SesamoiditisAtanasia Barabas

Chapman University, DPT 2015Student Physical Therapist, Bauer PT

Anatomy ● 2 sesamoid bones in the tendon of the flexor hallucis

near the 1st MTP joint

● Function to:● to increase the mechanical advantage of the flexor

hallucis longus and brevis and increase plantarflexion strength at the 1st MTP joint

● Disperse forces to the medial forefoot

Pathology

● Inflammation of the FHL tendon surrounding the sesamoid bones due to overuse and repetitive stress● Causes can be structural, such as pes cavus foot type,

and/or mechanical in nature

Symptoms• Results in pain with weight bearing on the

forefoot

• Gradual onset of pain, worsened with increasing activity

• Aggravating factors include wearing high heels, jumping, running, stairs, and dancing

• Symptoms are alleviated with rest, ice, and non-weight bearing positions

Considerations for Treatment● First ray position and mobility

● Rear foot alignment and mobility

● Forefoot alignment

● Dorsiflexion range of motion

● Demand placed on the foot in ADLs or sports

● Current stage of healing

Clinical Findings● Common findings for individuals with this pathology

include:

● Loss of ROM at 1st MTP joint

● Decreased plantarflexion and dorsiflexion strength of great toe● Painful static test

● Tenderness to palpation on of the 1st MT head on the plantar aspect

● Decreased weight bearing ability due to pain

Differential Diagnosis● Bursitis

● Chrondromalacia

● Tenosynovitis of the FHL

● Sesamoid fracture

● MRI and X-ray can assist in diagnosis process

Treatment● EdURep Model

● Educate the patient about the nature of their pathology● Unload the tissue and allow tissue healing to occur● Reload the tissue to increase ROM and strength as

needed● Progress treatment to mimic functional activities and meet

the demand the patient puts on the tissue in their daily lives

Patient Education● Educate the patient about how they are placing excess

stress on the involved structures

● Teach patient how to move without stressing the sesamoids● Re-education for squatting, standing, walking

Unloading Phase● Decrease the stress on the sesamoids by dispersing

forces over the forefoot● Use metatarsal pads or soft arch support● Taping the 1st MTP joint into slight plantarflexion● Lower heel height

● Avoid activities that reproduce symptoms● No jumping● No excessive 1st MTP dorsiflexion

Reloading Phase● Once the patient is out of the inflammatory phase of

healing, progress to reloading the tissue to strengthen it and avoid re-injury

● Exercises focusing on FHL strength

● Stretching the 1st MTP joint to improve dorsiflexion

● Improving ankle ROM

Progress● Once the patient has sufficient strength and range,

progress to adding weight bearing and functional exercises that mimic the activities the patient has to get back to

● Squatting, jumping, running

References● Anwar R., Anjum S.N., Nicholl J.E. Sesamoids of the Foot.

Current Orthopaedics. 2005. 19(1)40-48.

● Beaman D.N., Nigo L.J. Hallucal Sesamoid Injury. Operative Techniques in Sports Medicine. 7(1)7-13.

● Image- http://sesamoiditis.net

● Image-http://www.eorthopod.com/content/sesamoid

● Image-http://www.performancefoot.com/ball-of-foot-pain-relief/47-dancers-sesamoid-pad-felt-1-4inch.html

● Image- http://www.protherapysupplies.com