Pathology of the sesamoid bones of the foot

On the plantar side of the metatarsophalangeal joint of the first toe, in the structure of the flexor apparatus there are two small bones smaller than a pea. Despite the fact that the bones are very small in size, they play a huge role during walking, running, jumping and other stress on the foot. If the sesamoid bones are involved in any pathological process, they become a source of severe pain, significantly worsening the patient’s quality of life.

Anatomy

At the base of the first toe is the first metatarsophalangeal joint, which is important from a functional point of view. Two small sesamoid bones are located on the plantar side of this joint: one is located on the inside, the other on the outside. The sesamoid bones are located inside the flexor tendons of the first finger. These structures together form the flexor apparatus of the first toe. Since the first finger bears heavy loads, these loads are performed due to the flexion apparatus. Sesamoid bones increase the leverage of the flexor tendons on the phalanges of the first finger, and also reduce the force of friction between the tendons and soft tissues in the position of extension of the first finger.

Other animals[edit]

Causes

Pain syndrome can develop for various reasons. One of the reasons is overload of the ligamentous apparatus of the sesamoid bones. This condition may be called sesamoiditis. Overload most often develops after excessive running or dancing.

Another cause of pain associated with the sesamoid bones is fractures. Fractures can occur when landing directly on the first metatarsophalangeal joint of the foot. So-called stress fractures of the sesamoid bones may also occur. Stress fractures occur due to constant exposure to large loads on the sesamoid bone apparatus. This is typical for athletes; athletes are most often affected.

Another reason is arthrosis of the joint between the head of the first metatarsal bone and the sesamoid bones. When the big toe moves, the sesamoid bones slide anteriorly and posteriorly along the plantar surface of the head of the first metatarsal bone. Like other joints in the body, this joint can develop arthrosis. Arthrosis in this joint is typical for patients with a high longitudinal arch of the foot. With a high longitudinal arch of the foot, the apparatus of the sesamoid bones is under greater tension and the joints of the sesamoid bones are subject to greater load. Eventually, the cartilage of the sesamoids and the head of the first metatarsal begins to deteriorate.

A rare cause is a disruption of the blood supply to the sesamoid bones, resulting in disruption of the bone structure. This condition is called avascular necrosis of the sesamoid bone. In this case, calcium deposits may additionally form in the soft tissues around the first metatarsophalangeal joint.

Sometimes pain from the plantar surface comes from additional soft tissue formations under the big toe. For example, plantar keratosis can cause pain on the plantar aspect of the first metatarsophalangeal joint.

Bone tissue is the mineralized connective tissue that forms bones. They perform important functions, such as protecting soft tissues, storing calcium and phosphates, and participating in movements. Bones are not inert organs. These are extremely dynamic structures in which processes of bone formation and decomposition constantly occur. In addition, recent research shows that bones influence the functioning of other organs and systems. In addition to the musculoskeletal function, they also perform an endocrine function, which is due to the release of biologically active substances from some of their cellular components. Bone tissue is composed of three types of cells: osteoblasts, osteoclasts and osteocytes.

Osteoblasts originate from mesenchymal stem cells. Their main function is associated with participation in the formation and mineralization of bone. They are cuboid cells that make up 4-6% of the cellular components of bone. Their morphological characteristics resemble proteins that synthesize cells - they have a well-developed endoplasmic reticulum and Golgi apparatus. Osteoblasts have membrane-bound parathyroid hormone receptors that are secreted by the parathyroid glands.
Osteoclasts are large multinucleated cells derived from monocyte precursors. They carry out the resorption of bone matter.
Osteocytes are flat cells with multiple growths and connections between them. They are densely located in the bone matrix, originate from osteoblasts and make up 90-95% of bone cells. Osteocytes are among the longest-lived cells with a lifespan of up to 25 years. After mechanical stimulation, osteocytes produce several second mediators such as ATP, nitric oxide, Ca 2+ and prostaglandins (PGE2 and PGI2), which influence bone physiology.

