Painful sesamoid of the great toe

Abstract

The painful sesamoid can be a chronic and disabling problem and isolating the cause can be far from straightforward. There are a number of forefoot pathologies that can present similarly to sesmoid pathologies and likewise identifying the particular cause of sesamoid pain can be challenging. Modern imaging techniques can be helpful. This article reviews the anatomy, development and morphological variability present in the sesamoids of the great toe. We review evidence on approach to history, diagnosis and investigation of sesamoid pain. Differential diagnoses and management strategies, including conservative and operative are outlined. Our recommendations are that early consideration of magnetic resonance imaging and discussion with a specialist musculoskeletal radiologist may help to identify a cause of pain accurately and quickly. Conservative measures should be first line in most cases. Where fracture and avascular necrosis can be ruled out, injection under fluoroscopic guidance may help to avoid operative intervention.

Keywords: Sesamoid; Pain; Great toe; Management; Forefoot

Core tip: This paper is a review article examining available evidence on the anatomy, function and common variation in the sesmoids of the great toe. There is discussion of the presentation, history, examination, investigations and subsequent management of the patient with a painful sesamoid. We discuss the role of operative intervention. We recommend early use of magnetic resonance imaging and discussion with a musculoskeletal radiologist to assist in diagnosis. Conservative management should be the first line in most cases.