CLINICAL CORRESPONDENCE
Congenital Missing Tibial Sesamoid in a Marathon Runner A Case Report Garry Shtofmakher, BA* Endri Afesllari, BS* Adam Rozenstrauch, MS* Thomas M. DeLauro, DPM* Randy E. Cohen, DPM* The absence of the hallucal tibial sesamoid is seldom seen in the clinical setting. We present a case of a symptomatic missing tibial sesamoid in a female marathon runner. (J Am Podiatr Med Assoc 104(5): 550-553, 2014)
The sesamoid bones develop within a tendon or a joint capsule. Some sesamoid bones are constant, such as the tibial and fibular sesamoids, while others are variable. The tibial and fibular sesamoids are positioned within the tendons of the flexor hallucis brevis and articulate on their dorsal surfaces with the plantar facets of the first metatarsal head. The crista, or intersesamoidal ridge, distinctly separates both sesamoids.1 In an examination of 186 radiographs of boys and girls 5 to 17 years old, Dharap et al2 showed that the ossification of the hallucal sesamoids begins at the age of 8 in girls and at 9 in boys and concludes by the age of 10 in both sexes.2 The sesamoids play a critical role in the function of the lower extremity. Root et al3 described their function as a requirement during the gait cycle. The sesamoids function to stabilize the first metatarsophalangeal joint (MPJ) during propulsion.3 Furthermore, Root et al discussed the implications of the congenital absence of the sesamoids by emphasizing the loss of propulsive function of the first ray. In addition, the absence of either sesamoid can manifest into a planar deformity such as hallux abducto valgus (HAV).4 Over the years, various authors have concluded that a missing tibial sesamoid could be symptomatic (painful), asymptomatic (painless), or associated with an HAV deformity.5-13 Table 1 presents an overview of previous case reports of a missing tibial sesamoid. The first two reported cases of an *New York College of Podiatric Medicine, New York, NY. Corresponding author: Garry Shtofmakher, BA, New York College of Podiatric Medicine, 53 East 124th Street New York, NY 10035. (E-mail: [email protected])
550
absent tibial sesamoid were by Inge, and neither patient reported any symptoms.5 Lapidus followed with an additional case of an absent tibial sesamoid.6 Zinsmeister and Edelman were the first to report two cases of congenital absence of the tibial sesamoid that presented with an associated HAV deformity.7 The authors emphasized the role of a weakened medial flexor hallucis brevis tendon as a predisposing factor to an HAV deformity. Goez and DeLauro8 found no cartilaginous analog of a missing tibial sesamoid intraoperatively. Wright9 was the first to describe a case of bilateral absence of tibial and fibular sesamoids with concomitant hallux varus in a prematurely born patient. Day et al10 reported a patient who was initially evaluated for a stress fracture, but subsequent radiographic evaluation revealed a missing tibial sesamoid. Interestingly, the patient was asymptomatic in the area of the missing tibial sesamoid. Kanatli et al11 presented a case in which first MPJ pain was associated with the absence of the tibial sesamoid. This anomaly was identified by both radiographic and magnetic resonance imaging (MRI) analysis. Gait analysis was additionally used to evaluate plantar pressure in this patient. Alshryda et al12 reported a case in which a patient presented with bilateral missing tibial and fibular sesamoids associated with a severe hallux valgus deformity. Lui et al13 reported a similar case of the bilateral absence of the tibial and fibular sesamoids associated with a hallux valgus deformity. However, the patient was an athlete in his early twenties. We present an additional case of a unilateral missing tibial sesamoid in a female
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Table 1. Summary of Articles
Authors Inge
Unilateral/ Bilateral Missing Tibial HAV Deformity present Year Cases(s) Age/Sex Sesamoid(s) Asymptomatic Symptomatic 1936
2
28/M
Unilateral
X
33/F
Unilateral
X X
Comments
Not reported
Lapidus
1939
1
30/F
Unilateral
Zinsmeister and Edelman
1985
2
24/F
Unilateral
55/F
Unilateral
X
Goez and Delauro 1995
1
50/F
Unilateral
X
Yes
No cartilaginous analog of tibial sesamoid was seen during surgery.
