This 17-year-old national representative player presented with an eight-week history of pain in the plantar surface of her great toe. This had come on insidiously. On examination she was found to have pain with hopping and walking on her toes, as well as localised tenderness over the medial sesamoid.
An x-ray series of the great toe shows an abnormality involving the medial sesamoid. There is a bipartate appearance with sharp and irregular margins. The MRI images show abnormal marrow signal within the medial sesamoid consistent with a fracture. There is no significant widening or proximal migration of the fracture fragments.
This young player was diagnosed with a sesamoid stress fracture. She was managed for a short period (two weeks) in a walking boot before moving into a supportive sports shoe with a custom orthotic (incorporating a medial post). While using the orthotic she was able to continue to do resistance training, cycling and pool-based activity. She was not allowed to run or play football during this phase of her recovery. At eight weeks post-diagnosis she was able to start a progressive running programme (in a running shoe). She was able to return to football about four months after her diagnosis. She has continued to use the orthotic in her running shoe and has made changes to her football boots.
Sesamoid problems can be difficult to definitively diagnose. One of the reasons for this is because bipartate sesamoids are common normal variant, being present in up to 30% of the general population. 90% involve the medial sesamoid and 80%-90% are bilateral. Compared to fractures, bipartite sesamoids are generally narrower and have distinct regular edges. They are generally also larger than a single, non-bipartate, sesamoid. When there is uncertainty about the diagnosis MRI is generally the imaging modality of choice.
The function of sesamoids is to distribute weight through the first ray, increase the mechanical advantage of the pull of flexor hallucis brevis and to stabilise the great toe. As the medial sesamoid normally carries the majority of the weight bearing forces passing through the first metatarsal head it is more commonly affected by injury (than the lateral one). Sesamoids have a tenuous and variable blood supply, especially the distal pole. These factors can lead to delayed or unsuccessful healing and substantial frustration for all involved.
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