Sesamoiditis

DR. CONNIE LEBRUN, MPE, CCFP(SEM), DIP SPORT MED, FACSM PROFESSOR, DEPARTMENT OF FAMILY PRACTICE FACULTY OF MEDICINE & DENTISTRY UNIVERSITY OF ALBERTA EDMONTON, ALBERTA, CANADA Anatomy of Sesamoids

• Sesamoid “complex” laterally on plantar aspect of foot • Two seed-shaped bones within medial and lateral heads of flexor hallucis brevis • Also receive attachments from adductor and abductor hallucis tendons Function of Sesamoids

• Transfers up to 50% of body weight • Load can reach >300% during “push-off” of run • Sesamoid disorders account for 1.2% of running injuries – Boike et al., 2011 • Incidence during ultramarathon running not known Sesamoids and Gait in Runners

• Functionally lengthen the first ray during late stance phase of gait to enable smooth lateral to medial weight transfer throughout the foot

From Kindred et al., 2011 Epidemiology of Sesamoiditis

• Runners • Dancers (ballet) • Gymnasts • Catchers • Workers such as carpenters or electricians • High heel shoes!! Differential Diagnosis

• Bursitis • Chondromalacia • Tenosynovitis of FHL • Sesamoid fracture

• X-ray including sesamoid views (like Merchant’s or skyline view of the knee) • Bone scan, US, CT, MRI as needed Presentation

• Painful foot, walking on lateral plantar aspect • Sometimes swelling or bruising, crepitus • Plantar pain with passive dorsiflexion of the great toe • Weakness or pain with resisted plantarflexion Pathology • Sesamoiditis (30%) – No radiological findings – Crepitus, tenderness and pain with extension of first MTP • Osteochondritis (10%) • Acute fracture (10%) • Chronic stress fracture (40%) – Most commonly in tibial sesamoid (larger, more WB) • Bursitis (5%), OA (5%) • A bipartite or multipartite sesamoid occurs in 5% to 33% of the population Sesamoiditis/Stress Fractures in Dancers

• Ballet – Readiness for “en pointe” • Tap • Jazz • Hip-hop** • Irish step dance • Ballroom • Competitive dance From Wilson et al. 2015 Rehabilitation in Dancers

• “Relative rest” • Cross-training • Dance-specific: – Adequate healing, ROM, flexibility, strength & balance • Technique: – Alignment, quality of Reformer (foreground) used movement, proper in dance rehabilitation setting muscle recruitment, prevention of From Wilson et al. 2015 compensation habits Treatment of Sesamoid Disorders

• Unload 1st MTP • Restrict impact type activities • Metatarsal pad or bar or orthotic with cutout • May need to be non- WB-ing until tenderness resolves - 6 weeks for stress fractures (high risk of non-union) • Corticosteroid injection • Excision Surgery for Sesamoid Disorders

• Partial sesamoidectomy • Complete sesamoidectomy • Bone grafting of sesamoid nonunion • Potential long-term biomechanical consequences • Small studies: – 5 athletes treated with partial sesamoidectomy for nonhealing stress fractures, all RTP within 6 months • Biedert and Hintermann 2003 – successful return to sport after a sesamoidectomy in a small cohort • Saxena and Krisdakumtorn 2003 References

• American Academy of Orthopaedic Surgeons [Internet]. Sesamoiditis. Accessed at orthoinfo.aaos.org/topic.cfm?topic=A00164. Accessed on December 7, 2016. • Biedert R, Hintermann B. Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. 2003; 24:137-41. • Boike A, Schnirring-Judge M, McMillin S. Sesamoid disorders of the first • metatarsophalangeal joint. Clin. Podiatr. Med. Surg. 2011; 28:269-85, vii. • Kindred J, Trubey C, Simons SM. Foot injuries in runners. Curr Sports Med Rep. 2011; 10:249-54. • Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy • in athletically active individuals. Foot Ankle Int. 2003; 24:415-9. • Wilson JC et al., Athletes doing arabesques: important considerations in the care of young dancers. Curr Sports Med Rep. 2015;14(6):448-454.