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Sesamoiditis

Sesamoiditis is an inflammatory condition of the sesamoid bones and associated tendons or ligaments, occurring in humans and horses.^[1] In humans, it affects the sesamoid bones and the surrounding tendons located in the ball of the foot, specifically beneath the first metatarsophalangeal (big toe) joint, often resulting from repetitive stress or overuse and classified as a form of tendinitis.^[2]^[3] These sesamoid bones—two small, pea-shaped structures embedded within the flexor hallucis brevis tendon—aid in weight-bearing and leverage during toe flexion, but become irritated when subjected to excessive pressure.^[3] The condition typically develops gradually, causing chronic pain that worsens with activity, and is distinct from acute sesamoid fractures, though both can present similarly.^[2]^[3] Common causes include high-impact activities such as running, ballet dancing, or baseball, which place repetitive force on the forefoot, as well as biomechanical factors like high foot arches, bunions, or wearing high-heeled shoes that shift weight forward.^[2]^[3] It is more prevalent among athletes, dancers, and individuals with occupations involving prolonged standing, and can also stem from underlying issues like gout, osteoarthritis, or prior trauma to the area.^[2] Symptoms often include a dull ache or sharp pain under the big toe that intensifies during push-off motions, along with swelling, bruising, tenderness to touch, and difficulty bending or straightening the toe.^[2]^[3] Diagnosis typically involves a physical examination, including tests for tenderness and range of motion, supplemented by imaging such as X-rays to rule out fractures, or advanced scans like MRI or bone scans if needed.^[2]^[3] Treatment is primarily conservative, emphasizing rest, ice application, nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief, and supportive measures like orthotic inserts, cushioned padding, or stiff-soled shoes to offload pressure; physical therapy may strengthen the area, and corticosteroid injections are used sparingly for persistent inflammation.^[2]^[3] In rare cases of non-response, surgical removal of the affected sesamoid bone may be considered, though it carries risks like altered foot mechanics.^[2]^[3] Prevention focuses on proper footwear with adequate arch support, gradual increases in activity intensity, and early intervention for foot deformities.^[2] Most cases resolve within weeks to months with nonsurgical care, allowing return to normal function.^[3]

Definition and Anatomy

Definition

Sesamoiditis is an inflammatory condition characterized by irritation or chronic inflammation of the sesamoid bones and the tendons that enclose them, often arising from repetitive stress, overuse, or acute trauma.^[2]^[3]^[4] This overuse injury primarily affects the tendons and associated sesamoid structures, leading to a form of tendinitis that can cause persistent discomfort in the affected area.^[3] The condition is particularly prevalent among physically active populations, including athletes, dancers, and runners, where it accounts for about 2.2% of all foot injuries and up to 18.3% of injuries involving the first metatarsophalangeal joint.^[5] In veterinary contexts, sesamoiditis is common in performance animals such as racehorses, where radiographic signs appear in approximately 26% of yearling Thoroughbreds examined.^[6] Sesamoiditis was first described in human podiatry in the early 20th century, with Swedish radiologist Axel Renander reporting cases of medial sesamoid osteochondritis in 1924.^[7] Unlike sesamoid fractures, which involve actual breaks or cracks in the bone often from hyperextension injuries, sesamoiditis primarily entails soft tissue inflammation without structural bone disruption.^[3]^[8] The sesamoid bones themselves are small, rounded structures embedded within tendons near certain joints.^[9]

Sesamoid Bones

Sesamoid bones are small, round bones embedded within tendons or ligaments, functioning as pulleys to enhance the mechanical efficiency of muscle-tendon units by providing a smooth gliding surface.^[9] These bones develop through ossification within tendinous tissue, often near joint surfaces, and are surrounded by a layer of cartilage that facilitates low-friction movement.^[9] In humans, sesamoid bones are most prominent in the foot, where two pea-sized medial and lateral sesamoids lie embedded in the flexor hallucis brevis tendon beneath the head of the first metatarsal.^[9] Additional sesamoids occur in the hand, typically numbering about five per hand at the metacarpophalangeal joints of the thumb, index, and little fingers, and in the knee as the patella, which is the largest sesamoid bone.^[9] Although present elsewhere, such as the os peroneum in the lateral foot or fabella in the knee, the hallux sesamoids are the most clinically relevant due to their role in weight-bearing.^[9] In horses, the proximal sesamoid bones consist of two triangular-shaped bones (medial and lateral) per fetlock joint, located on the palmar or plantar aspect of the metacarpophalangeal joint and embedded within the suspensory ligament, with the superficial and deep digital flexor tendons passing over their flexor surface.^[10] A distal sesamoid bone, known as the navicular bone, is also present in each digit at the distal interphalangeal joint.^[10] These bones are integral to the suspensory apparatus, supporting the fetlock during locomotion.^[11] Sesamoid bones primarily reduce friction between tendons and underlying bones, while increasing leverage to optimize force transmission during movement; in humans, they aid toe-off during gait, and in horses, they facilitate weight-bearing and shock absorption.^[9]^[11] Structurally, they are composed of dense cortical bone containing vascular canals, with a thin layer of articular cartilage on joint-facing surfaces.^[9] Anatomical variations include bipartite or multipartite sesamoids, which represent normal developmental non-fusion and occur in 10-30% of individuals, most commonly in the hallux sesamoids.^[12]