Wright
1998
1
19/F
Bilateral
X
Not reported
Bilateral absence of tibial and fibular sesamoids. Bilateral hallux varus noted. Patient was born premature (at 7 months gestation).
Day et al.
2002
1
57/F
Unilateral
Not reported
Presented for evaluation and treatment of stress fracture of 2nd metatarsal on right foot.
Kanatli et al.
2006
1
17/M
Unilateral
X
Not reported
MRI imaging and Gait study (EMED-SF) was performed on patient who was reported to engage in sports.
Alshryda et al.
2012
1
18/F
Bilateral
X
Yes (Both)
MRI imaging was performed. Patient had bilateral absence of tibial and fibular sesamoids.
Lui et al.
2013
1
23/M
Bilateral
X
Yes
MRI imaging was performed. Patient has bilateral absence of tibial and fibular sesamoids.
Current Paper
2013
1
38/F
Unilateral
X
Stage 1 HAV deformity
X-rays revealed bipartite tibial sesamoid on the left foot and missing tibial sesamoid on the right foot in a female marathon runner.
marathon runner in her thirties with radiographic evidence of a stage 1 HAV deformity.
Case Report A 38-year-old woman presented to a local outpatient podiatry clinic for a 2-month history of
Not reported X
X
Yes (both)
recurrent right plantar foot pain that was exacerbated while training for a marathon. The patient described the pain as ‘‘aching’’ and rated it on a visual analog scale as 8/10. The patient reported no prior self-treatment and had not sought medical attention for this problem. The condition worsened upon ambulation and improved with rest. No
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
551
significant medical or surgical history was reported. Physical examination demonstrated localized pain over the area of the sesamoids upon palpation. Physical examination was otherwise unremarkable. Dorsal-plantar and sesamoidal axial radiographs were taken to rule out fracture of the sesamoids. The radiographs revealed a bipartite fibular sesamoid in the asymptomatic left foot (Fig. 1) and a missing tibial sesamoid in the symptomatic right foot (Fig. 2). The short-term plan included placement of a dancer’s pad, which was fabricated for the symptomatic foot. As part of the long-term treatment plan, the patient was referred to the orthopedic department for further biomechanical evaluation and gait analysis. A component of the long-term treatment plan included fabrication of a functional foot orthosis. Unfortunately, the patient was lost to follow-up and no further treatment was rendered.
Discussion The literature suggests a potential association between HAV and missing tibial sesamoids. In the present case, the symptomology, soft-tissue swelling on the medial aspect of the first MPJ, and radiographic evidence suggested a stage 1 HAV deformity.14 Goez and DeLauro8 suggested that the lack of a tibial sesamoid does not produce a more
severe HAV deformity, and the findings in our case are in agreement with their statement. Marathon runners require the most biomechanically effective first MPJ function. One of the functional requirements of the first MPJ during the propulsive period of gait is normal mobility of the sesamoid apparatus and pertinent soft tissues.14 Therefore, a disruption of this apparatus will ultimately lead to an inefficient gait, which will require excess energy expenditure. To our knowledge, there have been no reports regarding a missing tibial sesamoid in a marathon runner. Owing to the increasing popularity of running, podiatrists are treating an ever-increasing number of runners. When presented with a case such as described here, conservative treatment would include modification of activities, and shoe modifications, aiming to lower the heel height and reduce the stress placed under the metatarsal heads. In addition, increasing the thickness of the sole would reduce ground reactive forces upon the foot. Metatarsal pads may be another effective treatment option. 15 When presented with an acutely symptomatic sesamoid, secondary to repetitive trauma to the forefoot due to running, a dancers pad can be used as in this case. This padding technique allows for redistribution of force and offloading of the sesamoid apparatus.16 When coupled with alteration of the athletes training regimen, resolution of symptoms can be achieved.
