sesamoiditis not healing

diagnosed in april as sesamoiditis have done all conservative measures stayed off foot for about 6 weeks then in a boot for another 8 weeks physical therapy exercises just got a cortisone shot on Monday have custom orthotics with cutout for sesamoid area still have discomfort when in a shoe and walking I have been off work since april I work for the usps as a carrier my route is pretty much all walking i've been doing this for 22 years I have been denied workers comp I'm almost out of sick and annual leave money is going fast paying for all this I really need a solution so what I'm asking I suppose is surgery my only other option?

RESPONSE

Hi,

There are very few instances where removing the sesamoid bone is recommended, but, you may be one of those cases.

For some people, the sesamoid bone may just be in the "wrong" place, meaning it is either a little too far forward and you are actually bearing weight on the bone, or you happen to have large sesamoid bones relative to someone else of comparable size, so your sesamoid bones are constantly being "traumatized", or perhaps you have what is known as a bipartate sesamoid which instead of having one sesamoid bone, you actually have two, which would also make the bone relatively larger.

In any event it is making it impossible for the problem to resolve.

Another factor to consider is the amount of fat that you have on the bottom of your foot. Over the years, I have noticed that those individuals who have sesamoiditis which is difficult to alleviate, also generally have very bony feet with little fat under the sesamoids, so once again this small bone is constantly being traumatized when you walk.

And finally, the last consideration is how much motion you have in your big toe joint in its ability to move up and down. The sesamoid bones are actually located in the tendons that allow the big toe to bend downwards. So... if your big toe bends upwards to an excessive degree (which is usually a good thing in most individuals), that can create more pressure on the sesamoids and cause them to hurt.

From your narrative, it sounds like you have pretty much tried everything out there to quiet down the sesamoids. The only variables I am not sure of is your orthotics and the shoes that you wear.

You mention the orthotics have a sesamoid accommodation. I would like to know if it is thick enough to actually protect the sesamoids. I have seen plenty of orthotics where the accommodation is useless.

I would also like to know if your orthotics offer enough cushioning in the sesamoid area as well. For example, if the orthotics are of the plastic nature and the plastic has not been cut out in the sesamoid area, then they are part of the problem and not the solution.

Secondly, I would be curious as to the type of shoe that you wear to work. I assume it is a work boot, but is it rigid enough so your big toe does not excessively bend upwards? Is it cushioned enough to help take some of the pressure off the inflamed sesamoid?

Lastly, the final consideration is whether or not the sesamoid is fractured. Simple x-rays may not always reveal a fracture. You would require a bone scan or MRI.

If you have a fractured sesamoid, then that might explain the continued pain over the last four months.

Assuming your orthotics are as I described and you are wearing a rigid work boot, and you do not have a fracture, then you would have to consider having the sesamoid removed.

Sometimes, depending on the situation, the sesamoid can be shaved down to make it smaller which in theory would also eliminate the pain, but you would have to meet certain criteria and since I cannot examine you, I have no idea if you would meet that criteria.

The problem with having a sesamoid bone removed totally, is that it will change the dynamics of the big toe joint. Depending which sesamoid bone has to be removed, as there are two, your big toe could either start to deviate toward the second toe and create a bunion or it could deviate the other way which is also a problem.

What might eventually be necessary is the big toe joint might have to be fused.

It really is beyond the scope of this discussion to go into all the details of what you might be facing.

My suggestion would be to see at least two foot surgeons in your area, first have your orthotics and shoes examined. If they are as I hoped they would be, and, if you are in enough pain, then consider having the sesamoid surgery as long as you are aware of the potential benefits and pitfalls.

Marc Mitnick DPM
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