Pathophysiology and Causes

Pathophysiology

Sesamoiditis arises primarily from repetitive microtrauma to the sesamoid bones and their associated soft tissues, leading to inflammation of the tendons and surrounding structures, which can cause localized edema and stress reactions within the sesamoids.^[3]^[13] This process is exacerbated by the sesamoids' role in enhancing tendon leverage and absorbing forces, making them vulnerable to cumulative overload without adequate recovery periods.^[2] The condition progresses through distinct stages. In the acute phase, inflammation predominates, characterized by soft tissue swelling.^[3] As it becomes chronic, bony proliferation, sclerosis of the sesamoid cortex, or subchondral cyst formation may emerge, often detectable via imaging as irregular bone contours and increased density.^[14]^[13] Biomechanical factors drive this evolution, with high compressive and shear forces acting on the sesamoids during weight-bearing propulsion; in humans, this occurs prominently during toe-off with dorsiflexion of the first metatarsophalangeal joint, while in horses, fetlock hyperextension during galloping intensifies the load on the proximal sesamoids.^[15]^[6] The inflammatory response amplifies pain signaling and tissue swelling while promoting further periosteal reaction.^[13] If untreated, this cascade can compromise vascular supply, potentially advancing to avascular necrosis through ischemia and bone death, particularly in the medial sesamoid where blood flow is more limited.^[14] Species differences are notable: in horses, sesamoiditis frequently incorporates desmitis of the suspensory ligament branches inserting on the proximal sesamoids, leading to broader metacarpophalangeal instability; in humans, it more commonly implicates strain of the flexor hallucis longus tendon, altering great toe flexion mechanics.^[16]^[13]

Causes and Risk Factors

Sesamoiditis primarily arises from mechanical overload on the sesamoid bones and their associated tendons, often due to repetitive high-impact activities that increase stress on the forefoot or fetlock region.^[2] In both humans and horses, acute trauma, such as direct impact to the sesamoid area from stubbing the toe or sudden fetlock hyperextension, can initiate inflammation, though chronic overuse is more common.^[3] This condition accounts for approximately 12% of great toe complex injuries among athletes, highlighting its relevance in high-demand physical pursuits.^[17] In humans, risk factors include participation in sports involving forceful push-off from the ball of the foot, such as running, ballet dancing, basketball, or baseball catching, which exacerbate pressure on the sesamoids.^[3] Individuals with high-arched feet (pes cavus) or bunions face elevated risk due to altered biomechanics that concentrate load on the sesamoid region, while frequent wear of high-heeled or thin-soled shoes further contributes by shifting weight anteriorly.^[4] Older adults with osteoarthritis are particularly susceptible, as degenerative changes amplify vulnerability to repetitive stress.^[2] Among athletes, sesamoiditis represents 2.2% of all foot injuries and up to 18.3% of first metatarsophalangeal joint injuries.^[18] In horses, particularly Thoroughbred racehorses, sesamoiditis often stems from intensive training on hard surfaces, leading to cumulative microdamage in the proximal sesamoid bones of the fetlock.^[19] Risk factors include poor limb conformation, such as upright pasterns, which unevenly distribute forces during high-speed galloping or jumping disciplines.^[20] Sexually intact males and horses with prolonged active training periods (e.g., over 300 days without layup) show higher susceptibility, often progressing to fractures.^[20] It is a leading cause of fetlock lameness in young racehorses, with radiographic signs present in about 26% of yearlings evaluated for sale.^[6]

