Sesamoid fractures are injuries involving the small sesamoid bones located beneath the head of the first metatarsal at the base of the great toe. These bones are embedded within the tendon of the flexor hallucis brevis and play a crucial role in weight-bearing, shock absorption, and biomechanical leverage during gait.

Sesamoid fractures are commonly seen in ballet dancers, runners, and athletes due to repetitive hyperextension stress at the first metatarsophalangeal (MTP) joint. Acute traumatic fractures may also occur after direct impact injuries such as falls onto the forefoot or heavy objects dropping onto the foot.

Epidemiology

Sesamoid fractures are relatively uncommon but are frequently observed in:

• Ballet dancers
• Long-distance runners
• Soccer players
• Basketball athletes
• Gymnasts

Stress fractures are particularly associated with repetitive forefoot loading and chronic hyperextension injuries.

Anatomy of the Sesamoid Complex

The sesamoid apparatus consists of two small bones:

• Medial (Tibial) Sesamoid
• Lateral (Fibular) Sesamoid

These bones are located within the plantar capsuloligamentous structure beneath the first metatarsal head.

Functions of the Sesamoids

The sesamoids serve several important biomechanical functions:

• Act as shock absorbers
• Increase the mechanical advantage of the flexor hallucis brevis tendon
• Reduce friction beneath the first metatarsal head
• Support weight-bearing during push-off
• Protect the flexor hallucis longus tendon

Because the first MTP joint bears substantial forces during ambulation and athletic activities, the sesamoids are vulnerable to both acute and stress-related injuries.

See Also: Foot Anatomy

Mechanism of Injury

Sesamoid fractures can occur through several mechanisms:

Direct Trauma

• Falling directly onto the forefoot
• Heavy object dropped on the foot
• Crush injuries

Hyperextension Injuries

Forceful dorsiflexion of the great toe may produce:

• Avulsion fractures
• Capsuloligamentous injury
• Plantar plate injury

Repetitive Stress

Chronic repetitive loading can lead to:

• Stress reactions
• Stress fractures
• Symptomatic nonunion

Types of Sesamoid Fractures

Acute Traumatic Fractures

Usually transverse fractures resulting from sudden trauma.

Stress Fractures

Develop gradually due to repetitive microtrauma.

Avulsion Fractures

Occur from traction forces during hyperextension injuries.

Nonunion Fractures

Failure of fracture healing, commonly seen after conservative management.

Symptoms of Sesamoid Fracture

Patients typically present with:

• Localized pain beneath the great toe
• Tenderness over the sesamoid complex
• Pain during walking or running
• Difficulty with push-off activities
• Swelling of the plantar forefoot
• Pain worsened by passive extension of the great toe
• Pain during active flexion of the first MTP joint

Athletes often complain of inability to perform explosive movements or dance maneuvers.

Clinical Examination

Physical examination may reveal:

• Point tenderness beneath the first metatarsal head
• Pain with dorsiflexion of the hallux
• Antalgic gait
• Plantar swelling
• Reduced toe-off strength

The examiner should compare both feet because congenital bipartite sesamoids are common.

Sesamoid Fracture Diagnosis

Plain Radiographs

Initial imaging includes:

• Anteroposterior (AP) views
• Lateral views
• Oblique views

These views usually demonstrate transverse fractures.

Tangential (Axial) Views

Useful for identifying:

• Small osteochondral fractures
• Avulsion injuries
• Fragment displacement

See Also: Calcaneus Fracture (Heel Fracture)

Computed Tomography (CT)

Useful when plain radiographs are inconclusive and for:

• Evaluating fracture configuration
• Detecting nonunion
• Surgical planning

Magnetic Resonance Imaging (MRI)

Helpful for:

• Stress fractures
• Bone marrow edema
• Associated soft tissue injury

Bone Scan

Technetium bone scans may identify occult stress fractures not visible on radiographs.

Differentiating Fracture from Bipartite Sesamoid

One of the most important diagnostic challenges is distinguishing a fracture from a congenital bipartite sesamoid.

Bipartite Sesamoid Characteristics

• Smooth, well-corticated margins
• Usually bilateral
• Seen in 10–30% of individuals
• Most commonly affects the tibial sesamoid

Fracture Characteristics

• Irregular fracture edges
• Localized tenderness
• Sharp separation line
• Associated soft tissue swelling

Bilateral radiographs are often helpful for comparison.

Sesamoid Fracture Treatment

Nonoperative Management

Most sesamoid fractures are initially treated conservatively.

Conservative Treatment Includes:

• Activity modification
• Offloading the forefoot
• Soft plantar padding
• Short leg walking cast for approximately 4 weeks
• Stiff-soled shoe or postoperative shoe
• Metatarsal pads for 4–8 weeks
• NSAIDs for pain control

Rehabilitation

After immobilization:

• Gradual return to weight-bearing
• Range-of-motion exercises
• Gait retraining
• Progressive strengthening

Surgical Treatment

Surgery may be considered when:

• Persistent pain exists despite conservative treatment
• Symptomatic nonunion develops
• Displaced fractures are present
• High-performance athletes require faster recovery

Surgical Options

Open Reduction and Internal Fixation (ORIF)

• Attempts to preserve the sesamoid
• Technically challenging
• May require prolonged recovery

Sesamoidectomy

Removal of the fractured sesamoid with tendon reconstruction.

This procedure may provide:

• Reliable pain relief
• Earlier return to sports
• Good functional outcomes

However, excessive resection may alter first-ray biomechanics.

Complications

Potential complications include:

• Nonunion
• Chronic plantar pain
• Hallux stiffness
• Altered gait mechanics
• Transfer metatarsalgia
• Hallux valgus deformity
• Reduced push-off strength

Prognosis

The prognosis depends on:

• Fracture type
• Early diagnosis
• Activity level
• Compliance with offloading

Most patients recover well with conservative treatment, although stress fractures and nonunions may require surgery.

Athletes may require several months before full return to high-impact activities.

Prevention

Preventive strategies include:

• Proper footwear
• Activity modification
• Shock-absorbing insoles
• Gradual training progression
• Avoiding repetitive hyperextension stress

Dancers and runners should pay special attention to forefoot loading mechanics.

Key Points

• Sesamoid fractures affect the small bones beneath the first MTP joint.
• Common in dancers, runners, and athletes.
• Pain is localized beneath the great toe and worsens with toe motion.
• Radiographs are first-line imaging, but MRI or CT may be necessary.
• Bipartite sesamoid must be differentiated from fracture.
• Most cases respond to conservative management.
• Symptomatic nonunion may require surgical intervention.

Frequently Asked Questions (FAQ)

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Bichara DA, Henn RF 3rd, Theodore GH. Sesamoidectomy for hallux sesamoid fractures. Foot Ankle Int. 2012 Sep;33(9):704-6. doi: 10.3113/FAI.2012.0704. PMID: 22995255. Pubmed
3. Daddimani RM, Madhavamurthy SK, Jeevannavar SS, Shettar CM. Fracture of the medial tibial sesamoid bone of the foot-case report. J Clin Diagn Res. 2015 Apr;9(4):RD03-4. doi: 10.7860/JCDR/2015/12899.5831. Epub 2015 Apr 1. PMID: 26023612; PMCID: PMC4437128. Pubmed