Figure 1. Dorsal-plantar (A) and sesamoidal axial (B) views of the left foot, demonstrating a bipartite tibial
sesamoid.
552
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Figure 2. Dorsal-plantar view of the right foot,
demonstrating a missing tibial sesamoid. Without the use of advanced imaging modalities such as MRI, one cannot definitively state whether a cartilaginous sesamoid is present.17 Because our patient was lost to follow-up, we could not obtain further imaging such as MRI to rule out a cartilaginous tibial sesamoid. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. STANDRING S: ‘‘Ankle and Foot,’’ in Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th Ed, edited by V Mahadevan, p 1441, Churchill Livingstone Elsevier, London, England, 2008. 2. DHARAP AS, AL-HASHIMI H, KASSAB S, ET AL: Incidence and ossification of sesamoid bones in the hands and feet: a radiographic study in an Arab population. Clin Anat 20: 416, 2007.
3. ROOT M, ORIEN W, WEED J: ‘‘Normal Motion of the Foot and Leg in Gait,’’ in Normal and Abnormal Function of the Foot, Vol 2, edited by SA Root, p 285, Clinical Biomechanics Corporation, Los Angles, CA, 1977. 4. COUGHLIN M: ‘‘Sesamoids and Accessory Bones of the Foot,’’ in Surgery of the Foot and Ankle, 6th Ed, edited by RA Mann and MJ Coughlin, p 467, Mosby, St. Louis, MO, 1993. 5. INGE G: Congenital absence of the medial sesamoid of the great toe. Report of two cases. J Bone Joint Surg 18: 188, 1936. 6. LAPIDUS PW: Congenital unilateral absence of the medial sesamoid of the great toe. J Bone Joint Surg 21: 208, 1939. 7. ZINSMEISTER BJ, EDELMAN R: Congenital absence of the tibial sesamoid: a report of two cases. J Foot Surg 24: 266, 1985. 8. GOEZ J, DELAURO T: Congenital absence of the tibial sesamoid. JAPMA 85: 509, 1995. 9. WRIGHT SM: Congenital hallux varus deformity with bilateral absence of the hallucal sesamoids. JAPMA 88: 47, 1998. 10. DAY F, JONES PC, GILBERT CL: Congenital absence of the tibial sesamoid. JAPMA 92: 153, 2002. 11. KANATLI U, OZTURK AM, ERCAN NG, ET AL: Absence of the medial sesamoid bone associated with metatarsophalangeal pain. Clin Anat 19: 634, 2006. 12. ALSHRYDA S, LOU T, FAULCONER ER, ET AL: Adolescent hallux valgus deformity with bilateral absence of the hallucal sesamoids: a case report. J Foot Ankle Surg 51: 80, 2012. 13. LUI TH, TAM KF: Hallux valgus deformity associated with bilateral absence of the tibial and fibular hallucal sesamoids. J Foot Ankle Surg 52: 254, 2013. 14. GERBERT J, PALLADINO SJ: ‘‘Preoperative Evaluation of the Bunion Patient,’’ in Textbook of Bunion Surgery, 4th Ed, edited by J Gerbert, p 1, Data Trace, Brooklandville, MD, 2012. 15. JAHSS MH: The sesamoids of the hallux. Clin Orthop Relat Res 157: 88, 1981. 16. PRISK VR, O’LOUGHLIN PF, KENNEDY JG: Forefoot injuries in dancers. Clin Sports Med 27: 305, 2008. 17. LE M INOR JM: Congenital absence of the lateral metatarso-phalangeal sesamoid bone of the human hallux: a case report. Surg Radiol Anat 21: 225–7, 1999.
