Sesamoiditis & Sesamoid Fracture Treatment 2026 | DPM

Sesamoid Anatomy and Function

The two sesamoids of the first metatarsophalangeal joint — the tibial (medial) and fibular (lateral) — are embedded within the two slips of the flexor hallucis brevis tendon. They articulate with the plantar facets of the first metatarsal head, functioning to protect the flexor hallucis longus tendon, distribute weight bearing across the first ray, and increase the mechanical advantage of the great toe flexors during push-off. The sesamoids bear up to 3x body weight during toe-off in running and significantly greater loads in jumping activities.

The tibial sesamoid is more prominently positioned and more commonly injured. Its blood supply enters primarily from the distal pole, creating a zone of relative hypovascularity at the proximal pole — the most common location for avascular necrosis (sesamoid osteonecrosis) following injury or chronic overloading.

Sesamoiditis vs. Sesamoid Stress Fracture: Critical Distinction

Sesamoiditis and sesamoid stress fracture present identically on clinical examination — both cause plantar first MTP pain with direct sesamoid palpation tenderness and pain with active toe dorsiflexion (loading the sesamoids through the flexor hallucis brevis). The distinction requires imaging.

Plain X-rays (weight-bearing AP, lateral, sesamoid axial view) identify displaced fractures and cortical disruption. However, stress fractures may appear normal on early X-rays, and the bipartite sesamoid can mimic fracture — the key radiographic distinction is that bipartite sesamoid fragments have rounded, sclerotic margins (chronic), while acute fractures have sharp, irregular margins. Comparison views of the opposite foot help when a bipartite sesamoid is suspected.

MRI is the gold standard when X-ray is inconclusive. It accurately demonstrates bone marrow edema in stress fractures, peritendinous soft tissue edema in sesamoiditis, cortical integrity, and any avascular necrosis signal changes. This distinction matters enormously — sesamoiditis resolves with weeks of conservative care; sesamoid fractures require 6-8 weeks of strict non-weight bearing in a boot; and sesamoid osteonecrosis may ultimately require sesamoidectomy regardless of conservative management duration.

Conservative Treatment for Sesamoiditis

Conservative sesamoiditis management is effective for most cases when the diagnosis is accurately made and treatment is appropriately targeted. The foundation is offloading — reducing the compressive and shear forces on the inflamed sesamoid with each step.

The dancer’s pad is a foam or silicone pad with a central cutout (aperture) placed on the plantar surface of the foot with the hole over the painful sesamoid. This offloads pressure from the sesamoid apex while distributing load to the surrounding tissue. Proper placement of the cutout directly over the sesamoid rather than the entire first MTH area is critical — too proximal misses the sesamoid, too distal loads rather than offloads it.

Custom orthotics with a built-in sesamoid cutout and first ray depression provide sustained offloading in all footwear — superior to adhesive pads for long-term management. A Morton’s extension (rigid extension under the hallux) combined with first ray relief reduces hallux dorsiflexion, limiting sesamoid loading during the toe-off phase of gait.

For acute sesamoiditis, a 2-4 week period of reduced activity and short-term immobilization (stiff-soled shoe or brief boot use) settles the inflammatory phase. Corticosteroid injection adjacent to the sesamoid — placed carefully to avoid intratendonal injection — provides significant relief in refractory cases.

Sesamoidectomy: When and How

Surgical sesamoidectomy is reserved for chronic sesamoiditis or sesamoid fracture/osteonecrosis unresponsive to 3-6 months of appropriate conservative care. The tibial sesamoid is removed more commonly; the fibular sesamoid is removed only when isolated fibular pathology exists, as tibial sesamoidectomy alone usually provides adequate relief.

Surgical technique is critical: aggressive retraction of the flexor hallucis brevis insertion must be avoided to prevent hallux flexion weakness and potential hallux valgus deformity. The sesamoid is removed through a plantar medial incision with careful preservation of the FHB tendon attachment and the sesamoid ligaments. Outcomes: 80-90% pain resolution. Risk of hallux deformity with aggressive technique is approximately 5-10% — meticulous preservation of the tendon insertion minimizes this risk.

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Frequently Asked Questions

How long does treatment take to work?

Most patients see improvement in 4-8 weeks with consistent conservative care. Persistent symptoms after 8 weeks need imaging and escalation.

When is surgery needed?

Surgery is reserved for cases that fail 3-6 months of conservative care, structural deformities, or fractures requiring stabilization.

Is this covered by insurance?

Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Custom orthotics often require diabetic or post-surgical justification.

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.