Painful sesamoid of the great toe

Magnetic Resonance Neurography of the Foot and Ankle

Peripheral neuropathies of the foot and ankle can be challenging to diagnose clinically due to concomitant traumatic and nontraumatic or degenerative orthopedic conditions. Although clinical history, physical examination, and electrodiagnostic testing comprised of nerve conduction velocities and electromyography are used primarily for the identification and classification of peripheral nerve disorders, MR neurography (MRN) can be used to visualize the peripheral nerves as well as the skeletal muscles of the foot and ankle for primary neurogenic pathology and skeletal muscle denervation effect. Proper knowledge of the anatomy and pathophysiology of peripheral nerves is important for an MRN interpretation.

Atraumatic Sport-Related Medial Sesamoid Pain: Conservative Treatment Outcome and Magnetic Resonance Imaging Features

Background

This study aimed to evaluate the effectiveness of conservative treatment in selected patients with atraumatic medial sesamoid pain (MSP) that developed during sports activities. The secondary aim was to determine the detailed underlying pathology in patients who did not respond to conservative treatment using magnetic resonance imaging (MRI).

Methods

From March 2015 to August 2022, we prospectively followed 27 patients who presented to our outpatient clinic with atraumatic sports-related MSP. The conservative treatment protocol for MSP included the use of oral analgesics, activity restriction, insole modification, local corticosteroid injections, and boot walker application with crutches. MRI was performed for all patients who experienced persistent pain despite the completion of conservative treatment.

Results

After the completion of the conservative treatment protocol, 48.1% of the patients reported a reduction in pain. Patients with younger age at pain onset (p = 0.001), higher body mass index (p = 0.001), and a bipartite medial sesamoid (p = 0.010) were more likely to experience persistent pain after conservative treatment. The type of sports activity was also a factor since running- and dancing-related MSP tended to respond better to conservative treatment compared to MSP originating from golf, futsal, and weightlifting with squatting. On MRI, 42.8% of patients showed no specific abnormal findings, with signal changes in soft tissues such as the subcutaneous fat and bursa being the most common, followed by intraosseous signal changes of the medial sesamoid bone and chondral or subchondral lesions of the medial sesamoid metatarsal joint (28.6% each).

Conclusions

Conservative treatment was successful in less than half of the patients who experienced MSP due to sports activity. Practitioners should be aware of the numerous possible causes of conservative treatment failure, such as bursitis, medial sesamoiditis, stress fracture, or chondral lesions between the medial sesamoid and metatarsal. MRI evaluation may be helpful in MSP patients who do not respond to conservative treatment.

Pediatric Foot: Development, Variants, and Related Pathology

Pediatric foot development throughout childhood and adolescence can present a diagnostic dilemma for radiologists because imaging appearances may be confused with pathology. Understanding pediatric foot development and anatomical variants, such as accessory ossification centers, is essential to interpret musculoskeletal imaging in children correctly, particularly because many of these variants are incidental but others can be symptomatic. We first briefly review foot embryology. After describing common accessory ossification centers of the foot, we explain the different patterns of foot maturation with attention to irregular ossification and bone marrow development. Common pediatric foot variants and pathology are described, such as tarsal coalitions and fifth metatarsal base fractures. We also discuss pediatric foot alignment and various childhood foot alignment deformities.

Differences in running biomechanics and tibiotalar cartilage T2 relaxation time between runners with and without asymptomatic tibial sesamoid bone marrow edema - clinical case series

The impact of asymptomatic bone marrow edema (BME) in sesamoids on running biomechanics remains largely unknown, but exploring this relationship could aid early detection of forefoot-related injuries with cost-effective modalities. This study aimed to compare the running biomechanics of runners with asymptomatic BME in the tibial sesamoids with that of healthy controls. Four runners with asymptomatic BME in tibial sesamoids and four healthy runners participated. Lower extremity joint kinetics and kinematics were assessed along with plantar pressure while running at a self-selected speed. The T2 relaxation time of the tibiotalar cartilage was measured using MRI-derived T2 maps. Compared to the non-injured group, the injured group exhibited significantly lower plantar pressure under the hallux (p = 0.001), increased peak ankle rotation angles (p = 0.025), reduced ankle power generation (p = 0.049), and increased knee extension torque (p = 0.015). No significant differences in T2 values of the tibiotalar cartilage were observed. It appears that runners with asymptomatic BME adapted their running strategies by modifying their ankle biomechanics and reducing plantar pressure, even in the absence of pain. While the precise implications of these biomechanical alterations warrant further investigation, this study provides valuable insights into the relationship between asymptomatic BME and running biomechanics.