Signs and Symptoms

In Humans

Sesamoiditis in humans often presents with sharp pain under the big toe joint, exacerbated by weight-bearing activities, swelling, and tenderness upon palpation, significantly impacting athletes and performers who rely on foot propulsion.^[3] A notable case involved MLB pitcher Josh Zeid, who in 2014 suffered bilateral sesamoiditis while with the Houston Astros, leading to placement on the 15-day disabled list and eventual season-ending sesamoidectomy surgery on both feet after initial attempts at rest and management failed.^[21]^[22] Zeid, who had debuted in 2013, made only 23 appearances that year with a 6.97 ERA before the injury sidelined him, though he later returned to minor league play with the Detroit Tigers organization in 2015.^[23] Similarly, New York Yankees infielder DJ LeMahieu experienced a fractured sesamoid bone in his right big toe in 2022, causing ligament damage and forcing him to miss the postseason despite conservative management that avoided surgery.^[24] The injury led to ongoing foot issues, contributing to reduced performance in subsequent seasons, including a .220 batting average in 2023 and further setbacks in 2024.^[25] In professional ballet dancers, such as those affiliated with the American Ballet Theatre, sesamoiditis is prevalent due to repetitive demi-pointe and en pointe positions that stress the sesamoid complex, often resulting in chronic pain that necessitates career adjustments like modified training or surgical intervention in severe cases during the 2010s.^[26] Among athletes, sesamoiditis accounts for a significant portion of forefoot injuries; for instance, it represented 62.6% of hallux sesamoid diagnoses in a study of young athletes, with running comprising 13.7% of affected sports.^[27] Most individuals recover fully with conservative approaches such as rest, orthotics, and physical therapy, but delayed diagnosis or treatment can lead to chronic issues that prematurely end athletic careers, as seen in prolonged recovery timelines for elite performers.^[3]

In Horses

Sesamoiditis in horses manifests primarily as inflammation and degeneration of the proximal sesamoid bones and associated soft tissues at the fetlock joint, leading to lameness that worsens with exercise or weight-bearing. Common signs include mild to moderate lameness in the affected limb, often bilateral in forelimbs, accompanied by heat, swelling, and palpable pain over the sesamoid region.^[28] Horses may also show resentment to hoof flexion tests or direct pressure on the sesamoids, with radiographic evidence of vascular channel enlargement or bone resorption supporting the diagnosis.^[6] In racing Thoroughbreds, sesamoiditis frequently progresses to more severe symptoms, such as acute lameness and instability, due to the high-impact forces during galloping. A 2020 retrospective study of fatal proximal sesamoid bone fractures in California Thoroughbred racehorses linked these catastrophic outcomes to underlying bone loss and stress remodeling akin to chronic sesamoiditis, with 70% of fractured bones showing reduced mineral density at lesion sites.^[19] These fractures, often presenting with sudden severe lameness and fetlock collapse, account for 45-50% of fatal musculoskeletal injuries in Thoroughbred racing.^[19] A cohort of Friesian horses illustrates the poor prognosis associated with advanced sesamoiditis symptoms like severe hindlimb lameness and axial osteitis. In a 2014 review of 12 cases from 2002-2012, horses exhibited acute lameness lasting an average of 1.9 months, with post-mortem findings revealing bone resorption and intersesamoidean ligament desmitis; only 22% achieved soundness for light riding after one year, while 56% remained lame.^[29] Chronic sesamoiditis consistently impairs long-term athletic performance through ongoing inflammation and joint instability, while acute fractures prove catastrophic, often necessitating euthanasia.^[28]

Diagnosis

Methods in Humans

Diagnosis of sesamoiditis in humans begins with a thorough clinical evaluation, focusing on patient history and physical examination to identify characteristic patterns of pain and activity-related triggers. Patients typically report insidious onset of pain localized to the ball of the foot beneath the first metatarsophalangeal (MTP) joint, often exacerbated by weight-bearing activities such as running, jumping, or dancing on hard surfaces.^[15] High activity levels in sports or occupations involving repetitive forefoot stress are commonly elicited, along with risk factors like high-arched feet or wearing flexible thin-soled or high-heeled shoes.^[15] During physical examination, the foot and great toe are dorsiflexed to expose the metatarsal head, followed by direct palpation of the sesamoids for localized tenderness, which is often most pronounced over the medial (tibial) sesamoid.^[15]^[3] The passive axial compression test, involving gentle upward bending of the big toe or simulated walking pressure on the sesamoids, reproduces symptoms and confirms involvement of these structures.^[2]^[5] Additional findings may include mild swelling, warmth, redness, or hyperkeratotic tissue at the site, with assessment of active range of motion in the MTP joint to evaluate for restricted flexion.^[15]^[3] Imaging modalities serve as adjuncts to clinical findings, with weight-bearing X-rays as the first-line investigation to detect bony abnormalities such as sclerosis, fragmentation, or cortical irregularity in the sesamoids.^[30] An axial sesamoid view is particularly useful, providing a profile of both sesamoids to identify subtle changes like irregular margins or density variations, though early sesamoiditis may appear normal on plain radiographs.^[30]^[3] Bilateral comparison helps differentiate bipartite sesamoids (smooth, rounded edges) from acute fractures (jagged edges).^[3] For soft tissue evaluation, magnetic resonance imaging (MRI) is recommended when X-rays are inconclusive, revealing bone marrow edema (high signal on STIR sequences, low or normal on T1) indicative of inflammation, tendonitis, or edema in the flexor hallucis brevis.^[30]^[3] Ultrasound offers dynamic assessment of sesamoid alignment, soft tissue swelling, or associated bursitis during weight-bearing, aiding in real-time evaluation of tendon involvement.^[5] Differential diagnosis involves clinical correlation to exclude conditions mimicking sesamoiditis, such as turf toe (first MTP sprain with acute hyperextension history), metatarsalgia (broader forefoot pain without focal tenderness), or gout (sudden inflammatory episodes with possible uric acid crystals).^[15] Arthrocentesis may be performed if circumferential joint swelling suggests infectious arthritis or gout, analyzing synovial fluid for crystals or infection.^[15] Other considerations include plantar warts, calluses, or stress fractures, ruled out via history of trauma, skin examination, and imaging.^[15]^[5] Diagnostic criteria center on reproduction of pain through sesamoid compression or loading during examination, combined with localized tenderness under the first metatarsal head, in the absence of alternative explanations.^[2]^[5] Radiographic signs, when present, support the diagnosis through evidence of sesamoid sclerosis or irregularity, though these are nonspecific and may overlap with osteonecrosis or chronic stress.^[30] If initial X-rays are negative but clinical suspicion remains high, advanced tests like bone scintigraphy (bone scan) are employed to detect stress reactions or early fractures via focal increased tracer uptake in the sesamoids.^[3] This modality is particularly sensitive for subtle bone irritation not visible on plain films.^[3]