Bone formation is carried out by activated osteoblasts. They synthesize components of the extracellular matrix - collagen type I, glycosaminoglycans, protoglycans, osteocalcin, osteonectin and sialoprotein. Osteoblasts are rich in alkaline phosphatase. Collagen is released in the form of collagen monomers, which quickly polymerize and form collagen fibers. Collagen fibers constitute an organic matrix in which calcium salts are deposited. Thus, osteoid tissue is formed. Once a portion of the osteoblasts are formed, they are placed in it and turn into osteocytes. Calcium salts are first precipitated as amorphous (non-crystalline) components, which then form hydroxyapatite crystals by substitution and addition of atoms, resorption and precipitation. These processes form the initial mineralization. Complete mineralization occurs after a few months. After this, osteoblasts stop their secretory activity and turn into osteocytes. Normal plasma calcium and phosphate concentrations are required for normal mineralization. This process depends on the active form of vitamin D3. Parathyroid hormone reduces the formation of collagen by osteoblasts, and cortisol inhibits the maturation of preosteoblasts and their transformation into mature osteoblasts. Exercise stimulates osteoblast activity and bone calcification. Some of the calcium salts remain in an amorphous state (without a crystalline structure). This is important because these salts are used to quickly extract calcium from bones in ECT. They represent exchangeable calcium (0.5-1.0%), which is always in equilibrium with Ca 2+ in ECT. Calcium metabolism is involved in rapid buffering mechanisms to maintain constant plasma concentrations of this mineral. Osteocytes are interconnected by many growths that connect them both to the bone surface and to osteoblasts. They are located in concentric layers in the bone matrix. This arrangement creates conditions for the transfer of Ca 2+ from the inside to the surface of the bone and from there to the DEC. This transfer by osteocytes is called osteocytic osteolysis. This removes calcium from newly formed crystals and does not reduce bone mass. Osteocytes are associated with rapid changes in plasma calcium concentration. They have osteolytic properties that are associated with short-term bone remodeling. Osteoclasts are large multinucleated cells with many mitochondria, lysosomes and a well-developed Golgi apparatus. They are rich in acid phosphatase. Bone resorption occurs on the surface of their folded membrane. Osteoclasts secrete organic anions (citrates), which increase the solubility of the mineral phase, and citrates. They carry out intercellular transport of calcium and sodium. Their lysosomes contain proteolytic enzymes, which, when released, affect the organic matrix and acids released from mitochondria - citric and lactic. The components of the extracellular matrix are degraded by extracellular collagenases, proteoglycanases, and proteolytic cathepsins. The processes of resorption of the bone matrix lead to its destruction, a decrease in bone mass and the release of calcium. Bone resorption by osteoclasts is associated with long-term bone remodeling. Bone tissue has high functional activity. At any given time, about 20% of bone matter is in the process of repair, called remodeling. This is a process of continuous resorption of bone substance followed by the construction of a new matrix and mineralization. Bone mass increases during the growth period due to the predominance of formation processes. The balance between formation and resorption stabilizes bone mass by age 50. After this, absorption predominates and total bone mass slowly decreases. Remodeling maintains the normal strength of bones and teeth. The rate of resorption and deposition in childhood is high, and in old age it is much lower. This is due to the fact that children's bones are less brittle than in adulthood.

Symptoms

Patients with pathology of the sesamoid bones usually feel aching pain from the plantar surface of the metatarsophalangeal joint of the first toe. When touched from the plantar side, the pain intensifies. Movement in the thumb joint is often limited. Patients notice that when walking, the pain intensifies before the foot pushes off for the next step. From time to time, the first metatarsophalangeal joint may become stuck or click, which increases pain. After rest, the pain goes away or weakens. Some patients report numbness in the area of the first and second toes.

Transitional metatarsalgia. Description of the disease and treatment in Germany

Treatment of hallux valgus in Germany

Reduced pain
Slowing down or correcting hallux valgus
Restoring the functions of the 1st finger and 1st metatarsophalangeal joint

Today in Germany they offer many methods for treating hallux valgus. The orthopedist decides which treatment is appropriate in an individual case after examining the patient. During the examination, the doctor pays attention to the degree of development of the pathology, existing diseases and the patient’s personal situation. However, the best treatment for hallux valgus in Germany is, of course, prevention.