Magnetic Resonance Neurography of the Foot and Ankle

Peripheral neuropathies of the foot and ankle can be challenging to diagnose clinically due to concomitant traumatic and nontraumatic or degenerative orthopedic conditions. Although clinical history, physical examination, and electrodiagnostic testing comprised of nerve conduction velocities and electromyography are used primarily for the identification and classification of peripheral nerve disorders, MR neurography (MRN) can be used to visualize the peripheral nerves as well as the skeletal muscles of the foot and ankle for primary neurogenic pathology and skeletal muscle denervation effect. Proper knowledge of the anatomy and pathophysiology of peripheral nerves is important for an MRN interpretation.

Hallucal sesamoiditis on a bipartite sesamoid bone: An uncommon cause of chronic great toe pain

The pathologies and lesions affecting the sesamoid bones of the hallux are uncommon and can be easily overlooked. Among them, sesamoiditis is a relatively rare condition known to cause severe great toe pain; lack of awareness of this particular entity leads to misdiagnosis, delayed treatment, and contributes to significant morbidity. Herein, we present a chronic sesamoiditis case occurring on a medial bipartite sesamoid bone, presenting as chronic great toe pain. The main purpose of this work is to discuss the role of magnetic resonance imaging and X-rays in the diagnosis process. To the best of our knowledge, no cases of great toe sesamoiditis occurring on a bipartite bone in no-athletic patients have yet been reported.

A Rare Case of Exostosis of the Medial Sesamoid Bone

Introduction

Exostoses in the foot and ankle are extremely rare with no current literature of exostosis of the sesamoid bone.

Case Report

A middle-aged woman was referred to orthopedic foot surgeons following a long-standing issue of a painful non-fluctuant swelling beneath her left hallux with normal imaging. Repeat X-rays, with sesamoid views of the foot, were conducted due to the patient's ongoing symptoms. The patient underwent a surgical excision and made a complete recovery. The patient is now able to comfortably walk for longer distances with no restrictions to her mobility.

Conclusion

Conservative management should be initially trialed to preserve the foot's functions and limit the risk of surgical complications. As in this case, when surgical options are explored, it is critical to preserve as much of the sesamoid bone as possible to restore and sustain function.

Displacement of the Metatarsal Sesamoids in Relation to First Metatarsophalangeal Joint Extension

Background:

Quantifying normal sesamoid movement in relation to first metatarsophalangeal joint (MTPJ1) motion is essential to identifying aberrant kinematics and understanding how they may contribute to forefoot pain and dysfunction. The present study aims to report sesamoid displacement in relation to MTPJ1 extension and to compare sesamoid displacement with MTPJ1 range of motion (ROM) from several imaging modalities.

Methods:

Using 10 fresh frozen cadaveric feet, sesamoid displacement was evaluated during simulated MTPJ1 extension. The ability of 3 MTPJ1 measurement techniques (goniometry, fluoroscopy, and unloaded cone beam computed tomography [CBCT]) in predicting sesamoid displacement were compared. Kinematics were expressed in a coordinate frame based on the specimen-specific first metatarsal anatomy, and descriptive statistics are reported.

Results:

In the sagittal plane in both neutral and maximally extended positions, the tibial sesamoid was located on average more anteriorly than the fibular sesamoid. The angular displacement of the tibial and fibular sesamoids in the sagittal plane were 30.2 ± 14.3 degrees and 35.8 ± 10.6 degrees, respectively. In the transverse plane, both sesamoids trended toward the body midline from neutral to maximum extension. The intersesamoidal distance remained constant throughout ROM. Of the 3 measurement techniques, MTPJ1 ROM from CBCT correlated best (R² = 0.62 and 0.81 [P < .05] for the tibial and fibular sesamoid, respectively) with sagittal plane sesamoid ROM.

Conclusion:

The sesamoids were displaced anteriorly and medially in relation to increasing MTPJ1 extension. CBCT was the most correlated clinical imaging technique in relating MTPJ1 extension with sesamoid displacement.

Clinical Significance:

This study advances our understanding of the biomechanical function of the sesamoids, which is required for both MTPJ1 pathology interventions and implant design. These findings support the use of low-dose CBCT as the information gathered provides more accurate detail about bone position compared with other imaging methods.