Methods in Horses

Diagnosis of sesamoiditis in horses begins with a thorough clinical evaluation, focusing on lameness assessment and historical context. Veterinarians perform a standardized lameness examination, observing the horse at a walk and trot to grade the degree of lameness, which is often mild to moderate and exacerbated by exercise on hard surfaces.^[1] Palpation of the fetlock region reveals heat, swelling, and pain, particularly when applying digital pressure to the sesamoid bones or using hoof testers to compress the area.^[28] Fetlock flexion tests provoke increased lameness upon release, helping localize discomfort to the distal metacarpal/metatarsal region.^[1] A detailed history is essential, noting recent increases in training intensity or racing workload, as sesamoiditis frequently affects high-performance horses such as Thoroughbreds.^[31] Imaging modalities are critical for confirming sesamoiditis and assessing its severity. Radiography, using dorsoproximal-palmarodistal oblique views of the fetlock, detects early signs such as remodeling, focal osteolysis, enlarged vascular channels, or fractures in the proximal sesamoid bones.^[31] Scintigraphy, or bone scanning, identifies early inflammatory changes through increased radiopharmaceutical uptake in the sesamoid region during the bone phase, which is particularly useful when radiographic findings are subtle.^[31] Advanced imaging like magnetic resonance imaging (MRI) or computed tomography (CT) provides detailed visualization of soft tissue involvement, including damage to the suspensory ligament attachments or bone marrow edema not visible on plain films.^[31] Diagnostic nerve blocks help isolate the pain source to the sesamoid apparatus. Perineural anesthesia, such as a low four-point block distal to the fetlock, is performed to desensitize the palmar/plantar nerves; significant improvement in lameness post-block indicates sesamoid involvement, though results can be inconsistent in chronic cases.^[28]^[31] Laboratory tests are employed selectively, primarily if joint effusion is present. Analysis of synovial fluid from the metacarpophalangeal/metatarsophalangeal joint evaluates for inflammation, infection, or degenerative changes, with cytology and culture to rule out septic arthritis, which can mimic sesamoiditis.^[31] Prognostic indicators rely heavily on radiographic grading systems to predict return to athletic function. The vascular channel grading scale (0-3) assesses the number of enlarged channels (≥2 mm wide) in the proximal sesamoid bones, where higher grades (e.g., 3) correlate with poorer outcomes, including reduced race starts and higher lameness recurrence rates.^[32] Overall prognosis is guarded, with early detection via imaging improving chances of conservative management success.^[1]

