Case report
J Indian Rheumatol Assoc 2004 : 12 : 0 - 0
AN UNCOMMON CAUSE OF GREAT TOE PAIN: SESAMOIDITIS
Anupam Wakhlu
Rheumatologist and Clinical Immunologist, Lucknow
Abstract :
A forty -five year old male presented with pain in both the great toes associated with mild swelling for the last
3-4 months. The pain was located at the inferomedial aspect of ball of both the great toes. The maximum
intensity of pain was in the evening, after a days work. The patient was able to walk with great difficulty after
donning padded shoes. It was partially relieved by intermittently ingested NSAID’s. Examination of the great
toes revealed redness, mild swelling and localized exquisite tenderness at the inferomedial aspect of the MTP
joints. The location of the tenderness corresponded exactly to the location of the medial sesamoid bones
bilaterally. A diagnosis of bilateral sesamoiditis was made. He was advised to use footwear with padded, soft
soles and put on NSAIDs. His pain resolved with this therapy over the next 3-4 weeks. An uncommon and
underdiagnosed cause of foot pain is highlighted.
Key words : Great toe pain, hyperuricemia, footwear
A forty -five year old average built male patient presented with pain in both the great toes associated with mild swelling for the last 3-4 months.
The pain was located at the inferomedial aspect of
ball of both the great toes, was moderate to severe
in intensity and insidious in onset. The maximum
intensity of pain was in the evening, after a days
work. The patient was able to walk with great difficulty after donning padded shoes. It was partially
relieved by intermittently ingested NSAID’s. The
patient was not a diabetic or hypertensive. There
was no history of involvement of other joints. The
patient was not an athlete and was not playing any
outdoor games, performing strenuous foot based exercises or taking long walks.
The general and systemic examination was
normal. His weight was normal for his age and
height. Examination of the great toes revealed redness, mild swelling and localized exquisite tenderAddress for correspondence
Anupam Wakhlu
Rheumatologist and Clinical Immunologist
B1/99, Sector G, Aliganj,
Lucknow, UP, INDIA 226024
E mail: [email protected]
ness at the inferomedial aspect of the MTP joints.
There was no redness or edema over the joint superiorly.
Investigations revealed a normal hemogram,
normal blood sugar, S. creatinine 0.9 mg/dl, S. uric
A. 8 mg/dl. Urine examination was normal. X ray of
the feet AP view are shown (Figure 1). The location of the tenderness corresponded exactly to the
location of the medial sesamoid bones bilaterally.
Figure 1: X-ray of both feet AP view show normal MTP
joints. There is no juxta-articular osteopenia, no erosions and no deposits. The white arrows show the medial and lateral sesamoid bones, which are part of the
normal anatomy of the joint. The larger arrows indicate the medial sesamoids bilaterally, which was the site
of exquisite point tenderness in the patient.
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A diagnosis of bilateral sesamoiditis involving the medial sesamoid bones of the great toe with
hyperuricemia was made. The patient was started
on NSIAD and advised rest. He was also advised
to use footwear with padded, soft soles. His pain
resolved with this therapy over the next 3-4 weeks.
Discussion and review:
Conventional wisdom would dictate that a
diagnosis of gouty arthritis (podagra) be made in a
case of hyperuricemia with pain in the great toes.
However, insidious onset of the pain, bilaterally
symmetrical involvement of the great toes with point
tenderness at the inferomedial aspect, corresponding to the location of the medial sesamoid bones,
helped clinch a diagnosis of sesamoiditis.
Although mechanical causes would likely
have also contributed to the development of sesamoiditis in this case, hyperuricemia could also have
led to gouty involvement of the sesamoids. There
are only 2 or 3 case reports in the literature which
describe gout as a cause of sesamoiditis or pain in
the sesamoids1,2.
The sesamoid bones are usually 2 seed
shaped bones (medial and lateral) that lie below
the first metatarsal head, embedded in the two tendons of the split flexor hallucis brevis. They are
both parts of true synovial joints with hyaline cartilage interfaces. Their location allows them not only
to modify the pressure of weight bearing but also to
provide a biomechanical advantage during walking3,4.
Pain in the first metatarsal sesamoids is an
underdiagnosed clinical entity that may contribute
up to 4 percent of overuse type foot injuries5. Sesamoiditis may be defined as inflammation of the sesamoid bones and/or apparatus due to varied biome-
chanical and non-mechanical factors causing pain
in the anatomical region of the sesamoids4,5,6.
Malaligned or deformed joints contribute to the development of this condition.
The pain of sesamoiditis may be a dull aching type or a sharp throbbing type, usually of insidious onset and may prevent the patient from walking.
It may be over one or both the sesamoids, although
the medial one is involved more frequently. Point
tenderness is elicitable over the inflamed bone, usually over the inferior and medial aspect of the ball
of the great toe, as was seen in this case.
The differential diagnosis of first metatarsal sesamoid pain is varied and includes3: Inflammatory bone disease e.g. rheumatoid arthritis or bony
infection, ligamentous or tendinous disruption, avascular necrosis or osteochondritis, stress fractures,
sesamoiditis, osteoarthritis, normally occurring bipartite sesamoid and gout1,2. Sesamoiditis is usually attributed to stressful mechanical activities.
The x-ray may be entirely normal. When first
MTP pain due to involvement of the sesamoid apparatus is considered as one entity, findings may include fracture of one or both sesamoids, sesamoid
multipartite, avascular necrosis, arthritic changes
and localized soft tissue swelling7,8. MRI is being
used more and more in the imaging of forefoot disorders. MR findings in the marrow of the sesamoid
bones (in sesamoiditis) include decreased or normal signal intensity on T1-weighted images and increased signal intensity on STIR images. The signal
intensity changes are similar to those caused by a
stress response but if the signal intensity of the sesamoids is abnormal on STIR but normal on T1weighted sequences, sesamoiditis is a more likely
diagnosis than stress response. Involvement of both
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sesamoid bones and presence of local synovitis, tendonitis or bursitis also favor a diagnosis of sesamoiditis7.
Initial management is conservative and includes rest, immobilization of the hallux in the neutral position, protective padding and footwear with
soft cushioned soles, NSAID or local corticosteroids injections2,3,8. Insoles with sesamoid protective padding may also be used. A short duration plaster cast may be given if fracture is suspected.
Therapy for gout is indicated if it appears to be the
cause. Mechanical factors and deformities will need
correction. If the patient does not respond to conservative management, sesamoidectomy is the treatment of choice, with varying figures quoted for pain
relief2,3. Postoperative complications may include
hallux varus, valgus and hammer toes9.
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