Diagnosis

The doctor will ask many questions about the development of the disease. You will be asked about your current complaints and past foot problems. The doctor will examine your feet. The examination may be a little painful, but it is necessary to identify painful points and check the movements of the fingers. The patient may be asked to walk around the room.

It is mandatory to take an x-ray (x-ray). Several projections are performed. One of them is the axial one, on which the sesamoid bones are clearly visible. This projection requires special placement and the X-ray beam comes at an angle.

An x-ray may reveal that the sesamoid bone is composed of two or more separate bones, as if it were a fracture, but the boundaries between them are smooth. This is normal and can occur in every tenth person. The x-ray evaluates the position of the sesamoid bones, as well as the space (articulation) between the metatarsal head and the sesamoid bones. The joint space normally appears uniform on x-ray. Narrowing and unevenness indicate pathology.

If it is difficult to judge the presence of a sesamoid fracture from a plain X-ray, a scan may be ordered. This is a test in which a special solution, a contrast agent, is injected intravenously. The contrast agent accumulates in the bone tissue in a certain way. By scanning the human skeleton with X-rays, special images are created that reflect the accumulated X-ray contrast agent. If there is a pathological focus in the bone tissue, then the pattern of accumulation of the contrast agent will look different. Each pathological process has its own unique pattern of contrast agent accumulation. In this way, a fracture can be distinguished from a congenital separation of the sesamoid bone.

To obtain the most complete picture of the disease, magnetic resonance imaging (MRI) may be necessary. Using MR images, you can study the relationships between the anatomical structures of the foot and exclude other pathological processes, including infection.

Metacarpal bones

The metacarpus consists of five tubular metacarpal bones. The metacarpal bone of the first finger is shorter than the others, but is distinguished by its massiveness. The longest is the second metacarpal bone. The following bones towards the ulnar edge of the hand decrease in length. Each metacarpal bone has a base, a body and a head.

The bases of the metacarpal bones articulate with the bones of the wrist. The bases of the first and fifth metacarpal bones have saddle-shaped articular surfaces, and the rest have flat articular surfaces. The heads of the metacarpal bones have a hemispherical articular surface and articulate with the proximal phalanges of the fingers.

Treatment

Conservative treatment

As a rule, treatment begins with conservative methods. Typically, in this case, nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, indomethacin, and ibuprofen, are recommended. These remedies usually relieve pain and inflammation well. You can try using special insoles that ease the load on the first metatarsophalangeal joint. Be sure to avoid using high-heeled shoes. The higher the heel, the greater the load on the forefoot, and therefore on the painful metatarsophalangeal joint. In some cases, your doctor may suggest injecting a steroid into the painful area. This usually helps relieve severe pain.

If there is a sesamoid fracture without a rupture of the extensor apparatus, wearing a plaster or plastic splint for approximately six weeks is recommended. After this, the patient must wear hard-soled shoes. The rigid sole holds the toe in a straight position, preventing the foot from rolling, thus relieving the load on the flexion apparatus. In some cases, the doctor may recommend treatment without the use of splints, prescribing the wearing of shoes with hard soles. If a fracture of the sesamoid bone occurs with a rupture of the flexor apparatus, then surgical treatment is necessary to fully restore function.

Stress fractures and aseptic necrosis of the sesamoid bone are less responsive to conservative treatment. Some doctors recommend a plaster or plastic splint for up to eight weeks without putting any weight on the leg. If after prescribing conservative treatment it does not get better within 8-12 weeks, then surgery is most likely necessary.

Treatment in Germany: Who suffers from Hallux valgus and who needs specialized treatment?

Hallux valgus disease in Germany affects predominantly (90%) women. With age, the frequency of such cases increases significantly. Sometimes younger women and men are also interested in treating hallux valgus in Germany. However, in this case, hallux valgus is a genetic disease, and not a consequence of wearing uncomfortable but beautiful heels.

Treatment for Hallux valgus is almost not carried out in those countries where the population wears more comfortable and open shoes or does not wear shoes at all. In Japan and China, it is customary to wear very narrow and elegant shoes: Therefore, treatment of Hallux valgus pathology is carried out in these countries, more often than, for example, in Germany.

