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

Understanding the Sesamoid Bones and Their Function

The two sesamoid bones — the tibial (medial) and fibular (lateral) — are small, pea-sized bones embedded within the flexor hallucis brevis tendon beneath the first metatarsal head. These bones serve as a pulley system that increases the mechanical advantage of the flexor tendons during push-off, absorb up to 50 percent of the weight-bearing load on the first metatarsal, and protect the tendon from compression against the ground.

During normal walking, the sesamoids glide within a groove (the sesamoid crista) on the plantar surface of the first metatarsal head. This articulation functions as a true synovial joint with cartilage surfaces, a joint capsule, and synovial fluid. Understanding this anatomy explains why sesamoid conditions produce such significant forefoot pain — an arthritic or fractured sesamoid joint is loaded with every step.

The tibial (medial) sesamoid bears approximately 67 percent of the sesamoid load during walking and is correspondingly more frequently injured than its lateral counterpart. It is also larger, positioned more centrally under the metatarsal head, and more vulnerable to both direct trauma and overuse pathology.

When Conservative Treatment Fails: Indications for Surgery

Sesamoidectomy is considered after a minimum 3-6 months of comprehensive conservative treatment has failed to adequately resolve symptoms. Conservative measures include offloading orthotics with a metatarsal cutout that redirects pressure away from the sesamoid, dancer’s padding beneath the first metatarsal, rigid-soled shoes that limit first MTP joint dorsiflexion, activity modification, and sometimes immobilization in a walking boot.

Specific indications for sesamoidectomy include chronic sesamoiditis refractory to conservative management, established nonunion of a sesamoid fracture causing persistent pain, avascular necrosis (AVN) of a sesamoid showing bone fragmentation on MRI, and intractable keratosis (callus formation) directly beneath a prominent sesamoid that recurs despite regular debridement and padding.

The decision to operate requires careful imaging assessment. MRI identifies bone marrow edema in sesamoiditis, fracture lines and nonunion characteristics, and the decreased signal intensity that indicates avascular necrosis. CT scan provides superior detail of bone architecture and is particularly valuable for distinguishing a true fracture from a bipartite sesamoid — a normal anatomic variant where the sesamoid develops as two separate ossicles.

The Sesamoidectomy Procedure: Surgical Technique

Sesamoidectomy is performed as an outpatient procedure under regional anesthesia (ankle block) supplemented with intravenous sedation. The surgical approach depends on which sesamoid is being removed. Tibial (medial) sesamoidectomy uses a medial incision along the first MTP joint, while fibular (lateral) sesamoidectomy requires a plantar-lateral or dorsal approach to access the deeper-positioned lateral bone.

The sesamoid is carefully shelled out from within the flexor hallucis brevis tendon, preserving as much tendon substance as possible to maintain pushoff strength. The intersesamoidal ligament is released only when necessary, and the plantar plate is repaired to prevent post-operative hallux valgus drift that can occur when the soft tissue balance of the first MTP joint is disrupted.

Isolated removal of one sesamoid (typically the tibial for medial sesamoid pathology) is strongly preferred over removing both. Removing both sesamoids dramatically reduces first MTP joint strength, transfers excessive load to the lesser metatarsals, and significantly increases the risk of cock-up deformity of the hallux. Dual sesamoidectomy is reserved for extremely rare cases with bilateral pathology.

Recovery Timeline and Rehabilitation Protocol

The first two weeks after sesamoidectomy involve limited weight-bearing in a surgical shoe with a metatarsal offloading pad. Sutures are removed at approximately 14 days, and gentle passive range of motion exercises begin to prevent adhesion formation around the first MTP joint. Weight-bearing is advanced as tolerated with a stiff post-operative shoe.

Weeks 3-6 focus on progressive weight-bearing and transition to a supportive athletic shoe with a custom orthotic that includes a metatarsal relief area. Active range of motion exercises increase in intensity, and intrinsic foot strengthening exercises (towel curls, marble pickups) begin to rebuild the flexor mechanism that was surgically disrupted.

Full recovery allowing return to impact activities typically takes 8-12 weeks, though some patients note continued improvement in forefoot comfort for up to 6 months. Return to running begins at week 8-10 with a gradual walk-run program, while return to activities requiring forceful push-off (dancing, sprinting, jumping sports) may take the full 12-week timeline.

Potential Complications and How We Manage Them

Hallux valgus drift (the big toe angling toward the second toe) is the most discussed complication of sesamoidectomy, particularly tibial sesamoid removal. The tibial sesamoid acts as a medial buttress for the hallux, and its absence can allow lateral deviation if the soft tissue repair is inadequate. Meticulous repair of the medial capsule, plantar plate, and abductor hallucis tendon attachment minimizes this risk.

Transfer metatarsalgia occurs when removal of a sesamoid shifts weight-bearing load from the first metatarsal to the lesser metatarsals, causing new pain under the second or third metatarsal heads. Pre-operative counseling addresses this possibility, and post-operative orthotics with metatarsal support are prescribed routinely to redistribute forefoot pressures.

