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Conditions of the Foot
by Dr. Mark H. Tompkins


Sesamoiditis

 

Sessmoid (two small bones that reside under the big toe joint) + itis (inflammation) = Sessmoiditis.

Structure/Function

The sessmoid bones of the foot consist of two individual bones.the tibial - and the fibular -sessmoids. For more anatomical information regarding these bones, please visit the webpage. .

These two small bones function like tiny knee-caps under the big toe joint. They are intra-capsular structures attached to small muscles which function to help plantar-flex (move downward) the 1st metatarsal-phalangeal joint (big toe joint). These bones are of variable size and occasionally may consist of less than/more than 2 bones, which are normal inherited conditions. If there are two bones within an individual sessmoid bone it is referred to as a bi-partite sessmoid bone, three would be tri-partite, etc. Anatomical variations of these bones are fairly common and in the majority of cases, lead to no significant pain or problems.

Pathology

Sessmoiditis, or injury and resultant inflammation of one or both of these bones, is a common problem in the general population, with a higher incidence in active individuals, such as athletes, soldiers, or manual laborers. The etiology of sessmoiditis is the result of impact, or repetitive stress factors. The tissues surrounding the connection of these bones with the underside of the first metatarsal head become inflamed and cause acute (or chronic) pain with shoe gear and ambulation. The most common type of inflammation of the sessmoid bones is referred to as capsulitis. Other inflammatory conditions that may be associated with the sessmoid bones and their associated structures are: periostitis (inflammation of the tissues surrounding the bones); myositis (inflammation of the associated muscles); neuritis (inflammation of the associated nerves); and tendonitis (inflammation of the associated tendons). All of these inflammatory conditions cause significant pain directly under the big toe joint during the 'toe-off' portion of the human gait cycle. This typically causes a supinatory-type gait alteration which commonly is felt/observed as walking more 'on the outside' portion of the foot. This gait-alteration leads to undue stress and pressure on parts of the foot and lower extremity not customary during normal locomotion. Compensatory pain on the top and/or outside of the foot is common and many times leads to lower leg, knee, and/or hip pain. In addition to inflammatory conditions associated with the sessmoid bones, mention of another type of injury is worth noting. Due to the anatomically small nature of these bones, combined with their location (under the big toe joint) and resultant excessive forces distributed through these bones, fractures are a common injury. Two main types of fractures occur with sessmoid bone injuries. 1. An overt fracture is a distinctly identifiable fracture (on standard x-rays) that occurs within the body of the bone(s). It involves both the outer-shell, or cortex of the bone, and the inside, or the cancellous portion of the bone. 2. A stress fracture is an injury which occurs to the 'outside' of the bone(s) and predominantly injures the cortex, or outer shell of the bone, and many times is unremarkable on initial x-ray examination. There are varying degrees of stress fractures which occur within these bones. Individuals with anatomical variations within the sessmoid bone(s) are more prone to fracture injuries. Overt fractures of the sessmoid(s) are normally diagnosed through a complete patient history, a thorough physical exam, and standard foot x-rays. However, stress fractures of the sessmoid(s) are sometimes much more difficult to discern. Many stress fractures are unremarkable on initial standard foot x-rays, and a diagnosis can only be confirmed through a specialized radiological examination referred to as a bone scan.usually a technetium99 triphasic scan.

Treatment

Treatment of sessmoid injuries is initially dependent upon proper diagnosis. Related conditions that may mimic sessmoid pathology include (but are not limited to): flexor hallucis longus tendonitis and/or injuries/ruptures; 1st MPJ capsulitis and/or injury;.; neuritis and/or nerve injuries of the plantar proper digital nerve(s); fractures and/or injuries of the first metatarsal head; and arthritic considerations including degenerative joint disease, gout, psoriasis, etc. Mild cases of sessmoiditis can typically be treated with accommodative padding either applied to the foot, shoe, or insoles, OTC and/or prescription insert/orthotics; and anti-inflammatory treatments such as physical therapy and oral medications (either OTC and/or prescription). Moderate to severe cases of sessmoiditis are treated with varying levels of immobilization from trauma shoes and cam-walkers, to BK casting with non-weight bearing, depending upon severity. Injection therapy is commonly used consisting of a local anesthetic and corticosteroids such as celestone or hexadrol. Also physical therapy and prescription-strength non-steroidal medications are used in conjunction with immobilization. In both cases, a reduction in the amount of physical activity is necessary to allow the sessmoid bones and related structures time to properly heal. This is followed by a progressive increase in activity with accommodative support consisting of shoe modification and/or insert/orthotics devices. Treatment of sessmoid fracture injuries is dependent upon the type and severity of the individual injury. Mild stress fractures are typically treated with an orthopedic trauma shoe or cam-walker/AFO (ankle-foot-orthosis) for a variable period of time, then progressive activity with shoe accommodation, insert/orthotics devices, and physical therapy. Moderate to severe stress fractures are most effectively treated with a BK (below the knee) cast with or without weight bearing for a period of from 4-6 weeks. Then progression into a trauma shoe or cam-walker with physical therapy, before returning to normal shoes and activities. Many times OTC and/or prescription shoe inserts (orthotics) are helpful in preventing re-injury to these structures. Overt fracture of the sessmoid bones commonly poses a precarious and sometimes poor prognosis. Mild overt fractures of the sessmoid bones are almost always amenable to BK casting and similar treatment regimens as utilized in moderate to severe stress fracture injuries. Severe overt fractures of the sessmoid bones..ones resulting in displacement of the fracture fragment(s) of the individual bone(s).can lead to disabling pain and significant gait alterations leading to resultant ankle, knee, hip, and/or back-related symptoms. Due to the location and exorbitant stresses placed upon these bones, combined with a poor blood supply, many times these fractures lead to non-, or mal-unions of these bones. Due to the above factors, it is very difficult to 'fix' these fractures surgically. Extended BK, non-weight bearing, casting is the treatment of choice for these fractures. If continued pain and symptomatology is demonstrated after appropriate immobilization is attempted, excision (removal) of the fractured bone(s) is usually the treatment of choice.

Conclusion

Sessmoiditis and related pathology of the sessmoids bones are a fairly common injury treated in Podiatric physicians offices. If you develop unremitting discomfort or pain under or within your big toe joint, it is a good chance that the sessmoids bone(s) are the culprit. If reducing your activity, wearing more supportive shoes, and/or using OTC inserts, does not relieve your pain, prompt medical attention is recommended. Mild cases of sessmoiditis can develop into debilitating forms or stress fractures and/or overt fractures of these bone(s) that many times leads to unnecessary surgery.

 

 

OTHER COMMON
FOOT PROBLEMS

Athletes Foot

Bio-Mechanical Pain

Bunions

Calluses & Corns

Diabetic Foot

Flat Feet

Hallux Limitus/Rigidus

Hammer Toes

Heel Pain/Heel Spur

Ingrown Nails

Metatarsalgia

Morton's Neuroma

Neuropathy

Orthotics

Plantar Fasciitis

Plantar Warts

Running Injuries

Sclerosing Injection Treatments

Sesamoiditis

Severs Disease

Shin Splints

Sweaty Feet/Odor

Toenail Fungus

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Dr. Mark Tompkins | 4402 Vance Jackson, Suite #146 | Phone: 210-341-2202

Copyright © 2001-2009 Dr. Mark H. Tompkins.  All rights reserved.