Sesamoidectomy: Surgical Removal of Sesamoid Bone for Chronic Pain and Fracture Non-Union

Quick answer: Sesamoidectomy Surgical Removal Sesamoid Bone Chronic Pain Fracture has multiple potential causes including mechanical, neurological, vascular, and inflammatory. The most common causes we identify are overuse, ill-fitting shoes, and biomechanical imbalance. Red flags requiring urgent evaluation: warmth/redness (infection), inability to bear weight (fracture), and unilateral swelling without injury (DVT). Call (810) 206-1402.

What Are the Sesamoid Bones?

The sesamoid bones are two small, pea-sized bones embedded within the flexor hallucis brevis tendon beneath the first metatarsophalangeal (MTP) joint — the big toe joint. Like the patella (kneecap), the sesamoids act as a pulley, improving the mechanical advantage of the tendon that flexes the big toe. They also protect the tendon from direct pressure during weight-bearing and absorb significant shock during the push-off phase of gait.

Despite their small size, the sesamoids bear substantial forces — up to three times body weight during running — making them susceptible to a range of painful conditions that, when they fail to respond to conservative management, may ultimately require surgical removal.

Indications for Sesamoidectomy

Sesamoid Stress Fracture Non-Union

Sesamoid stress fractures are common in runners, dancers, and athletes who load the forefoot repetitively. Most stress fractures heal with appropriate offloading and rest over six to twelve weeks. However, the fibular (lateral) sesamoid in particular occupies an avascular zone in some patients — meaning its blood supply is insufficient to support reliable healing. When a sesamoid stress fracture progresses to non-union despite extended conservative management, sesamoidectomy provides definitive treatment.

Avascular Necrosis (Osteonecrosis) of the Sesamoid

Avascular necrosis occurs when the blood supply to the sesamoid is disrupted — whether from trauma, repetitive stress, or spontaneous in patients with vascular risk factors. The bone undergoes progressive fragmentation and collapse. Conservative treatment with offloading rarely reverses established AVN. Sesamoidectomy removes the necrotic bone and eliminates the pain source.

Chronic Sesamoiditis Refractory to Conservative Treatment

Chronic sesamoiditis — inflammation of the sesamoid-tendon interface without discrete fracture — can persist despite extended trials of offloading orthotics, sesamoid pads, corticosteroid injection, and activity modification. When symptoms have persisted for six months or longer with appropriate conservative management and continue to limit function significantly, sesamoidectomy is a reasonable surgical option.

Bipartite Sesamoid Painful Fragmentation

Approximately 25 percent of the population has a bipartite tibial sesamoid — a sesamoid divided into two fragments by a fibrocartilaginous junction rather than a single unified bone. This is a normal anatomic variant that is typically asymptomatic. However, following trauma or repetitive stress, the junction between the two fragments can become inflamed and painful, simulating a fracture. When conservative treatment fails to provide lasting relief for symptomatic bipartite sesamoid, sesamoidectomy addresses the painful junction definitively.

Surgical Technique

Sesamoidectomy is performed through a small plantar medial (tibial sesamoid) or plantar lateral (fibular sesamoid) incision, or through a dorsal approach. The fibular (lateral) sesamoid is more commonly removed — it is located in a less critical position biomechanically than the tibial sesamoid, and its removal carries lower risk of hallux valgus deformity postoperatively. When removing the tibial (medial) sesamoid, careful preservation of the medial soft tissue structures prevents big toe deviation.

The sesamoid is identified within the tendon substance, and the tendon is carefully split along its length to expose the sesamoid. The bone is excised and the tendon is repaired with absorbable sutures to restore its structural continuity. The incision is closed in layers and the foot is placed in a protective dressing.

Recovery After Sesamoidectomy

Protected weight-bearing in a surgical shoe or boot is maintained for three to four weeks while the tendon heals. Progression to regular footwear begins at four to six weeks. Full return to athletic footwear and activity typically occurs at eight to twelve weeks. Some patients experience altered forefoot mechanics after sesamoidectomy — custom orthotics with metatarsal support can optimize forefoot load distribution and improve functional outcomes.

Consultation for Sesamoid Pain

If you have been experiencing forefoot pain beneath the big toe joint that has not responded to conservative treatment, sesamoid pathology may be the cause. Contact Balance Foot & Ankle for evaluation including clinical examination, weight-bearing X-ray, and advanced imaging when indicated, along with a comprehensive treatment plan.

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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

In Our Clinic: What We See

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.

Frequently Asked Questions

When should I see a doctor?

See a podiatrist if pain persists past 2 weeks, prevents normal activity, or is accompanied by red-flag symptoms (warmth, swelling, numbness, inability to bear weight).

Can I treat this at home?

Mild cases respond to RICE protocol (rest, ice, compression, elevation), supportive shoes, and OTC anti-inflammatories. Persistent symptoms need professional evaluation.

How long does it take to heal?

Most soft tissue injuries resolve in 2-6 weeks with appropriate care. Bone injuries take 6-12 weeks. Chronic conditions need longer-term management.

What is Stress fracture?

Stress fracture 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 stress fracture 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 stress fracture 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 stress fracture 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.