High-Resolution Ultrasound of the Forefoot and Common Pathologies

Forefoot pain is common in clinical practice. Careful history taking and routine physical examination are initially performed for diagnosis, but imaging can confirm the clinical suspicion and play a key role in management. Ultrasound (US) can provide a visualization of the fine anatomy of the forefoot and is a useful method for evaluating various lesions causing forefoot pain. In this review, we provide the detailed anatomical structures of the forefoot and their normal appearances on US. We also focus on the most common pathologies affecting the forefoot, including plantar plate tear, sesamoiditis, bone fracture, synovitis, tenosynovitis, bursitis, Morton’s neuromas, and foreign bodies.

Concentrated Bone Marrow Aspirate Injection for Hallux Sesamoid Disorders

Concentrated bone marrow aspirate (CBMA) offers an alternative to sesamoid resection in end stage sesamoid pathology. CBMA potentiates the anti-inflammatory effect, stimulates local tissue regeneration and osteogenesis, when injected into bone. The purpose of this study is to evaluate the functional outcomes in a cohort of athletes following CBMA injection for the treatment of hallux sesamoid disorders. A retrospective case series of consecutive patients treated with CBMA injection for hallux sesamoid disorders were identified. Radiographs, Foot and Ankle Outcome Scores (FAOS), and Visual Analogue Scale (VAS) score were collected pre- and postinjections. Descriptive statistics were presented as the mean and standard deviation for continuous variables and frequency as percentages for categorical variables. Fifteen consecutive patients with were included with a mean follow-up time of 20.1 (range 12-34) months. Significant improvement in all scoring subscales of the FAOS and VAS score was noted preinjection compared to final follow-up postinjection (p < .001). Eight of 11 patients that were involved in sports prior to the CBMA injection returned to play, with 7 successfully returning to preinjury level status. Three patients required further treatment (20%). The case series suggests that CBMA injection is a safe and effective treatment option for hallux sesamoid disorders with a high rate of return to play.

Simultaneous medial and lateral hallucal sesamoid fractures in a basketball player mimicking bipartite sesamoid condition

Simultaneous fractures of the medial and lateral hallucal sesamoids from sports injuries are an extremely uncommon occurrences, with only one case reported in a hurdler. We describe an unusual injury in a basketball player resulting in simultaneous fractures of the medial and lateral hallucal sesamoid bones, a presentation, which we believe has not been reported before in the literature. With a growing interest in sports, the frequency of such injuries will undoubtedly rise. We highlight the clinical characteristics, biomechanical mechanism, role of complementary cross-sectional imaging in the diagnosis of hallucal sesamoid fractures. This case report emphasizes the need of high index of suspicion in reaching conclusive diagnosis of such rare injuries to prevent long term complications such as avascular necrosis or non-union and facilitate early return to sporting activities.

Hallux sesamoid complex imaging: a practical diagnostic approach

A wide variety of pathologies can affect the hallux sesamoid complex of the foot, including traumatic, micro traumatic, degenerative, inflammatory, vascular, infectious, and neoplastic conditions. Symptoms are quite nonspecific, mainly related to pain in the plantar surface of the first metatarsal head. In this context, imaging is important for the etiologic diagnosis of hallux sesamoid complex pathology with implications in patient management. The hallux sesamoid complex has a complex anatomy, and pathologic processes of this region are poorly known of radiologists. Besides, some entities such as "sesamoiditis" remain poorly defined in the literature. Schematically, conditions affecting sesamoids will be divided into two major groups: intrinsic anomalies (sesamoid bone being the center of the pathologic process) and extrinsic anomalies (diseases secondarily involving sesamoid bones). Thus, in this article, after a review of anatomical key points and pathologies affecting the hallux sesamoid complex, a practical multimodality approach for the diagnosis of hallux sesamoid pathologies will be proposed.

Functional Outcome of Sesamoid Excision in Athletes

BACKGROUND

Sesamoid injuries can have a significant effect on the ability of athletes to return to play. The literature shows mixed results with sesamoid excisions and the ability to return to sports.

HYPOTHESIS/PURPOSE

The purpose was to describe patient-reported outcomes and return to sports in athletes after sesamoidectomy with a proper surgical technique and a well-structured rehabilitation protocol. It was hypothesized that sesamoid excision would demonstrate reproducible and encouraging long-term patient outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients from a single surgeon's practice who underwent sesamoidectomy between January 2006 and September 2015 were identified. Medial sesamoids were excised through a medial approach, and lateral sesamoids were excised through a plantar approach. The plantar structures were adequately repaired after excision. The Foot Function Index-Revised (FFI-R), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey and Single Assessment Numeric Evaluation (SANE) questionnaire were also collected. Athletes were defined as those who participated in sports at a high school level or higher.