Treatment

Non-Surgical Approaches

Non-surgical approaches to managing sesamoiditis focus on reducing inflammation, alleviating pain, and promoting healing through conservative measures, which are typically the first-line treatments for both humans and horses in mild to moderate cases. These methods aim to offload stress from the sesamoid bones and surrounding tissues while allowing gradual recovery, with success rates of 70-80% reported in mild presentations when adhered to promptly.^[33]^[34] Rest and immobilization form the cornerstone of initial treatment. In humans, the RICE protocol—rest, ice, compression, and elevation—is recommended for acute inflammation, involving cessation of aggravating activities, icing the affected foot for 20 minutes several times daily, compression with padding, and elevation to reduce swelling. Orthotics or padded insoles are often prescribed to redistribute pressure away from the sesamoids, with stiff-soled shoes to limit motion and offload pressure from the sesamoids. For horses, strict stable rest for 4-8 weeks is standard to limit weight-bearing and prevent further injury, often combined with controlled hand-walking to maintain circulation without overload.^[5]^[3]^[28] Medications target pain and inflammation effectively in both species. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (typically 400-600 mg three times daily for humans) or phenylbutazone (2.2-4.4 mg/kg daily for horses) are commonly administered to reduce swelling and discomfort. Topical agents like diclofenac gel applied to the affected area provide localized relief in humans, complementing oral therapy. Corticosteroid injections may be administered into the joint or surrounding area for cases with persistent inflammation, although used cautiously due to potential side effects such as tendon weakening.^[3]^[28]^[35]^[2] Physical therapy supports rehabilitation by improving flexibility and strength. In humans, stretching exercises for the foot flexors—such as seated big toe curls or calf stretches held for 10-30 seconds and repeated 5-10 times daily—help restore range of motion once acute pain subsides. For horses, controlled hand-walking (starting at 5-10 minutes twice daily and gradually increasing) rebuilds ligament strength after the initial rest period, under veterinary supervision to avoid reinjury.^[5]^[36] Adjunct therapies enhance tissue healing in refractory cases. Extracorporeal shockwave therapy or therapeutic ultrasound is applied to stimulate blood flow and repair, with sessions spaced 1-2 weeks apart showing improved outcomes in promoting resolution. These modalities are used judiciously, particularly in horses for sesamoid-related lameness.^[37]^[38] Monitoring progress involves regular clinical assessments and follow-up imaging, such as radiographs or MRI, at 4-8 weeks to evaluate healing and adjust the regimen if needed. In humans, persistent pain beyond 2-4 weeks prompts repeat imaging to confirm resolution; similar radiographic checks guide equine recovery to ensure safe return to activity.^[39]^[40]

Surgical Interventions

Surgical interventions for sesamoiditis are reserved for cases where conservative treatments have failed after 3-12 months, particularly in the presence of fractures, nonunions, or persistent chronic pain that significantly impairs function.^[41]^[42] These procedures are infrequently required, as most patients respond to non-invasive management.^[42] In humans, the primary surgical option is sesamoidectomy, involving partial or complete excision of the affected sesamoid bone, typically the tibial (medial) or fibular (lateral) sesamoid in the hallux. The medial-plantar approach is commonly used for the tibial sesamoid to minimize risks to the medial plantar nerve, while a plantar approach accesses the fibular sesamoid, protecting branches to the hallux. If adhesions are present, release of the flexor hallucis brevis tendon may accompany the excision to restore mobility.^[41]^[42]^[43] In horses, surgical management often involves arthroscopic debridement to remove fracture fragments or malacic bone from the proximal sesamoid, accessed via the metacarpophalangeal or metatarsophalangeal joint. For associated desmitis of the distal sesamoidean ligaments or intersesamoidean ligament, tenoscopic debridement or repair techniques, such as desmoplasty, address torn fibers and promote healing.^[44]^[45]^[46] Postoperative care in humans includes non-weight-bearing with crutches for 2 weeks, followed by progression to a walking shoe for 4-6 weeks and immobilization such as a splint or cast for up to 12 weeks, with full rehabilitation spanning 3-6 months. In horses, protocols emphasize stall rest and controlled handwalking for 2-3 months, often supplemented by anti-inflammatory medications and gradual return to exercise over 6-12 weeks to prevent reinjury.^[42]^[47]^[48]^[44] Outcomes in humans demonstrate high efficacy, with studies reporting complete pain resolution in up to 100% of cases and patient satisfaction rates of 80%, alongside significant improvements in functional scores such as the Foot and Ankle Ability Measure. Potential complications include transient neuritis (up to 17%), infection (3-4%), or deformities like hallux valgus, though reoperation rates remain low at 14%. In horses, prognosis varies by lesion severity, with 50-77% returning to racing after fragment removal, but poorer results (around 22% achieving soundness for riding) in cases of axial osteitis or extensive ligament damage; risks include persistent lameness or infection.^[42]^[43]^[45]^[44]

Prevention

Strategies for Humans

Preventing sesamoiditis in humans involves targeted modifications to footwear, activities, and biomechanics to minimize repetitive stress on the sesamoid bones beneath the big toe joint. Selecting appropriate footwear is foundational, as ill-fitting or unsupportive shoes can exacerbate forefoot pressure. Supportive shoes with cushioned soles and wide toe boxes help distribute weight evenly and reduce compression on the sesamoids, while avoiding high heels or minimalist running shoes prevents excessive dorsiflexion and impact loading.^[2]^[3] Soft-soled, low-heeled options or stiff-soled shoes like clogs further offload the area during daily activities.^[3] Activity modifications play a critical role in reducing overuse risks, particularly for athletes and dancers prone to repetitive push-off motions. Implementing gradual training increases allows tissues to adapt without overload. Cross-training with low-impact alternatives like swimming or cycling diversifies stress and preserves cardiovascular fitness while sparing the forefoot. Early recognition and intervention for minor pains, such as through rest or the RICE method (rest, ice, compression, elevation), can halt progression to full sesamoiditis by addressing inflammation promptly.^[49]^[33] Biomechanical aids enhance prevention by correcting structural vulnerabilities. Custom orthotics are particularly beneficial for individuals with high arches (pes cavus), which increase sesamoid loading; these devices provide arch support and metatarsal pads to redistribute pressure away from the sesamoids. Strengthening exercises targeting intrinsic foot muscles improve stability and shock absorption in the forefoot. Pre-participation screening for dancers and athletes, including gait analysis and assessment of risk factors like pes cavus, enables early identification and tailored interventions to mitigate injury likelihood.^[50]^[51]^[52] Long-term strategies focus on sustainable habits to lessen cumulative forefoot load. Maintaining a healthy weight through diet and exercise reduces overall pressure on the sesamoids during weight-bearing activities, with even modest reductions in body mass index correlating to decreased forefoot stress. Regular footwear assessment for wear and periodic professional evaluations ensure ongoing support, preventing recurrence in at-risk populations.^[49]^[3]