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
553
Congenital Missing Tibial Sesamoid in a Marathon Runner A Case Report Garry Shtofmakher, BA* Endri Afesllari, BS* Adam Rozenstrauch, MS* Thomas M. DeLauro, DPM* Randy E. Cohen, DPM* The absence of the hallucal tibial sesamoid is seldom seen in the clinical setting. We present a case of a symptomatic missing tibial sesamoid in a female marathon runner. (J Am Podiatr Med Assoc 104(5): 550-553, 2014)
The sesamoid bones develop within a tendon or a joint capsule. Some sesamoid bones are constant, such as the tibial and fibular sesamoids, while others are variable. The tibial and fibular sesamoids are positioned within the tendons of the flexor hallucis brevis and articulate on their dorsal surfaces with the plantar facets of the first metatarsal head. The crista, or intersesamoidal ridge, distinctly separates both sesamoids.1 In an examination of 186 radiographs of boys and girls 5 to 17 years old, Dharap et al2 showed that the ossification of the hallucal sesamoids begins at the age of 8 in girls and at 9 in boys and concludes by the age of 10 in both sexes.2 The sesamoids play a critical role in the function of the lower extremity. Root et al3 described their function as a requirement during the gait cycle. The sesamoids function to stabilize the first metatarsophalangeal joint (MPJ) during propulsion.3 Furthermore, Root et al discussed the implications of the congenital absence of the sesamoids by emphasizing the loss of propulsive function of the first ray. In addition, the absence of either sesamoid can manifest into a planar deformity such as hallux abducto valgus (HAV).4 Over the years, various authors have concluded that a missing tibial sesamoid could be symptomatic (painful), asymptomatic (painless), or associated with an HAV deformity.5-13 Table 1 presents an overview of previous case reports of a missing tibial sesamoid. The first two reported cases of an *New York College of Podiatric Medicine, New York, NY. Corresponding author: Garry Shtofmakher, BA, New York College of Podiatric Medicine, 53 East 124th Street New York, NY 10035. (E-mail: [email protected])
550
absent tibial sesamoid were by Inge, and neither patient reported any symptoms.5 Lapidus followed with an additional case of an absent tibial sesamoid.6 Zinsmeister and Edelman were the first to report two cases of congenital absence of the tibial sesamoid that presented with an associated HAV deformity.7 The authors emphasized the role of a weakened medial flexor hallucis brevis tendon as a predisposing factor to an HAV deformity. Goez and DeLauro8 found no cartilaginous analog of a missing tibial sesamoid intraoperatively. Wright9 was the first to describe a case of bilateral absence of tibial and fibular sesamoids with concomitant hallux varus in a prematurely born patient. Day et al10 reported a patient who was initially evaluated for a stress fracture, but subsequent radiographic evaluation revealed a missing tibial sesamoid. Interestingly, the patient was asymptomatic in the area of the missing tibial sesamoid. Kanatli et al11 presented a case in which first MPJ pain was associated with the absence of the tibial sesamoid. This anomaly was identified by both radiographic and magnetic resonance imaging (MRI) analysis. Gait analysis was additionally used to evaluate plantar pressure in this patient. Alshryda et al12 reported a case in which a patient presented with bilateral missing tibial and fibular sesamoids associated with a severe hallux valgus deformity. Lui et al13 reported a similar case of the bilateral absence of the tibial and fibular sesamoids associated with a hallux valgus deformity. However, the patient was an athlete in his early twenties. We present an additional case of a unilateral missing tibial sesamoid in a female
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Table 1. Summary of Articles
Authors Inge
Unilateral/ Bilateral Missing Tibial HAV Deformity present Year Cases(s) Age/Sex Sesamoid(s) Asymptomatic Symptomatic 1936
2
28/M
Unilateral
X
33/F
Unilateral
X X
Comments
Not reported
Lapidus
1939
1
30/F
Unilateral
Zinsmeister and Edelman
1985
2
24/F
Unilateral
55/F
Unilateral
X
Goez and Delauro 1995
1
50/F
Unilateral
X
Yes
No cartilaginous analog of tibial sesamoid was seen during surgery.
