapse visible on imaging, chronic sesamoiditis unresponsive to injections and offloading, and infected sesamoids in diabetic patients. Bipartite sesamoids that become symptomatic after acute trauma may also require excision.

Pre-surgical imaging includes weight-bearing X-rays, MRI to assess bone viability and surrounding soft tissue, and occasionally CT for detailed fracture pattern analysis. The sesamoid axial view X-ray provides the clearest visualization of both sesamoids and helps identify the specific bone causing symptoms.

Types of Sesamoid Surgery

Partial sesamoidectomy removes only the damaged portion of the sesamoid while preserving the remaining viable bone and its tendon attachments. This procedure is preferred when the injury is limited to one pole of the sesamoid, as it maintains more normal biomechanics. However, partial removal requires precise surgical technique to prevent ongoing symptoms from retained fragments.

Complete sesamoidectomy removes the entire affected sesamoid bone and is the most commonly performed procedure for nonunion fractures and avascular necrosis. The tibial sesamoid is removed through a medial approach, while the fibular sesamoid is accessed through a plantar or dorsal lateral approach. Tendon repair after removal is critical to prevent hallux valgus or hallux varus deformity.

Bone grafting procedures are occasionally attempted for avascular necrosis in young athletes who want to preserve both sesamoids. A vascularized bone graft can restore blood supply to the damaged sesamoid, but success rates are variable and recovery is prolonged. This option is reserved for highly motivated patients willing to accept longer rehabilitation.

The Surgical Procedure: What to Expect

Sesamoidectomy is typically performed as an outpatient procedure under ankle block regional anesthesia with sedation. The surgery takes 30-60 minutes depending on complexity. A small incision—usually 3-4 centimeters—provides access to the sesamoid while minimizing soft tissue disruption.

The surgeon carefully dissects around the sesamoid, preserving the flexor hallucis brevis tendon fibers that envelope the bone. After removing the sesamoid, the tendon defect is repaired with sutures to maintain big toe flexion strength and prevent angular deformity. The joint capsule is closed carefully to restore the normal soft tissue balance around the first metatarsal head.

Intraoperative fluoroscopy confirms complete sesamoid removal and appropriate alignment of the remaining structures. A compression dressing is applied, and the patient is fitted with a surgical shoe or walking boot before discharge. Most patients go home within 2-3 hours of surgery.

Recovery Timeline After Sesamoidectomy

Weeks 1-2 focus on wound healing and pain management. The foot is elevated above heart level as much as possible to minimize swelling. Weight bearing is limited to heel-only walking in a surgical shoe. Sutures are typically removed at the 10-14 day follow-up visit when the incision is inspected for proper healing.

Weeks 3-6 involve progressive weight bearing in a walking boot with a sesamoid offloading pad. Physical therapy begins with gentle range-of-motion exercises for the big toe joint. Most patients can return to desk work by week 3 and driving by week 4 if the non-driving foot was operated on, or week 5-6 for the driving foot.

Weeks 6-12 mark the transition back to regular footwear with a custom orthotic that includes a Morton’s extension or dancer’s pad to protect the surgical site. Walking distance gradually increases. Impact activities like running are typically restricted until week 10-12. Full recovery with return to all activities averages 3-4 months.

Potential Complications and How We Minimize Them

Hallux valgus drift—the big toe angling toward the second toe—is the most discussed complication after tibial sesamoidectomy. Meticulous tendon repair and early range-of-motion exercises reduce this risk. Fibular sesamoidectomy carries a corresponding risk of hallux varus (toe angling inward). Studies show complication rates below 5% when surgery is performed by experienced foot surgeons.

Transfer metatarsalgia—increased pressure under the second metatarsal head—can develop if the first metatarsal loses its weight-bearing capacity after sesamoid removal. Custom orthotics with metatarsal pads distribute pressure evenly and prevent this complication in most patients.

Nerve irritation along the incision can cause temporary numbness or tingling along the side of the big toe. This typically resolves within 3-6 months as the small sensory nerves recover. Scar tissue formation beneath the metatarsal head occasionally requires additional treatment with steroid injection or physical therapy modalities.

Long-Term Outcomes After Sesamoid Surgery

Published outcome studies report 85-92% patient satisfaction rates following sesamoidectomy for appropriate surgical indications. Most patients achieve significant pain reduction within 6 weeks and return to full activity by 3-4 months. Athletic patients typically return to sport between 3-6 months depending on the demands of their activity.

Long-term biomechanical studies show that removal of a single sesamoid produces measurable but clinically insignificant changes in first ray mechanics. Patients compensate effectively through adjacent muscle strengthening and orthotic support. Removal of both sesamoids—which is avoided whenever possible—produces more significant biomechanical alterations.

Follow-up X-rays at 3, 6, and 12 months after surgery monitor alignment and identify any progressive changes requiring intervention. Most patients require custom orthotics for 1-2 years after surgery, with many transitioning to over-the-counter supportive insoles for long-term maintenance.

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.

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.

Related Care at Balance Foot & Ankle

Clinical sesamoid services at our Howell and Bloomfield Township offices.

Foot BracingCustom OrthoticsCortisone Injections

Book an appointment with a podiatrist

Removing a sesamoid changes how the big toe works for good, so the decision is worth making after an exam that establishes what conservative care has already been given a fair trial. Balance Foot & Ankle sees patients at two offices — Howell in Livingston County, and Bloomfield Township in Oakland County.

Call (810) 206-1402 or use the form below and our team will find you an appointment time.