Strategies for Horses

Prevention of sesamoiditis in horses focuses on minimizing excessive stress on the proximal sesamoid bones through structured approaches to training, farriery, and overall management. Training protocols emphasize gradual conditioning to allow for proper bone and soft tissue adaptation, incorporating varied surfaces such as softer footing to reduce impact loading on the fetlock joint.^[53] Sudden intense work, particularly in young horses under two years old, should be avoided, as it can overload immature sesamoid bones during their remodeling phase, increasing fracture risk.^[53] Modifying training intensity and frequency, such as limiting high-speed workouts, has been shown to lower the incidence of sesamoid-related injuries in racehorses.^[54] Farriery plays a critical role in balancing the fetlock load to alleviate pressure on the sesamoid bones. Proper shoeing techniques, including rolled toes to promote smoother breakover and reduce tension on the suspensory apparatus, help distribute forces more evenly during locomotion.^[55] Adding pads or wedge shoes can further support the heels and maintain optimal hoof-pastern alignment, preventing excessive dorsiflexion that strains the sesamoids.^[56] Regular hoof care, every 4-6 weeks, ensures balanced trimming and shoeing to address conformational issues like low heels, which contribute to uneven loading.^[57] Management practices support musculoskeletal health by promoting natural movement and nutritional balance. Daily pasture turnout encourages low-impact exercise, fostering muscle development around the fetlock and improving overall joint stability, while disruptions to turnout routines have been linked to higher rates of orthopedic issues.^[58] Nutritional support with diets balanced in key minerals like calcium, phosphorus, and trace elements such as copper and zinc is essential for maintaining bone density and integrity, particularly in growing or performance horses prone to sesamoid stress.^[59] In breeding and selection, avoiding high-risk conformations—such as upright pasterns or straight hocks that increase fetlock hyperextension—is recommended to reduce predisposition to sesamoid overload.^[60] Radiographic screening of yearlings identifies early sesamoid variants, like vascular channel enlargement or enthesophytes, which correlate with a fivefold higher risk of future suspensory branch injuries and sesamoiditis; horses showing moderate to severe changes may be excluded from breeding programs or intense training.^[53] Ongoing monitoring through routine lameness examinations in performance horses allows for early intervention at subtle signs of fetlock discomfort, such as mild swelling or gait asymmetry, enabling prompt rest to prevent progression to full sesamoiditis.^[61] Periodic imaging, including ultrasound of the suspensory branches and radiographs, complements clinical checks to detect bony changes before they cause clinical lameness.^[62]

Notable Cases

In Humans

Sesamoiditis in humans often presents with sharp pain under the big toe joint, exacerbated by weight-bearing activities, swelling, and tenderness upon palpation, significantly impacting athletes and performers who rely on foot propulsion.^[3] A notable case involved MLB pitcher Josh Zeid, who in 2014 suffered bilateral sesamoiditis while with the Houston Astros, leading to placement on the 15-day disabled list and eventual season-ending sesamoidectomy surgery on both feet after initial attempts at rest and management failed.^[21]^[22] Zeid, who had debuted in 2013, made only 23 appearances that year with a 6.97 ERA before the injury sidelined him, though he later returned to minor league play with the Detroit Tigers organization in 2015.^[23] In professional ballet dancers, sesamoiditis is prevalent due to repetitive demi-pointe and en pointe positions that stress the sesamoid complex, often resulting in chronic pain that necessitates career adjustments like modified training or surgical intervention in severe cases during the 2010s.^[26] Among athletes, sesamoiditis accounts for a significant portion of forefoot injuries; for instance, it represented 62.6% of hallux sesamoid diagnoses in a study of young athletes, with running comprising 13.7% of affected sports.^[27] Most individuals recover fully with conservative approaches such as rest, orthotics, and physical therapy, but delayed diagnosis or treatment can lead to chronic issues that prematurely end athletic careers, as seen in prolonged recovery timelines for elite performers.^[3]