Surgical treatment

Sesamoid bone removal

Your doctor may suggest removing part or all of the sesamoid bone. When the sesamoid bone is partially removed, the other sesamoid bone is able to provide a fulcrum for the flexors. However, if both bones are removed, the flexors will not be able to function normally and the first toe will become claw-shaped. Therefore, surgeons usually avoid removing both sesamoid bones.

When the sesamoid bone is fractured, surgery is performed to remove non-functional fragments and restore the integrity of the flexor apparatus. For stress fractures in athletes, when the most complete recovery is needed, surgery can be performed using bone grafts. To remove the sesamoid bones, an incision is made on the inside of the foot. Sometimes it becomes necessary to perform this operation from an incision along the plantar side of the foot between the heads of the first and second metatarsal bones.

Surgical treatment of Hallux valgus in Germany: Specific goals

Elimination of acute pain and mobility restrictions:

After surgery, patients want to have normal, straight and beautiful feet from an anatomical point of view, capable of withstanding loads both during sports and in everyday life. The Gelenk-Klinik clinic in Germany will do everything possible to fulfill the wishes of patients and provide high-quality treatment.

Correction of the position (osteotomy) of the toe bones:

Osteotomy is a very important intervention that can prevent arthrosis of the 1st metatarsophalangeal joint, as well as other problems in the foot, namely in its anterior part (for example, hammertoe and hamate deformities). The purpose of this operation is long-term normalization of gait and restoration of the mechanical axis during foot roll.

Stabilization of the 1st metatarsophalangeal joint with arthrosis:

Due to hallux valgus, arthrosis (wear and tear) of the 1st metatarsophalangeal joint may occur, which can be treated with joint-preserving surgery (arthroscopy) or surgery to immobilize the joint (arthrodesis). In addition, modern medicine in Germany also offers the use of total or partial dentures.

Rehabilitation

Rehabilitation after conservative treatment

If the pain syndrome is mild, the doctor may allow you to continue your daily activities immediately, but with the condition that you use shoes with hard soles. If the disease is moderate, you will need to use crutches and not put any weight on your leg for a period of several days to two to three weeks. If the pain is severe, you will need to walk on crutches without putting any weight on your leg for several weeks. Typically, full recovery should not be expected until four to six weeks.

Physical therapy can help reduce pain and swelling. If there are no contraindications, then ultrasound and thermal procedures are prescribed. Sometimes the use of anti-inflammatory ointments and creams is combined with physiotherapy.

Rehabilitation after surgical treatment

After surgery, most patients are advised to use crutches and avoid putting weight on the leg. For those who have undergone restoration of the flexor apparatus of the first toe or bone grafting, immobilization with a plaster or plastic splint is recommended. After this, it is recommended to wear shoes with hard soles until complete recovery. The results of bone grafting of the sesamoid bone can be assessed after 2 months by performing an MRI.

Physical therapy exercises are required. Depending on the operation performed, exercises begin at different times after the operation, gradually increasing the load and complexity. Therapeutic exercise is necessary to restore and maintain muscle tone of the lower leg and foot.

Surgical treatment of hallux valgus in Germany: Good cosmetic result

Rice. 3: Treatment of hallux valgus in Germany: Beautiful feet without pain

1. Minimum implantation material.
2. Treatment with minimal incisions.
3. Treatment with short sutures.
4. Minimal scarring.
5. Seam in the invisible area of the toe and foot

Due to the general medical risk, as well as post-operative restrictions on movement in everyday life during the recovery process, in Germany it is not possible to prescribe treatment for Hallux valgus just because the aesthetic appearance of the foot is impaired. However, doctors at the Gelenk-Klinik clinic in Germany understand perfectly well that every person wants to look beautiful, and make every effort to ensure that surgical treatment in Germany brings the patient the desired result. Surgical treatment of the foot in Germany involves minimal skin incisions, minimal scarring, and minimal use of special implant material.

In the case of progressive hallux valgus with a more pronounced bunion, it makes sense to undergo conservative or surgical treatment in Germany to straighten the 1st toe, even if the patient does not yet feel severe pain.

Please note that the later you contact a foot specialist in Germany, that is, the later you start treatment, the more significant the resulting damage will be, which is mainly observed in women.

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