Great Toe And Sesamoids

Stress fractures of the great toe and sesamoids are seen less frequently than other sites of stress-related injury, but when they do occur the diagnosis may be more difficult, resulting in a delay in diagnosis if this injury is not considered [8]. Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Athletes who have pain in the first metatarso-phalangeal joint and who are exposed to excessive running, jumping, and repeated forced dorsiflexion of the first metatarsophalangeal seem to be predisposed to this injury [21]. As with stress-related injury in other locations, the symptoms typically occur during training without a history of trauma. Approximately 1% of all running injuries involve the sesamoids; 40% of these are stress fractures and 30% are sesamoiditis [22]. Sesamoiditis/osteochondritis, avascular necrosis, stress response of the synchondrosis of partite sesamoid bones, traumatic fractures, osteomyelitis, and bursitis between the tibial sesamoid and the tendon of the flexor hallucis brevis may all occur in this location. One or both sesamoid bones may be involved.

Plain films are commonly normal. Nuclear scintigraphy may show focal increase radiotracer activity over one or both sesamoid regions. MRI of sesamoid stress response and stress fractures most commonly shows low T1 signal intensity and increased signal intensity on T2 and short-tau inversion-recovery (STIR) sequences (Fig. 1A, B).

MRI signal alterations of stress response of sesamoids and sesamoiditis overlap. Increased STIR signal intensity and low T1 signal have been described with sesamoid stress response, as opposed to increased STIR signal intensity and normal T1 signal, which favor sesamoiditis. Sesamoiditis also more commonly involves both sesamoid bones, and may be associated with bursitis, ten-dinosis, and tenosynovitis [23,24].

Table 1

Most common sites of stress injuries

Location

Incidence

Tibia

33%

Navicular

20%

Metatarsals

20%

Femur

11%

Fibula

7%

Pelvis

7%

From Csizy M, Babst R, Fridrich KS.

''Bone tumor'' diagnostic error

in stress fracture of the medial tibial

plateau. Unfallchirurg 2000;103(11)

:993-5 [in German].

Medial Sesamoid

Fig. 1. (A) Axial T1 SE. Medial sesamoid stress fracture. Seventeen-year-old runner with replacement of fat marrow signal by edema (arrow) related to the stress fracture. (B) Coronal T2 FSE fat-suppressed (FS), same patient. Medial sesamoid stress fracture. Transverse low signal line consistent with fracture plane (arrow).

Fig. 1. (A) Axial T1 SE. Medial sesamoid stress fracture. Seventeen-year-old runner with replacement of fat marrow signal by edema (arrow) related to the stress fracture. (B) Coronal T2 FSE fat-suppressed (FS), same patient. Medial sesamoid stress fracture. Transverse low signal line consistent with fracture plane (arrow).

Treatment typically involves avoidance of physical activity and attention to predisposing extrinsic factors such as footwear [25,26]. Hulkko and Orava [27] reported 15 cases of stress fractures of the hallucal sesamoids in athletes. The mean patient age was 22.3 years old. Nine patients were males and 6 were females. Eight fractures involved the medial sesamoid, six involved the lateral sesamoid, and in 1 patient both sesamoids were involved. Ten patients were treated conservatively. Five patients required surgical excision of the fragmented involved sesamoid and gradually returned to training 6 to 8 weeks after surgery. Pathology confirmed fibrotic nonunion of the stress fractures [27].

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Responses

  • annett schwab
    What is sesamoid stress fracture?
    8 years ago

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