In Horses

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Jul 28, 2020 · The most common fatal injury in racehorses in the United States, PSB fractures account for 45-50 percent of such injuries in Thoroughbreds, and ...Missing: prevalence | Show results with:prevalence
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Risk factors for proximal sesamoid bone fractures ... - AVMA Journals
Proximal sesamoid bone fractures are the principal cause of catastrophic suspensory apparatus failure in Thoroughbred racehorses. No epidemiologic studies have ...
[22]
Zeid hopes ailing feet don't require surgery - MLB.com
Jul 27, 2014 · Astros relief pitcher Josh Zeid, who was placed on the 15-day disabled list Saturday night with left foot bilateral sesamoiditis, said Sunday he hopes to be ...
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https://www.mlb.com/player/josh-zeid-473646
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Josh Zeid Stats, Age, Position, Height, Weight, Fantasy & News
Left foot bilateral sesamoiditis. June 13, 2014, Houston Astros recalled RHP ... MORE MLB SITES & AFFILIATES. MLB Players Alumni Association · MLB Players ...
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What to do about Yankees infielder DJ LeMahieu's toe injury
Nov 28, 2022 · LeMahieu was sidelined through the playoffs because of a broken sesamoid bone in his right big toe that led to ligament damage in his second toe.Missing: famous | Show results with:famous
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DJ LeMahieu Hopes to Regain Form After Injury-Marred Seasons
Feb 18, 2025 · LeMahieu missed the 2022 playoffs because of the injury, eventually diagnosed as a broken sesamoid bone in his right big toe that led to ...
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Lower Extremity Injury Patterns in Elite Ballet Dancers
Since ballet predisposes the sesamoids to significant force during demi pointe and en pointe as well as in jump landings, it is not uncommon for dancers to ...
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Hallux Sesamoid Injury Characteristics in Young Athletes ... - PubMed
May 1, 2022 · Results: The most common diagnosis was sesamoiditis (62.6%). The top 3 primary sports were dance (34.6%), running (13.7%), and soccer (11.7%).
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Conservative Treatment of Sesamoiditis: A Systematic Literature ...
Jul 3, 2025 · Treatment for sesamoiditis typically begins with conservative management strategies aimed at alleviating pain, reducing inflammation, and ...
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Sesamoiditis in Horses: Causes, Symptoms and Treatment | Mad Barn
### Diagnostic Methods for Sesamoiditis in Horses
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Axial osteitis of the proximal sesamoid bones and desmitis of the ...
Nov 19, 2014 · Axial osteitis of the proximal sesamoid bones and desmitis of the intersesamoidean ligament has been described in Friesian horses as well as in ...
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Jul 5, 2019 · Sesamoid injuries in horses can be difficult to repair and even catastrophic; here's what can go wrong and how to prevent it from happening.
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[PDF] Santa Anita Fatalities Report - California Horse Racing Board
In both instances, there was a dis- proportionate number of proximal sesamoid bone fractures and a perception by horseman that the track surface was problematic ...
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Sesamoiditis | Radiology Reference Article | Radiopaedia.org
Mar 9, 2018 · Sesamoiditis (rare plural: sesamoiditides) is an inflammatory condition involving the sesamoid bones, usually a diagnosis of exclusion.Missing: mechanism | Show results with:mechanism<|control11|><|separator|>
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Disorders of the Pastern and Fetlock in Horses
The most common sesamoid fractures in Standardbreds and Thoroughbreds are apical (see sesamoid bone apical fracture images). They are due to overextension and ...P1 Fractures · Palmar Osteochondral Disease... · Sesamoiditis In Horses
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Axial sesamoiditis in the horse: A review - PMC - NIH
Mar 29, 2018 · Axial sesamoiditis or osteitis of the proximal sesamoid bones (PSBs) in the horse is described as a rare condition. The cause remains unknown and speculative.
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Radiological findings in the proximal sesamoid bones of yearling ...
Jan 18, 2024 · By 2 years of age, the prevalence of this finding had greatly reduced and <1% of 2-year-old sesamoids were affected. Paired sales radiographs ...
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Shockwave Therapy | Albuquerque Podiatrist | Foot Pain Treatment
High Success Rates. Clinical studies consistently demonstrate shockwave therapy's effectiveness, with success rates ranging from 70-90% for conditions like ...
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Painful sesamoid of the great toe - PMC - NIH
Sesamoiditis is a painful condition affecting the sesamoids and can occur with or without trauma. This may be due to cartilage abnormalities similar to ...
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What is sesamoiditis in horses? - Your Horse
Jan 10, 2024 · Treatment options This may be required for around 30 days, with hand-walking for up to 60 days, to prevent your horse reinjuring the sesamoid ...Missing: therapy | Show results with:therapy
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Sesamoid osteonecrosis treated with radial extracorporeal shock ...