RESULTS

Of the 108 feet that met the inclusion criteria, 26 werelost to follow-up, leaving 82 feet for analysis at a mean 31.3 ± 26.0 months. There were 72 female patients and 10 male patients included in the final analysis, with a mean age of 44.9 ± 20.2 years. There were 54 medial, 18 lateral, and 10 medial and lateral sesamoid excisions. There were 26 competitive athletes with follow-up appointments (dancer, n = 12; pivot sport athlete, n = 8; runner, n = 6). Both the entire study population and the athletes demonstrated a significant improvement in SF-12, SANE, VAS, and FFI-R cumulative at the latest available follow-up (P < .05). Among the athletes, 80% were able to return to competitive sports at a mean 4.62 ± 1.01 months after surgery. The median satisfaction score among all patients was 97.5%. There was no difference in the success rate between the different etiologies at any of the follow-up intervals.

CONCLUSION

Chronic sesamoid pain is difficult to treat, but this study confirms that with a meticulous surgical technique and a dedicated postoperative rehabilitation program, encouraging patient-reported outcomes can be expected with a minimal risk of complications. Moreover, in the current study, 80% of competitive athletes were able to return to sports at a mean of 4.62 months after surgery.

Sports Imaging of Team Handball Injuries

Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

Radiological Study on Sesamoid Bones of the Foot among Omani Subjects

OBJECTIVES

The prevalence and appearance of sesamoid bones in the foot vary considerably among different populations and ethnic groups. We sought to evaluate the prevalence and distribution patterns of foot sesamoid bones among Omani patients referred for radiological investigation.

METHODS

We conducted a retrospective study among patients who had been referred for foot X-ray from January to December 2018. We used the chi-square test to determine the gender and age influence on the prevalence of sesamoid bones, and the Spearman's correlation coefficient to assess the coincidence of specific distributions of sesamoid bones at the metatarsophalangeal (MTP) joints.

RESULTS

A total of 774 foot radiographs composed of 442 right foot radiographs and 332 left foot radiographs were reviewed for the presence of sesamoid bones at MTP and interphalangeal (IP) joints of the foot. We observed a high prevalence rate of sesamoid bones at the fifth MTP joint (13.7%), and first IP of the great toe (9.9%). There were nine distinctive patterns of sesamoid bones. The coincidence of sesamoid bones at two or more MTP joints was 14.6%, with a high prevalence rate at first and fifth MTP joints (10.3%). Moreover, the prevalence rate of sesamoid bones increased with increasing age at the fifth MTP joint.

CONCLUSIONS

The prevalence of sesamoid bones in the foot is considerably high in Omani subjects and needs further prospective studies. Meanwhile, our findings could be helpful for clinicians to consider ailments of sesamoid bones during differential diagnosis in Omani patients who present with foot pain and discomfort.

The shape of the transverse arch in high heels while standing

Introduction

High heeled shoes have long been worn in society and they are known to cause biomechanical imbalances to not only the foot, but the whole musculoskeletal system. This study aims to show the detailed changes that happen to the shape of the transverse arch of the foot in high heels, using two different inclination degrees.

Methods

68 women participated in this study. Two custom-made high heels were made with inclinations of 15 degrees and 30 degrees (cm). A weight-bearing ultrasound was used to assess the coronal view of the transverse arch in standing. ANOVA and Tuckey tests were used to compare the results between 0 degrees, 15 degrees and 30 degrees inclinations.

Results

The transverse arch height was slightly increased as the heel height increased (0DI-15DI: p = 0.5852 / 15DI-30DI: p = 0.395 / 0DI-30DI: p = 0.0593). The transverse arch length (0DI-15DI: p = 0.0486 / 15DI-30DI: p = 0.0004 / 0DI-30DI: p = 0.1105) and the area under the metatarsal heads (0DI-15DI: p = 0.0422 / 15DI-30DI: p = 0.0180 / 0DI-30DI: p = 0.9463) significantly decreased as the heel height increased.

Discussion

The main changes were viewed in the 30 degrees inclinations compared to 0 degrees inclination. When the toes are dorsiflexed in high heels, it stimulates the Windlass mechanism which in turn stiffens the plantar fascia and adducts the metatarsal heads, while the soft tissues shrink in response to loads.

Conclusion

High heels affected the shape of the transverse arch even in short term standing, and these effects increased as the height of the heel increased.

