Background
Sesamoid injuries of the first metatarsal phalangeal joint in athletes occur with sports that place repetitive stress on the plantar aspect of the great toe. Performing artist athletes are particularly at risk for injury given the load placed on the hallucal sesamoid bone often inherent in the activity. Risk factors may include choice of sport, volume of training, sex, bone density, BMI and biomechanical profile of the lower extremity. Hallucal sesamoid evaluation and treatment remains poorly defined in the literature.
The aim of this study is to analyze all sesamoid injuries presenting to a sports medicine clinic. The goal of the study is to increase understanding of the injury profile, diagnostic evaluation, treatment regime, and return to sport of athletes with hallucal sesamoid injuries. The long-term goal is to develop evaluation and treatment algorithms that serve to guide clinical decision-making, and improve time to return to sport.
Methods
A comprehensive retrospective chart review was conducted of athletes presenting to a tertiary level sports medicine clinic located within a pediatric medical center. Electronic medical records were searched using the search term sesamoid. To be included in the study, the injury had to definitively involve the hallucal sesamoid and be related to sports participation. Exclusion criteria included patients with a chronic disease or condition that might affect bone healing or confuse the diagnosis of sesamoid injury, prior history of surgery to the foot, and insufficient management records. Descriptive statistics were used to analyze outcome variables including specific diagnosis, clinical prognoses, diagnostic imaging tools and treatment types. Additionally, a correlation analysis was performed for time from pain onset to first clinic visit, and time to return to participation. Little or no correlation was considered 0.00-0.25, weak correlation was considered 0.25-0.50, moderate correlation was considered 0.50-0.75 and strong correlation was considered 0.75 -1.00.
Results
326 athletes with 359 hallucal sesamoid injuries were identified. The mean age of the cohort was 15.8 ± 3.8 years (median: 15.3, 95% CIs: 15.46 – 16.24); 86% (n=309) were female and 14% (n=50) of the injuries were male. The mean BMI of the cohort was 21.28 ± 3.5 mg/kg2. Table 1 presents the sports for the athletes in the cohort. The leading sports included 40% (n=144) dance, 13% (n=48) running, and 13% (n=47) soccer. Activities that top the list for females include dance 44% (n=137) and running 13% (n=39). In comparison, male athletes participated in soccer (20%, n=10), running (18%, n=9), and football (10%, n=5) as well as other diverse sports.
The most common injuries across both sexes were sesamoiditis (30%, n=107), followed by sesamoid stress fracture (13%, n=46). Table 2 Where self-reported data on dance/sport practice time was recorded, 31% (n=65) reported practicing 10-15 hours per week. Figure 1 The average reported time between injury or the onset of pain to the first clinic visit was 143 days (median: 42, 95% CIs:116.87-169.15). The mean time between pain onset and first clinic visit was greater for female athletes as compared to male athletes (146 days and 119 days). The average time from first presentation to clinic to returning to participation was 115 days (median: 72, CIs:100.7-129.49). Spearman’s rho demonstrated a strong correlation between time from pain onset to first clinic visit and the time to return to participation in both males (? (rho) = 0.82, p < 0.001) and females (? = 0.79, p < 0.001). Males experienced a shorter duration from the first clinic visit to return to participation (mean: 72 days, median 33), than females (mean: 121 days, median 77).
The most common diagnostic imaging modalities used were radiographs (72.14%, n=259) and MRI (56.55%, n=203). In both males and females the most common initial treatments included a combination of: walking boot (51.53%, n= 185), physical therapy (38.72%, n=139), and activity modification (34.82%, n=125). These remained the most popularly prescribed treatments in the second and third treatments as well.
Conclusions/significance
Female athletes participating in dance and running, and male soccer, running and football athletes lead the list for injury to the hallucal sesamoid. Sesamoiditis and sesamoid stress fracture were the leading diagnoses in this cohort. Athletes who presented to clinical attention sooner also returned to sport/dance sooner when compared to athletes who delayed seeking medical attention. Continued research will serve to support anticipatory guidance and education surrounding hallucal sesamoid clinical presentation and need for timely evaluation and treatment in order to minimize time loss from sport/performing artist activity.
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