Weakened push-off strength is a theoretical concern but rarely clinically significant after isolated single sesamoidectomy. Studies measuring first ray plantarflexion strength after unilateral sesamoidectomy show approximately 10-15 percent reduction in peak force — a difference most patients cannot perceive during daily activities. Athletes may notice reduced explosive push-off power, which improves with targeted rehabilitation.

Alternatives to Sesamoidectomy

Bone stimulator therapy using pulsed electromagnetic field (PEMF) devices can promote healing in sesamoid stress fractures and may prevent the need for surgical excision. Treatment involves applying the device to the plantar first MTP area for 3-4 hours daily over 3-6 months, with healing monitored by serial imaging.

Corticosteroid injection into the sesamoid-metatarsal articulation provides temporary relief for sesamoiditis and can serve as both a diagnostic and therapeutic tool. If a single injection provides significant but temporary relief, it confirms the sesamoid as the pain generator while buying time for other conservative measures to take effect.

Autologous blood injection and platelet-rich plasma (PRP) therapy represent emerging biologic treatments for chronic sesamoiditis and partial sesamoid fractures. By delivering concentrated growth factors directly to the damaged tissue, these treatments may promote healing in cases that haven’t responded to traditional conservative therapy but don’t yet warrant surgical excision.

The Most Common Mistake We See

The most common mistake is misdiagnosing a bipartite sesamoid (a normal anatomic variant present in 10-30 percent of people) as a fracture and pursuing unnecessary treatment. Bipartite sesamoids have smooth, rounded edges on X-ray, while true fractures show irregular, jagged margins. Comparing X-rays of the other foot can help — bipartite sesamoids are bilateral 90 percent of the time.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

How painful is sesamoidectomy recovery?

Post-operative pain is typically moderate and well-controlled with prescribed medications for the first 5-7 days. The plantar incision area can remain tender with direct pressure for 4-6 weeks, which is why offloading orthotics are prescribed during recovery. Most patients rate their post-operative discomfort as significantly less than the chronic sesamoid pain they experienced before surgery.

Will I be able to run after sesamoidectomy?

Yes. Most patients return to running 8-12 weeks after surgery with a gradual progression program. Isolated single sesamoidectomy preserves sufficient first ray strength for running, and many competitive runners successfully return to their previous mileage with appropriate rehabilitation and orthotic support.

How do you tell the difference between sesamoiditis and a sesamoid fracture?

Sesamoiditis develops gradually with diffuse swelling and aching under the big toe joint, while sesamoid fractures often follow a specific traumatic event with acute, localized pain. X-rays may show a fracture line, but MRI is the gold standard for distinguishing sesamoiditis (bone marrow edema without fracture) from stress fracture (visible fracture line with surrounding edema) and from avascular necrosis (decreased signal intensity indicating bone death).

What is the success rate of sesamoidectomy?

Published studies report 85-90 percent patient satisfaction rates after isolated sesamoidectomy performed for appropriate indications. Success is highest when surgery is performed for clear pathology confirmed on MRI (AVN, established nonunion, or refractory sesamoiditis) and when patients complete the full rehabilitation protocol including orthotic use and gradual return to activity.

The Bottom Line

Chronic sesamoid pain that persists despite thorough conservative treatment can be effectively resolved with sesamoidectomy. The key to successful outcomes is accurate diagnosis, appropriate patient selection, meticulous surgical technique that preserves soft tissue balance, and guided rehabilitation. If pain under your big toe joint is limiting your activities despite months of conservative care, schedule a consultation to discuss whether sesamoidectomy is the right next step.

Sources

1. Aper RL, et al. The effect of hallux sesamoid excision on the flexor hallucis brevis moment arm. Clin Orthop Relat Res. 1996;(325):209-217.
2. Lee S, et al. Sesamoidectomy: indications, surgical technique, and outcomes. Foot Ankle Clin. 2019;24(2):251-260.
3. Richardson EG. Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 1999;7(4):270-278.
4. Bichara DA, et al. Sesamoidectomy for hallux sesamoid fractures. Foot Ankle Int. 2012;33(9):704-709.

Sesamoid Surgery in Michigan

When conservative treatments fail to resolve chronic sesamoid pain, sesamoidectomy can provide lasting relief. Dr. Tom Biernacki performs precise sesamoid surgery at Balance Foot & Ankle.

Learn About Our Foot Pain Treatments | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Cohen BE. “Hallux sesamoid disorders.” Foot Ankle Clin. 2009;14(1):91-104.
2. Richardson EG. “Hallucal sesamoid pain: causes and surgical treatment.” J Am Acad Orthop Surg. 1999;7(4):270-278.
3. Lee S, et al. “Sesamoidectomy for hallux sesamoid fractures.” Foot Ankle Int. 2008;29(12):1222-1227.