✅ Medically reviewed by Dr. Thomas Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026

Sesamoidectomy: Complete Guide to Sesamoid Removal Surgery

The sesamoid bones are two small, pea-sized bones embedded in the tendon beneath the first metatarsophalangeal (MTP) joint at the base of the big toe. These bones function like pulleys, increasing the mechanical advantage of the flexor hallucis brevis tendon and absorbing significant ground reaction forces during push-off in gait. When sesamoid pathology cannot be resolved conservatively, surgical removal — called sesamoidectomy — may become necessary. This guide explains when sesamoidectomy is indicated, what the procedure involves, and what to expect during recovery.

When Is Sesamoidectomy Indicated?

Sesamoidectomy is a last resort after conservative management has failed. Conditions that may ultimately require surgical sesamoid removal include:

Avascular necrosis (AVN) of the sesamoid — Loss of blood supply leads to progressive bone death. Because sesamoids receive blood supply from a single vessel, AVN is relatively common after sesamoid fractures and after repeated corticosteroid injections. Once AVN is established, the sesamoid cannot heal normally and often requires removal.

Failed sesamoid stress fracture treatment — Stress fractures of the sesamoids often heal with protected weight-bearing, orthotics, and activity restriction. However, a subset of sesamoid stress fractures — particularly those in competitive athletes or those with poor vascularity — develop fibrous non-union (failure to heal with solid bone). When non-union causes persistent pain despite 6+ months of conservative care, sesamoidectomy is considered.

Chronic sesamoiditis unresponsive to treatment — Sesamoiditis (inflammation without fracture) typically responds well to orthotics, activity modification, and injections. When chronic sesamoiditis persists beyond 12 months of dedicated conservative care with documented radiographic changes, surgical removal may be warranted.

Comminuted (shattered) sesamoid fracture — Acute traumatic fractures that are severely comminuted and not reconstructible are occasionally managed with primary sesamoidectomy, though this is uncommon.

Conservative Treatment Before Surgery

Before recommending sesamoidectomy, your podiatric surgeon at Balance Foot & Ankle will ensure you have completed an adequate trial of conservative management. This typically includes custom orthotics with sesamoid accommodation (a cutout beneath the affected bone), stiff-soled or carbon fiber footwear, activity modification, corticosteroid injections (limited to 2–3 to avoid AVN), and in some cases, bone stimulation therapy. MRI is used to assess sesamoid viability and guide the decision for surgery.

The Sesamoidectomy Procedure

Sesamoidectomy is typically performed as an outpatient procedure under local anesthesia with sedation. The surgical approach depends on which sesamoid is affected:

Tibial (medial) sesamoidectomy uses a medial or plantar-medial incision along the inner border of the first MTP joint. The sesamoid is carefully dissected free from the surrounding tendons and joint capsule. Meticulous repair of the flexor hallucis brevis tendon and plantar plate is essential to prevent hallux valgus (bunion) development as a complication.

Fibular (lateral) sesamoidectomy uses a plantar-lateral or dorsal web-space approach. This sesamoid is technically more challenging to access and requires care to protect the digital nerve running in the first web space.

Recovery After Sesamoidectomy

Recovery from sesamoidectomy follows a structured protocol aimed at protecting the tendon repair and gradually restoring function:

Weeks 1–3: Non-weight-bearing or heel-only weight-bearing in a surgical shoe or boot. Wound care and suture management. Swelling management with elevation and ice.

Weeks 4–6: Gradual progression to weight-bearing in a firm-soled shoe. Range-of-motion exercises begin. Most patients are back to flat walking shoes by week 6.

Months 3–4: Progressive return to athletic shoes and activity. Custom orthotics are fabricated to protect the first MTP joint long-term. Most sedentary patients have returned to normal activity.

Months 4–6: Return to sport and high-impact activity for athletes, pending clinical assessment and strength testing.

Risks and Complications of Sesamoidectomy

Sesamoidectomy is generally well-tolerated, but potential complications include transfer metatarsalgia (pain shifting to adjacent metatarsals), hallux valgus (bunion development after tibial sesamoidectomy if the tendon repair is inadequate), cock-up toe deformity (hallux extensus), infection, nerve injury, and persistent pain. Choosing an experienced podiatric foot and ankle surgeon significantly reduces complication risk.

At Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan, our surgeons perform sesamoidectomy with meticulous technique and comprehensive post-operative follow-up to optimize outcomes. If you have been struggling with sesamoid pain unresponsive to conservative care, contact us to discuss whether surgical evaluation is appropriate for your situation.

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Related Treatment Guides

• Plantar Fasciitis & Heel Pain Treatment
• Custom 3D Orthotics
• Sports Foot & Ankle Injury Treatment
• Bunion Treatment

Michigan patients experiencing foot or ankle problems can schedule an appointment at Balance Foot & Ankle — with locations in Howell (4330 E Grand River) and Bloomfield Hills (43494 Woodward Ave #208). Call (810) 206-1402 for same-week availability.

Medical References & Sources

• American Podiatric Medical Association — Patient Education
• American Orthopaedic Foot & Ankle Society — Foot Conditions

Clinical References

1. Bichara DA, et al. “Sesamoidectomy for hallux sesamoid fractures.” Foot & Ankle International. 2012;33(9):704-706.
2. Aper RL, et al. “The effect of hallux sesamoid excision on the flexor hallucis longus moment arm.” Clinical Orthopaedics and Related Research. 1996;(325):209-217.
3. Richardson EG. “Hallucal sesamoid pain: causes and surgical treatment.” Journal of the American Academy of Orthopaedic Surgeons. 1999;7(4):270-278.