Wright
1998
1
19/F
Bilateral
X
Not reported
Bilateral absence of tibial and fibular sesamoids. Bilateral hallux varus noted. Patient was born premature (at 7 months gestation).
Day et al.
2002
1
57/F
Unilateral
Not reported
Presented for evaluation and treatment of stress fracture of 2nd metatarsal on right foot.
Kanatli et al.
2006
1
17/M
Unilateral
X
Not reported
MRI imaging and Gait study (EMED-SF) was performed on patient who was reported to engage in sports.
Alshryda et al.
2012
1
18/F
Bilateral
X
Yes (Both)
MRI imaging was performed. Patient had bilateral absence of tibial and fibular sesamoids.
Lui et al.
2013
1
23/M
Bilateral
X
Yes
MRI imaging was performed. Patient has bilateral absence of tibial and fibular sesamoids.
Current Paper
2013
1
38/F
Unilateral
X
Stage 1 HAV deformity
X-rays revealed bipartite tibial sesamoid on the left foot and missing tibial sesamoid on the right foot in a female marathon runner.
marathon runner in her thirties with radiographic evidence of a stage 1 HAV deformity.
Case Report A 38-year-old woman presented to a local outpatient podiatry clinic for a 2-month history of
Not reported X
X
Yes (both)
recurrent right plantar foot pain that was exacerbated while training for a marathon. The patient described the pain as ‘‘aching’’ and rated it on a visual analog scale as 8/10. The patient reported no prior self-treatment and had not sought medical attention for this problem. The condition worsened upon ambulation and improved with rest. No
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
551
significant medical or surgical history was reported. Physical examination demonstrated localized pain over the area of the sesamoids upon palpation. Physical examination was otherwise unremarkable. Dorsal-plantar and sesamoidal axial radiographs were taken to rule out fracture of the sesamoids. The radiographs revealed a bipartite fibular sesamoid in the asymptomatic left foot (Fig. 1) and a missing tibial sesamoid in the symptomatic right foot (Fig. 2). The short-term plan included placement of a dancer’s pad, which was fabricated for the symptomatic foot. As part of the long-term treatment plan, the patient was referred to the orthopedic department for further biomechanical evaluation and gait analysis. A component of the long-term treatment plan included fabrication of a functional foot orthosis. Unfortunately, the patient was lost to follow-up and no further treatment was rendered.
Discussion The literature suggests a potential association between HAV and missing tibial sesamoids. In the present case, the symptomology, soft-tissue swelling on the medial aspect of the first MPJ, and radiographic evidence suggested a stage 1 HAV deformity.14 Goez and DeLauro8 suggested that the lack of a tibial sesamoid does not produce a more
severe HAV deformity, and the findings in our case are in agreement with their statement. Marathon runners require the most biomechanically effective first MPJ function. One of the functional requirements of the first MPJ during the propulsive period of gait is normal mobility of the sesamoid apparatus and pertinent soft tissues.14 Therefore, a disruption of this apparatus will ultimately lead to an inefficient gait, which will require excess energy expenditure. To our knowledge, there have been no reports regarding a missing tibial sesamoid in a marathon runner. Owing to the increasing popularity of running, podiatrists are treating an ever-increasing number of runners. When presented with a case such as described here, conservative treatment would include modification of activities, and shoe modifications, aiming to lower the heel height and reduce the stress placed under the metatarsal heads. In addition, increasing the thickness of the sole would reduce ground reactive forces upon the foot. Metatarsal pads may be another effective treatment option. 15 When presented with an acutely symptomatic sesamoid, secondary to repetitive trauma to the forefoot due to running, a dancers pad can be used as in this case. This padding technique allows for redistribution of force and offloading of the sesamoid apparatus.16 When coupled with alteration of the athletes training regimen, resolution of symptoms can be achieved.
