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Hi, I am a Physiotherapist from New Zealand. I have encoutered some sesamoiditis in my practice but most have resolved with conservative treatment including padding and activity modification.

I am currently struggling with a case, my own. I know this forum is not meant for personal use, however I wish to gain a greater knowledge of the stabilizing structures of the first MTPJ. If possible could respondents please provide references to direct me.

Female 27, I have extremely cavus feet and a history of recurrent ankle sprains on my left (injured side). Previously very active before my foot gave out on me. Now I am an aquatic creature yearning to run on land again.

It all started when I was 22 when I started getting pain under the ball of my left foot. Unfortunately I was one of those people that played (competitive soccer and triathlons) through the pain. During soccer training involving jumping drills… my sesamoid gave out.

I was diagnosis with a fibular sesamoid fracture (left) and after spending months in a POP and moon boot the fracture did not heal. The pain was localised to the plantar aspect of my foot fibular sesamoid location.

The surgeon was concerned about the other sesamoid giving out and so performed a dorsiflextory wedge osteotomy along with a plantar approach excision of my fibular sesamoid.

The recovery went well, although the end result was worse because of the angle alteration of the metatarsal. After 16 long months of walking the speed of a tortoise the dorsiflextory wedge osteotomy was reversed using a calcaneal bone graft (ouch).

The recovery from the second surgery went well and I am now able to walk 30 minutes at a medium pace without significant pain if I use my good (right) foot to provide the main propulsion (push off) I am also suffering from medial knee pain on my left (bad) side as a result of the sesamoid removal. How does the removal of a sesamoid (fibular) affect the biomechanics of the lower limb?

Aggravating/Easing Behaviours
Agg = Well.. walking (pushing off) on my forefoot. Sore with movement – lingers for about 30 minutes after forced extension
Uphill and downhill
Ease = nil (not moving it)

24 Hour Pattern
No AM pain. Mechanical based.

Main Area of Pain
Plantar Aspect joint line and medial aspect of MTP joint.

Subjective/Objective Measures
Joint feels “looser” there is actually GREATER range of movement (extension) on the operated side (left). I am able sublux the MTP joint dorsally and laterally. I can sublux the joint by flex/ext occasionally and also by applying a miniscule amount of force directed post-anteriorly and pressing laterally. Also I am unable to “crack” my left MTP. I used to be able to crack both MTPJs. Also when flexing both MTPs the biomechanics are not symmetrical. For example in my good (right) foot it seems as though the MTP pops up (dorsally) whereas in my bad foot (left) the MTP does not.

Diagnostic/Clinical Tests
An MRI performed last year (before surgery 2) confirmed that the plantar plate is intact
Positive Anterior Drawer (instability) Test of the MTP
Films – there is joint space and no osteophytes seen. Tibial sesamoid intact. Position ?

Conservative Treatments
I have tried countless orthotics in consultation with my Podiatrist, but he does not believe any orthotics can fix my lose, subluxing MTP joint.

Goals
Running (my ultimate goal) occasionally is attempted but never for greater than 2 minutes and followed by 2 days of pain in the MTP joint.

My Interpretation
My MTP joint in loose due to the disruption of the capsuloligamentous structures while excising the fibular sesamoid. The adaptive way to walk without causing pain is putting more pressure on the medial aspect of my MTP and also causing medial knee pain.

Proposed 3rd Surgery
My orthopaedic surgeon is proposing that an hallucis adductor tendon transposition might provide my toe with some stability. He can also tighten up the lateral capsule at the same time.

My Question
1. How would transferring the Hallux Add tendon help provide stability to the joint? This has been reported in the literature with Hallux Abd and Medial sesamoidectomy (McCormick and Anderson, 2009) but I could not find anywhere in the literature regarding isolated hallux add tendon transposition post fibular sesamoidectomy. Please help.

Thank you very much for reading. I look forward to some insight.

McCormick and Anderson. 2009. The Great Toe: Failed Turf Toe, Chronic Turf toe, and complicated sesamoid injuries. Foot and Ankle clinics of North America.

