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Saturday, May 7, 2011

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!


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


  1. Dr. Blake, I emailed all the x-ray views of my foot that I have taken at this point. I had them read by a radiologists at one of our local imaging centers, he believes it is a partate and not a fx. I have an appointment scheduled with a local podiatrist, however it is not until June 6th (which will be just over 6 weeks post injury). I have been keping it taped and icing it. I have also built up a pad under my orthotics to take pressure off the sesamoids. Pain is still present, but I can tell when I don't have it taped.

    I'm thinking about being one of those annoying patients who bugs the office staff to try to get in sooner. I also thought about faxing the Dr. a brief hx, and letting him know what I have been doing, and that I have x-rays already. I just haven't decided if I want to be annoying or not. LOL

  2. Hi Tiff and Richard

    I have found this blog to be of particular interest as not ont am I too a chiropractor but have recently examined a patient with the same diagnostic challenge.

    I have x-rayed both feet and found a bipartate sesamoid on one foot and a tripartate on the symptomatic foot. The radiologist's report states that this is of normal appearance but I'm not convinced. The patient has no history of trauma yet is presently on crutches and taking pain killers with anti-inflammatories due to alot of localised swelling.

    Interested in your suggestions/outcome


    1. Rory, Thank you for the email. Please get an MRI so the diagnosis is clearer. It is a crucial test in almost all sesamoid injuries. It makes the diagnosis for sesamoiditis vs fracture much more clear. If it is impossible to get an MRI for some reason, I would then have to treat as a fracture with all of the tips in previous postings on sesamoid fractures. Hope this helps. Rich

  3. Hi,i am relatively sedentary weighing in at 155kgs. I have been attending a metabolic clinic for 6 months which includes 4 gym sessions per week. I recall using a machine which I pushed with my feet on a plate. I was pushing 110 kHz when I felt a pop in the ball of my foot. I ced it but a soreness developed under my 1st & 2nd toe. I continued to ice it & used nsaids, then it bruised over a few days. Since then (4 weeks) it has become more and more painful with numbness under the second toe pad and the ball of my foot. My GP ordered xray which showed an apparent sesamoid fracture. My GP says it's not fractured but the xrays appear to show a large irregular fracture. I don't know how to upload the xrays I'm afraid but could you tell me how to know the difference between a fracture & a normal variant?


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.