SESAMOID STRESS FRACTURES
(diagnosed 12/8/09)

Obssessively Researching the Injury!

Six to eight weeks of relative rest will allow most stress fractures to heal. But Dr. Francis O'Connor and Dr. Robert Wilder, authors of the "Textbook of Running Medicine," note that navicular stress fractures, proximal fifth metatarsal fractures and sesamoid fractures require careful medical supervision, casting and, in some cases, surgery.

LEAH'S X-RAYs

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GALLERY OF OTHER X-RAYS FOUND IN MY RESEARCH

tibial (medial) sesamoid (more commonly injured) and fibular (lateral) sesamoid

Stress fractures of the great toe and sesamoids are seen less frequently than other sites of stress-related injury, but when they do occur the diagnosis may be more difficult, resulting in a delay in diagnosis if this injury is not considered [8]. Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Athletes who have pain in the first metatarsophalangeal joint and who are exposed to excessive running, jumping, and repeated forced dorsiflexion of the first metatarsophalangeal seem to be predisposed to this injury [21]. As with stress-related injury in other locations, the symptoms typically occur during training without a history of trauma. Approximately 1% of all running injuries involve the sesamoids; 40% of these are stress fractures and 30% are sesamoiditis [22]. Sesamoiditis/osteochondritis, avascular necrosis, stress response of the synchondrosis of partite sesamoid bones, traumatic fractures, osteomyelitis, and bursitis between the tibial sesamoid and the tendon of the flexor hallucis brevis may all occur in this location. One or both sesamoid bones may be involved. Plain films are commonly normal. Nuclear scintigraphy may show focal increase radiotracer activity over one or both sesamoid regions. MRI of sesamoid stress response and stress fractures most commonly shows low T1 signal intensity and increased signal intensity on T2 and short-tau inversion-recovery (STIR) sequences (Fig. 1A, B). MRI signal alterations of stress response of sesamoids and sesamoiditis overlap. Increased STIR signal intensity and low T1 signal have been described with sesamoid stress response, as opposed to increased STIR signal intensity and normal T1 signal, which favor sesamoiditis. Sesamoiditis also more commonly involves both sesamoid bones, and may be associated with bursitis, tendinosis, and tenosynovitis [23,24].

Treatment typically involves avoidance of physical activity and attention to predisposing extrinsic factors such as footwear [25,26]. Hulkko and Orava [27] reported 15 cases of stress fractures of the hallucal sesamoids in athletes. The mean patient age was 22.3 years old. Nine patients were males and 6 were females. Eight fractures involved the medial sesamoid, six involved the lateral sesamoid, and in 1 patient both sesamoids were involved. Ten patients were treated conservatively. Five patients required surgical excision of the fragmented involved sesamoid and gradually returned to training 6 to 8 weeks after surgery. Pathology confirmed fibrotic nonunion of the stress fractures [27].

Saxena A, Krisdakumtorn T (2003). Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int 24(5): 415-9.
Sesamoidectomy of the first metatarsophalangeal joint in athletically active patients may be indicated in cases of chronic sesamoiditis resistant to nonsurgical care or symptomatic displaced fractures or nonunion. Painful scar, hallux deviation, and delayed return to activity
are all potential complications. These need to be considered especially when performing surgery in the athletically active individual. Twenty-six sesamoidectomies in 24 patients (21 females and 3 males) were reviewed for type of sesamoidectomy, incision location, time to
return to activity, and complications. Mean age was 35.4 years (range, 16-68 years) with mean follow-up 86.4 months. Eleven athletes (defined as professional or varsity level sports) operated on had a mean return to activity of 7.5 weeks (range, 4-10 weeks), while 13
"active" patients had a mean return to activity of 12.0 weeks. This difference was statistically significant using the t-test, (p < .02). There were 10 fibular and 16 tibial sesamoids excised. Complications included one hallux varus and two cases of postoperative scarring with
neuroma-like symptoms, all associated with fibular sesamoidectomy; there was one case of hallux valgus deformity with tibial sesamoidectomy. Despite the functional importance of tibial and fibular sesamoids, athletically active individuals can return to sports after a
sesamoidectomy as early as 7.5 weeks

Richardson EG (1987). Injuries to the hallucal sesamoids in the athlete. Foot Ankle 7(4): 229- 44.
The sesamoids of the great toe, which are small and seemingly insignificant bones, can be the site of disabling pathology for the athlete. Sesamoiditis, osteochondritis, partite sesamoids with stress fractures, displaced fractures, and osteomyelitis have all been
reported in the athlete. Bursitis beneath the tibial sesmoid and flexor hallucis brevis tendonitis also occur in the athlete and may be confused with sesamoid injury. Excision of the involved bone is the recommended treatment for displaced fractures and for less severe
conditions such as sesamoiditis, osteochondritis, and nondisplaced fractures, if conservative management fails to relieve symptoms..