May 22, 2017 · We propose that rESWT is a good non-surgical option for treatment of this disabling condition, where other conservative treatments have failed ...
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Shockwave - Equine Tendon
Benefits of Shockwave Therapy in Horses It can also be used for treating bone spavin, navicular syndrome, sesamoiditis, splints, non-healing wounds, stress ...
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https://pubmed.ncbi.nlm.nih.gov/39075767/
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Sesamoid Injuries in Horses: Types, Treatment & Prevention | Mad Barn
### Conservative Treatment for Sesamoid Injuries in Horses
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Sesamoid Injuries of the Hallux - Foot & Ankle - Orthobullets
Dec 29, 2024 · Complete or Partial Sesamoidectomy. approaches. approach to tibial sesamoid. medial-plantar approach. high risk of injuring proper branch of ...
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Is Fibular Sesamoidectomy a Viable Option for Sesamoiditis ... - NIH
Jun 19, 2019 · Fibular sesamoidectomy may be a safe, viable procedure for patients with sesamoiditis who fail conservative measures.Missing: indications | Show results with:indications
[47]
Early Functional Outcomes and Complications of Tibial and/or ...
Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, ...
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Axial osteitis of the proximal sesamoid bones and desmitis of the ...
Nov 19, 2014 · The objectives of this study were to review the outcome of clinical cases of this disease in Friesian horses and analyse the pathology of the ...
[49]
Racing performance after arthroscopic removal of apical sesamoid ...
Aug 6, 2025 · Data show that arthroscopic removal of apical proximal sesamoid fracture fragments is successful at restoring ability to race in skeletally ...
[50]
Outcome of desmoplasty and fasciotomy for desmitis involving the ...
Aug 1, 2006 · Results suggest that desmoplasty with fasciotomy is a viable treatment option in horses with proximal suspensory desmitis that have not responded to stall rest.Missing: repair | Show results with:repair<|separator|>
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[PDF] Sesamoidectomy - The University of Kansas Health System
Phase I - Maximum Protection. Weeks 0 to 2: ▫ Post-operative posterior splint. ▫ Non-weight bearing at all times with use of crutches o No scooter.
[52]
[PDF] Sesamoidectomy - Dr Simon Zilko
FROM 6-12 WEEKS Full recovery is usually 3-6 months, and can take up to 12 months. Every pafient's recovery is individual and depends on the severity of the ...
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How to Prevent Sesamoiditis | Forefoot Pain Relief Tips
Oct 3, 2025 · Prevent sesamoiditis and forefoot pain with proper shoes, cross-training, and gradual activity increases. Learn expert tips to protect your ...
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Atraumatic Sport-Related Medial Sesamoid Pain - NIH
In other words, we can hypothesize that a higher arch caused by pes cavus may increase the pressure on the medial sesamoid, making pain relief more difficult to ...
[56]
Sesamoiditis - Physiopedia
Sesamoiditis is a chronic injury, caused by frequent pressure and results in irritation and painful inflammation of the surrounding tissues.
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Sesamoiditis in Horses: Causes, Symptoms and Treatment | Mad Barn
### Prevention Strategies for Sesamoiditis in Horses
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Exercise Affects Proximal Sesamoid Bone Pathology in Racehorses
Feb 16, 2022 · Modifying training programs and monitoring lesion sites might help protect against PSB fractures in this population of horses.
[59]
Full rolling motion shoes in equine podiatry
After trimming the hoof (flat) the appropriate size F.R.M.S. is chosen, after marking right and left, the shoe is placed on the bottom of the hoof, centred in ...
[60]
Farrier Offers Guidance On Shoeing To Protect Sesamoid Bones In ...
Feb 1, 2021 · In the end, from the farrier's perspective, Stanley said it all comes down to maintaining the hoof/pastern angle. Up-close photographs of horses ...
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Clinical and Radiological Evaluation of Racehorses with Sesamoiditis
The body conformation and low-heeled hoof structure play a role in the development of sesamoiditis in horses and should be considered. ... Foot Care and Farriery.
[62]
Associations between turn out practices and rates of ...
Dec 26, 2023 · ... sesamoiditis), which affected 18% of foals remaining in the study ... farriery, or a change to routine, for example, spending part of ...<|separator|>
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Ligament Inflammation in Horses: Consider Bone Supplements for ...
Jun 2, 2021 · “For this reason, using a supplement like Triacton will help prevent severe loss of bone mineral density during rest and also improve ...
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Sesamoiditis | EquiMed - Horse Health Matters
Aug 15, 2014 · Preventing sesamoiditis in athletic horses is difficult, but efforts can be made to limit exercise on hard surfaces and to act promptly when ...
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https://madbarn.ca/sesamoid-injuries-in-horses/
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Sesamoiditis and Suspensory Branch Changes? Keep a Close Eye
Feb 9, 2016 · Ultrasound and x ray exams can help identify horses potentially at-risk for injury so they can be managed appropriately.