Lynne

Interesting case, pity its you though!

Honestly (from the information supplied)...I think the 3rd surgery will not assist you.

The dynamic forces are too great, your foot type (cavus) is too complex, and the only reliable procedure for 1st MTPJ instability post sesamoidectomy is a 1st MTPJ fusion.

From a physiotherapy perspective this sounds horrible. From a podiatry perspective it is not so bad. People run marathons with 1st MTPJ fusions.

Yes, sagittal plane movement is compromised, but you tend to compensate for this adequately through the IP joint of the hallux over time.

I would seek further surgical opinions, perhaps podiatric and orthopaedic, before making a decision.

LL

__________________
*****************************************
Remember, it's just a foot.

A fibular sesamoidectomy done by a competent foot surgeon is the only surgical procedure you needed in the first place. I have never seen a fibular sesamoidectomy cause the problems you describe and no foot surgeons that I know would peform a dorsiflexion osteotomy of the first metatarsal while also performing a fibular sesamoidectomy. Like LL, I agree that you now you need an arthrodesis procedure of the 1st metatarsophalangeal joint. I have a patient who is 60+ years old doing iron-man triathlons (Hawaii, etc) that I did an arthrodesis on a few years ago. Don't worry, contrary to what sagittal plane theorists believe, a restriction of hallux dorsiflexion motion will not produce a flat foot deformity. Have the surgery done by someone (probably by someone other than your current surgeon) that does them routinely and you should have no problem. Good luck!!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Related threads:
Other threads tagged with sesamoiditis

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Hi Lynne:
I agree with Kevin, in retrospect the DFWO on the first Met was unnecessary.
The angle and length of the first met is rather important. In a young active athlete like yourself the Dorsal wedge was a tricky proposition.

Your overall length of the first met, even after a graft, is most likely shorter than you started with, causing laxity in the 1st MTPJ.

Was the Fibular sesamoid removed through a dorsal or plantar incision?
Why do you feel the capsular elements of the first MTPJ were disrupted by this procedure?
How is the strength of the FHL?
Does your hallux purchase the ground on static stance?
What is your activity level now?
What actually hurts when you are running?

Steve

PS:

Don't let anyone remove your remaining sesamoid!

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Thank you DrSArbes for your reply

To answer some of your questions:

-The fibular sesamoidectomy was performed with a plantar incision (for better exposure) has healed very well.

-I feel the lateral structures MAY have been disrupted because of the varus instability of the MTP joint. The capsulo-ligamentous structure MAY have also become lax due to chronic synovitis after the first surgery (sesamoidectomy & DFWO)

-The strength of the FHL is pretty good, however not symetrical. The EHL COULD be unmatched by weaker FHL contributing to the dorsal subluxation.

-My hallux purchases "slightly" off the ground. I can only tell looking closely at pictures I have taken, therefor minor.

-Activity Level - I have turned into an aquatic creature. I swim for fitness. I can go for walks but do not fully push off on my left. I compensate by predominantly using the strength of my right for main propulsion. This is tolerable currently.

-Area of Pain -the plantar aspect underneath the MTP is the main source of pain. It feels as though it is pain on the joint line more distal (towards the phalanx) than the tibial sesamoid.

In retrospect, yes, the DFWO was unnecessary, as evidenced by the huge improvement after it reversed. I think it is amazing the difference 1 or 2 mm has on MTP function. I did have several independent orthopods examine my foot and both recommended a sesamoidectomy and DFWO. I believe it was because my extremely cavus foot was always recorded as a "deformity" instead of an extreme variant of normal.

My next port of call would be to get some lateral weight bearing films taken to see if the metatarsal is back to its original length and angle and then go from there.
Pinning the lax structures (like a shoulder) with an adductor transfer MAY help to tighten the structures that have been “loosened” by the change in the angle and length of the metatarsal.

If is doesn't work... there is always fusion. How successful is fusion with an extremely cavus foot?

Thank you for your interest.

Cheers.