The Pediatric Foot and Ankle

Foot and ankle pathology is common in the pediatric population. Common issues may be traumatic in nature, congenital, or age dependent. This article reviews common problems and pathology found in the pediatric foot and ankle.

Hallux sesamoid fractures in young athletes

Objective: To describe the evaluation, management and recovery time of hallux sesamoid fractures in young athletes.Methods: A retrospective chart review was performed in a large academic teaching institution over a 5-year period (1/1/2010-12/31/2014). All patients with a sesamoid injury were initially included. Excluded were those patients who: 1) did not receive the diagnosis of hallux sesamoid fracture, had a history of prior foot surgery, or had medical records inadequate for analysis, 2) had missing or unclear diagnostic imaging, 3) were age >21 years, or 4) did not report sports participation. Descriptive statistics were employed to analyze the data.Results: Fifty-eight patients (51 females and 7 males) with a mean age of 15.4 years (range: 9-21) were identified with a total of 59 sesamoid fractures. Dancing (37.9%), running (13.8%), and gymnastics (13.8%) were the most common sports reported among these patients. A greater number of fractures were classified as repetitive stress injuries (83.1%), rather than acute traumatic injuries (16.9%). Fractures were treated conservatively in the majority of cases (89.8%), and only six fractures (10.2%) were treated surgically. Most patients (84.7%) were able to return to sports and activities. The average time from diagnosis/start of treatment to pain-free state/cleared to return to sport was 161.4 days.Conclusion: Diagnosis of sesamoid fractures can be challenging, but overall most patients do well with conservative treatment and are able to return to sports and activities. Providers should keep sesamoid fracture in the differential when evaluating patients with pain in the area around the base of the first toe, especially in dancers, gymnasts, and runners. Understanding that the recovery from a sesamoid fracture can be a prolonged process may help patients develop realistic expectations.

Sesamoid osteonecrosis treated with radial extracorporeal shock wave therapy

Sesamoid osteonecrosis is a disabling condition resulting in severe forefoot pain, for which there are limited treatment options. We present a 52-year-old man with 1-year history of pain, aggravated by walking and playing tennis. On examination, pain was localised to plantar aspect of the first metatarsophalangeal joint. Imaging revealed evolving end-stage avascular necrosis of lateral sesamoid with early secondary degenerative changes. Previous exhaustive conservative treatment had been unsuccessful in alleviating his pain. As an alternative to surgery, radial extracorporeal shock wave therapy (rESWT) was proposed. Treatment protocol was 2000 pulses at frequency of 5 Hz, and pressure was varied from 1.2 to 1.8 bar according to patient tolerance. A total of eight sessions were delivered. At completion of treatment, the patient reported minimal discomfort to no pain and was able to return to playing tennis with no recurrence. We propose rESWT to be an effective novel conservative treatment for sesamoid osteonecrosis.

Radial Soundwave for Sesamoidopathy in Athletes: A Pilot Study

The purpose of the present study was to evaluate the efficacy of radial soundwave therapy (RSW) for the management of sesamoiditis, symptomatic bipartite sesamoids, and avascular necrosis in athletic patients. The data from 10 patients undergoing RSW for sesamoiditis were retrospectively studied. Three treatments at 2.4 Bar and 13 Hz, for a total of 2500 pulses in each session, were administered to the affected sesamoid approximately 1 week apart. The Roles and Maudsley score and the visual analog scale (VAS) were used to assess disability and pain. An overall improvement was seen in reported pain after RSW. The pretreatment VAS score was 5.9 ± 1.7 and the post-treatment VAS score improved to 2.3 ± 2.4 (p = .0001). The activity pretreatment Roles and Maudsley score was 3.1 ± 0.3 and the post-treatment score was 1.5 ± 0.7 (p = .00003). All but 1 of the patients (90%) reported some or complete relief of pain. The mean time to return to activity was 10.1 ± 15.6 weeks, although this value was biased by 1 patient requiring 1 year to return to activity. Eliminating this patient, the average time to return to activity was 5.4 ± 5.6 weeks. Three patients in the cohort did not have to stop their desired activity at all, including 1 gymnast and 1 runner. Of these 3 patients, 2 (20% of all patients) reported complete relief of pain (VAS score of 0) after treatment. The third patient experienced a significant decrease in pain, with the VAS score, improving from 7 to 1. The results of the present study have demonstrated that RSW can be a viable treatment of certain symptomatic sesamoid pathologies and can be considered a valid alternative to surgery.