Patient With Chronic Sesamoiditis

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Patient Info: 21 yo male presented recently after a two-year journey with lateral sesamoid pain. This started due to him running without enough rest. The following conservative treatments have been implemented.

• Shockwave therapy (3 sessions)
• Knee scooter for 3 months (slight relief)
• Walking book for 2 months
• 1 marcaine injection (he had this injection without ultrasound guiding and is having more pain than pre-injection, this is why he initially visited me)
• PT twice (only irritated the sesamoid area more)
• Daily contrast baths for years
• Custom orthotics and dancer pads (tried two different orthotics with no significant relief) he says the biggest improvement of any conservative therapy was using "altra" zero drop shoes

His foot shape is normal and shows no deformity other than a slight baker's bunion. He has full range of motion in the hallux and does not have any pain as I test his range of motion. He has pain when dorsiflexing the hallux only if he applies pressure to the bottom of the toe. No pain when not active. Under and slightly behind the lateral sesamoid area he has a small lump that appears as he dorsiflexes the hallux. He has no pain when I palpate the lateral sesamoid area which leads me to doubt myself.

Additionally he has had 2 MRI's and 2 x-rays. The first MRI showed significant inflammation in the lateral sesamoid but no break. The second MRI is included below and shows that the sesamoid is still inflamed but the internal structure seems to be damaged. Both x-rays were unremarkable.

As of now walking is very difficult for him unless he compensates significantly. I am considering a lateral sesamoidectomy but worried there might be something I'm missing. He recently left his work that requires standing and is hoping his newfound rest will help.

 

The lateral sesamoid pain is a symptom. Treating the symptom without determining the cause will lead to failure. You must identify the cause and treat that cause directly.

Run a treadmill analysis.

• At heel contact is the calcaneus pronated, and at full foot contact the ILA collapse to the ground? If so, you may be dealing with a PreClinical Clubfoot deformity.

• At heel contact is the ILA contour intact, but at midstance, prolapses? If so, you may be dealing with Rothbarts foot.

Either of these foot deformations, if present, can result in a chronic inflammation of the sesamoid bone. Prescribe the appropriate proprioceptive insole All other interventions will fail.