An interesting case: Sesamoid Fracture

I diagnosed a sesamoid fracture in a young woman this week. The presenting complaint, on Wednesday, was of “pain in the ball of the foot under the big toe joint for nearly 9 months, but 3 days ago (Sunday), whilst doing a long day shift the pain got really bad and only stops when I take weight off the foot.”

The ball of the foot was noticeably swollen, but not inflamed. However, when I applied light finger pressure to the area the pain increased and was particularly bad at one spot. The lady has a high-arched foot (pes cavus), but it is flexible not rigid. She is not overweight, but is very active everyday of the week -including some weekends – working long hours. She told me that she usually wears a low heeled shoe or sandal, but it had become impossible to wear slip-ons or ‘push-ins’ because of the pain. The only relief was to wear trainers with a thick sole. When the weight was removed by sitting or resting in bed there was no pain.

By applying a protective pad to the sole and the arch, with a cut-out around the painful area, painfree walking was possible. An X-ray was requested; both feet for reasons that I’ll explain shortly and a follow-up appointment was arranged for Thursday morning.

We met on Thursday and the X-ray showed a clear break in the lateral sesamoid. The pain was also worse because the padding had slipped backwards and out of position. By repositioning the pad, the pain was relieved again. I instructed her to use trainers as often as possible and suggested that she do the replacement padding herself. In addition I arranged for her to be fitted with an Aircast below knee walker, which she could borrow from the practice on Friday after work.

The treatment for this condition is mainly patience and removal of pressure. Which is why I decided on the Aircast. When we fitted the Aircast walking was immediately painfree. Now we both have to wait for the bone to fuse as one or even two bones.

There are two sesamoids under the ball of each foot. They allow a particular muscle to pull the foot down during standing and walking; they also survive a lifetime of bending at the ball (the first metatarso-phalangeal joint). In some people, one of the sesamoids is naturally bifurcate and can look as if it is fractured – called a normal variant -that is why I asked for both feet to be X-rayed. This fracture may heal in two parts also, which won’t be a problem.

Pain in this part of the foot is quite common. It is caused by excessive amount of shearing, compression or tensile stress over the joint. It can be associated with sports like golf and tennis. Starting running or training and doing too much or running in old trainers. Wearing old worn shoes, where the inner sole gets a deep imprint. It can be associated with rheumatoid athritis, or even standing on a ladder for long periods, when you aren’t used to doing that! Nearly always it affects people with a high arched foot who have over-used their feet.

Initially the bone and the joint under them become inflamed and that is called sesamoiditis. Ignore this and a sesamoid fracture may result.


Andrew has taught at the University as well as providing podiatry services in South Africa since 1977. Twice chair of the Podiatry Association of South Africa and a commentator on care of your feet on both radio and television he now works in private practice in Cape Town and Hout Bay.

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Katelyn - May 25, 2009 Reply

hi, I just wanted to say that am going through a similar injury, but in my case i have been in almost constant pain for almost a year now and i have had x-rays and ct scans and MRI’s and more x-rays and bone scans done and I have been placed in an air cast with no relief, I have been wearing custom made orthodics since a month after the injury which was first diagnosed as turf toe, and later diagnosed as a facture, and still have had no relief. I am a rugy player and I play in the front row, which puts an extra pressure on the ball of my foot, but I have been inactive trying to heal my foot for almost 6 months now. again with no relief.
I have tried padding, and aircasts and I wear only running shoes all day long and when at home I wear crocks sandles so as to not put pressure on it on my home’s hardwood floors.
I am currently trying physio which gives me a little relief for short periods of time, but all in all I have not had much luck.
I have seen a surgon about it and was told that the surgery could very likely place me in more pain than I am already in because of all the tendons and nerves surrounding the bone.
all in all i am very frustraited and have decided to suck up the pain and proceed with my rugby career.
Moral of story. Take care of your feet, because every step I take is very painful and it looks like it will be like that for the rest of my life. I am only 20 years old.
if you have any ideas for me that would be great!!

    Andrew - June 7, 2009 Reply

    Hi Katelyn
    Sounds like you have done all that you can so far, all of which is standard care. You have reached the “last chance saloon!”
    Have you been checked out by a SPECIALIST orthopaedic foot surgeon? It looks to me as if the only thing you haven’t tried is to have a cast (Fibreglass) put on. It isn’t usually done, but it might be the only way to off-load the foot for some length of time. Surgery to remove the offending sesamoid is possible but has risks – but it is a known procedure. Where do you live and have you also seen a podiatrist with a special interest in sports podiatry?


Katelyn - June 8, 2009 Reply

Thanks so much for that reply!
I am from Waterloo Ontario, Canada
I saw an orthopedic surgion, I think. I did not know there were podiatrists with special interest in sports podiatry. The lady who made my orthodics works at a sports therepy clinic here in Waterloo. I dont know if that counts, she has other practices though. I am unsure of if there is a more specific specialist I am able to see.


    Andrew - June 10, 2009 Reply

    Hi Katelyn
    Why not Google podiatrists in Ontario? I bet there is an Association of Podiatrists. There are South African podiatrists in Toronto. As far as I know Canadian podiatry follows the US model, but there are also others and possibly a training faculty.
    I suppose the alternative is a sport specialist orthopaedic surgeon!


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