Lee S, James WC, et al. (2005). Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int 26(10): 803-9.
BACKGROUND: Functional loss and clinical evidence of hallux malalignment have been reported to follow isolated tibial sesamoidectomy. METHODS: Thirty-two patients with isolated tibial sesamoidectomies were identified. Patients with a diagnosis of peripheral
neuropathy, diabetes mellitus, inflammatory arthropathy or previous foot surgery were excluded as were patients who had concomitant joint realignment procedures. Twenty patients were available for followup with the Short Form-36 (SF-36), Foot Function Index
(FFI) disability scale, visual analog scale (VAS), and questionnaire at an average of 62 9 (range 10 to 157) months after surgery. Fourteen patients returned for physical examination, radiographs, and pedographic and isokinetic examination. RESULTS: Physical examination
of the 14 patients did not reveal any significant change in clinical alignment, range of motion or tenderness. Preoperative and postoperative comparison radiographs did not reveal significant differences in the intermetatarsal (IM) angle, hallux valgus (HV) angle distal metatarsal articular angle (DMAA), or sesamoid alignment (sesamoid station). Postoperative outcome measurements (VAS, SF36, and FFI) for 20 patients found significant relief of pain and improved functional outcome. Computerized dynamic pedographic measurements (Performance Orthotic) for 12 patients did not reveal any altered plantar pressures in the region of the hallux metatarsophalangeal joint. Isokinetic measurements of ankle plantar flexion push-off strength in eight patients did not reveal significant differences in side-to-side measurements. Eighteen of 20 (90%) patients indicated that they were able to resume all preoperative activities; six (30%) had extreme difficulty or an inability to stand on tip toe, but this did not impact their activities of daily living or their athletic endeavors. Two patients (14.3%) developed transfer metatarsalgia, but only one was symptomatic. CONCLUSION: Isolated tibial sesamoidectomy is a safe and effective treatment for recalcitrant tibial
sesamoiditis. Hallux malalignment and deformity resulting in functional loss and change in hallux alignment can be avoided by meticulous surgical technique with repair of the soft tissues.

Biedert R, Hintermann B (2003). Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int 24(2): 137-41.
The purpose of this study was to determine whether specific symptoms and findings are present in patients with symptomatic stress fractures of the sesamoids of the great toe and, if so, whether partial sesamoidectomy is sufficient for successful treatment. Five consecutive
athletes (five females; mean age 16.8 years [range, 13 to 22 years]) with six feet that were treated for symptomatic stress fractures of the sesamoids of the great toe were included in this study. Four athletes (five feet) performed rhythmic sports gymnastics; the fifth athlete
was a long jumper. Some swelling to the forefoot and activity-related pain that increased in forced dorsiflexion, but disappeared at rest was found in all patients. While plain X-rays evidenced fragmentation of the medial sesamoid, MRI (n=2) and frontal plane CT scan
(n=3) did not always confirm the diagnosis, but bone scan (n=3) and axial as well as sagittal CT scan were useful to detect the pathology. After failure of conservative treatment measures, surgical excision of the proximal fragment was successful in all patients, and
there were no complications. All patients were pain free and regained full sports activity within six months (range, 2.5 to six months). At final follow-up which averaged 50.6 months (range, 20 to 110 months), the overall clinical results were graded as good/excellent in all
patients, and there was only one patient with of restriction sports activities. The obtained AOFAS-Hallux-Score was 95.3 (75 to 100) points. Apparently, stress fractures occur more often at the medial sesamoid, and females are mainly involved. When a stress fracture is
suspected, bone scan and CT scan are suggested as more reliable in confirming the diagnosis than other imaging methods. When conservative treatment has failed, surgical excision of the proximal fragment is recommended. Blundell CM, Nicholson P, et al. (2002).