Sesamoids: Broken or Normally Just in Pieces




 

Here the inside or medial or tibial (same name for the same bone) sesamoid appears broken into 2 pieces, but is it? Sometimes, these sesamoids never completely become whole, and they are in 2, 3, or 4 pieces. This can be there natural condition and can make the diagnosis of a broken sesamoid difficult at times. With this preclude, here is a recent email I received.

Dr. Blake,


Here is a fun one for you... debating on tripartite sesamoid vs. sesamoid fx.

Personal history, I'm a 28yo female who is fairly active. I danced from childhood through college. Within the past year I have started running and completed my first half marathon on April 10, 2011. I am also a chiropractor who is on my feet most of the day and in various squat and lunge positions when I am adjusting patients. Needless to say, I'm hard on my feet.


While training for my half marathon the only foot problems I had was blisters. After I finished my half, I had pain all over my feet, I attributed this to blisters (since I had SEVERAL). I did not run any the week after my half. I teach dance one night a week, and did not notice any unusual pain during this week. One week after the half I ran a 5K, after this I noticed some soreness under the ball of my foot on the medial side. This was mainly a pulling/stretch then I extended my toes. That following Thurs, I trained with a running group, and we sprinted hills. I pushed it! We sprinted up hill forward 5 times and backward 3 times. I'm not sure exactly when I noticed the pain changing, but a couple days later I realized that standing in releve' (on the balls of my feet) was unbearable (I could only stay there for about 2 seconds, typically it's doesn't bother me at all).

Since then I have not ran, and I am very careful while teaching dance and adjusting. Since it is not getting any better, I have started to play around & look up more things. I have pinpoint tenderness under the fibular sesamoid, the rest of my foot is normal. When I passively extend my toes it hurts but not unbearable. If I flex my 2nd toe against resistance (while keeping my big toe neutral) I have intense pain right at the sesamoid in question. I have had to alter the way I adjust because one of my typical stances has my right foot in a lunge behind me, and can't get enough power from that foot due to the pain right now. (I'm just under 5'4", so I have to use my entire body to adjust some of my patients.) Tuning fork on and around the affected area is negative.


I have attached 2 different pics of the AP x-ray. I apologize they are not the best pics. Due to the fact that tripartite sesamoids are typically bilateral, I will take a XR of my left foot to check that. (I have to get back to our main office to take the x-ray.) Other things I have came across are that bipartite and tripartite sesamoids are typically on the medial sesamoid, while mine is on the lateral. I do have some other congenital anomalies in my spine, so having them in my feet wouldn't surprise me.

I have been icing, trying different taping, and not working out. (However it's not getting any rest when I'm working.) I did your kinesiotaping this morning, however it really didn't restrict my big toe extension. Any suggestions?

While researching this topic, I came across your page, and decided I'd share with you my story. Have a great day!

Tiff

Tiffany's lateral or fibular sesamoid appears to be broken, but is it? The question drives radiologists and doctors crazy at times.

Tiffany, Thank you for the great email. Yes, it is a complicated question? Tripartite or broken? But what about both? You can break the cartilaginous bond between the sesamoids and it must be treated as a fracture. You can break the fibrosis bond between the sesamoid pieces and it must be treated as a fracture. You must treat the most dangerous possibility, because all docs live with patients that the misread the sesamoid injury, thinking it was just bipartite or tripartite, and were wrong. These end up needing surgery, which could have been avoided. These may end up with some disability, which could have been avoided. My protocol now, and it has taken me 30 years of practice to get here, is to get a MRI of possible sesamoid fractures. If this is still questionable, then get a bone scan to look for hot spots. If this is still questionable, get followup xrays in 6 weeks. Fractures tend to show a changing pattern in the bone, even on xray. Since it is the fibular sesamoid, get an Oblique and Plantar Axial xrays which show it well.

     Tiff, you have a classic pattern on long 2nd metatarsal. Are you sure it is not the lateral capsule of the 2nd MPJ that is injured? Please please email any photos of subsequent tests you get.

     If I were you, until you are 100% sure, I would treat it as a fracture. The big toe joint is the most important joint in your foot. Err on being extra careful with this injury. Rich