Figure 1. Dorsal-plantar (A) and sesamoidal axial (B) views of the left foot, demonstrating a bipartite tibial
sesamoid.
552
September/October 2014 Vol 104 No 5 Journal of the American Podiatric Medical Association
Figure 2. Dorsal-plantar view of the right foot,
demonstrating a missing tibial sesamoid. Without the use of advanced imaging modalities such as MRI, one cannot definitively state whether a cartilaginous sesamoid is present.17 Because our patient was lost to follow-up, we could not obtain further imaging such as MRI to rule out a cartilaginous tibial sesamoid. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. STANDRING S: ‘‘Ankle and Foot,’’ in Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th Ed, edited by V Mahadevan, p 1441, Churchill Livingstone Elsevier, London, England, 2008. 2. DHARAP AS, AL-HASHIMI H, KASSAB S, ET AL: Incidence and ossification of sesamoid bones in the hands and feet: a radiographic study in an Arab population. Clin Anat 20: 416, 2007.
3. ROOT M, ORIEN W, WEED J: ‘‘Normal Motion of the Foot and Leg in Gait,’’ in Normal and Abnormal Function of the Foot, Vol 2, edited by SA Root, p 285, Clinical Biomechanics Corporation, Los Angles, CA, 1977. 4. COUGHLIN M: ‘‘Sesamoids and Accessory Bones of the Foot,’’ in Surgery of the Foot and Ankle, 6th Ed, edited by RA Mann and MJ Coughlin, p 467, Mosby, St. Louis, MO, 1993. 5. INGE G: Congenital absence of the medial sesamoid of the great toe. Report of two cases. J Bone Joint Surg 18: 188, 1936. 6. LAPIDUS PW: Congenital unilateral absence of the medial sesamoid of the great toe. J Bone Joint Surg 21: 208, 1939. 7. ZINSMEISTER BJ, EDELMAN R: Congenital absence of the tibial sesamoid: a report of two cases. J Foot Surg 24: 266, 1985. 8. GOEZ J, DELAURO T: Congenital absence of the tibial sesamoid. JAPMA 85: 509, 1995. 9. WRIGHT SM: Congenital hallux varus deformity with bilateral absence of the hallucal sesamoids. JAPMA 88: 47, 1998. 10. DAY F, JONES PC, GILBERT CL: Congenital absence of the tibial sesamoid. JAPMA 92: 153, 2002. 11. KANATLI U, OZTURK AM, ERCAN NG, ET AL: Absence of the medial sesamoid bone associated with metatarsophalangeal pain. Clin Anat 19: 634, 2006. 12. ALSHRYDA S, LOU T, FAULCONER ER, ET AL: Adolescent hallux valgus deformity with bilateral absence of the hallucal sesamoids: a case report. J Foot Ankle Surg 51: 80, 2012. 13. LUI TH, TAM KF: Hallux valgus deformity associated with bilateral absence of the tibial and fibular hallucal sesamoids. J Foot Ankle Surg 52: 254, 2013. 14. GERBERT J, PALLADINO SJ: ‘‘Preoperative Evaluation of the Bunion Patient,’’ in Textbook of Bunion Surgery, 4th Ed, edited by J Gerbert, p 1, Data Trace, Brooklandville, MD, 2012. 15. JAHSS MH: The sesamoids of the hallux. Clin Orthop Relat Res 157: 88, 1981. 16. PRISK VR, O’LOUGHLIN PF, KENNEDY JG: Forefoot injuries in dancers. Clin Sports Med 27: 305, 2008. 17. LE M INOR JM: Congenital absence of the lateral metatarso-phalangeal sesamoid bone of the human hallux: a case report. Surg Radiol Anat 21: 225–7, 1999.
Journal of the American Podiatric Medical Association Vol 104 No 5 September/October 2014
553
