Feet > Sesamoid Disorders > Treatments

   Surgical Excision

Treatment Introduction

When conservative treatment does not heal your sesamoid disorder, or if you have lost blood supply in the area, your physician may recommend surgery to remove the damaged sesamoid from your foot. Removing one sesamoid typically does not affect your ability to walk or run, but some patients may lose a little strength and range of motion in their big toes. You should talk with your physician about the possible effects of sesamoid excision on your sports and activities.

The actions you take before surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

At most medical centers, you will go to “patient admissions” to check in for your operation. There may be separate check-in areas for ambulatory outpatient (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or an assistant about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your foot may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or an assistant and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under anesthesia.

   Arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

Surgical excision of your sesamoid typically takes about 1½ hours to perform. A local anesthetic, called an ankle block, is injected into your ankle to numb your foot. You usually are sedated so you sleep through the procedure.

   A small incision, about two centimeters long, typically is made on the top part of your foot at the base of your big toe, either on the inside or outside of the big toe. The incision’s location depends on which sesamoid is removed.

   The tendon (flexor hallucis brevis) covering the sesamoid is opened and the bone is cut away from the tendon and removed from your foot.

   Any damaged soft tissue is repaired.

   Your tendon is sewn back together and tightened so that it continues functioning normally.

   Your incision is closed with stitches. A splint is applied to immobilize your foot and ankle, and you are taken to the recovery room.

After your sesamoid is removed, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia and sedatives wear off. Your foot will be elevated and immobilized in a plaster splint when you wake up. There usually is minimal bleeding after surgery. You typically cannot see the incision in your foot because it is wrapped in the splint. The dressing around your wound helps stabilize your big toe in the proper position. Try to keep your toe still and your foot relaxed. After surgery, you usually experience some pain. Adequate pain medications will be prescribed for you. You will be given intravenous (IV), oral, or intramuscular pain medications as needed. Your surgeon typically prescribes crutches and you are usually instructed to keep weight off your foot for the first few weeks. You may meet a physical therapist in the hospital who helps you learn to get around using crutches. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of the doctor, will determine when you can prepare to go home. Most patients leave the hospital the same day after surgery. Make sure to have someone available to drive you home, as you will be unable to drive a car.

For four to five days after your sesamoid is removed, you should keep off your feet, elevate your foot above heart level, and move around the house as little as possible. You should try to rest and avoid too much movement for at least a week. Crutches usually are prescribed for one to two weeks so you can keep your body weight off your foot. Rest as much as possible with your foot elevated. This helps blood drain away from your foot and can control swelling. Household tasks that require you to be on your feet may be difficult for two to four weeks. Try to have someone around the house to help with any physical chores. The dressing covering your wound inside your post-surgery foot splint usually does not need to be changed until the splint is removed. It is important that the dressing remains wrapped around your big toe securely to help hold the toe in position. If the dressing comes loose, you should call your physician. When the dressing is no longer needed, your physician may recommend taping your big toe in position. There is a risk after your sesamoid is removed of what is called toe “migration”. This means your big toe may become slightly deformed. Taping your toe in position for two to eight weeks after surgery can help your toe heal correctly. Your physician, nurse, or trainer can tape your big toe if necessary. Though each case is different, a typical follow-up schedule after you leave the hospital may go as follows:

   Seven to 10 days – Stitches come out and your splint is removed. Most patients are put into a removable brace called a cam walker that immobilizes your ankle and has a solid bottom so your toes do not bend.

   Two to four weeks – Slowly return to bearing some weight on your foot as you can tolerate the pain. Most patients can begin moving their big toe two to three weeks after surgery but the toe should remain taped to avoid deformity. Always wear the cam walker or cast shoe when putting any weight on your foot. You ordinarily rely less and less on the crutches for support as pain decreases.

   Two to six weeks – You typically can cease wearing the cam walker and return to normal shoe wear.

   Six to eight weeks – More vigorous walking exercises usually can begin. Start with short distances and do not walk farther than pain allows.

Formal physical therapy may not be necessary after surgery to remove your sesamoid. Many patients can adequately restore motion and strength in their big toe with a regular cardiovascular exercise program. Most patients can return to sports and activities within two or three months after surgery. Begin exercising with short walks and increase the duration and intensity as pain allows. Start lightly stretching your big toe about two to three weeks after surgery, as instructed by your physician. You may be able to use stationary cycles or swim without causing much pain in your foot three to four weeks after the injury. When your pain is gone, start with low impact exercises. Progress to light jogging before sprinting, jumping, and cutting. More vigorous running and exercise typically can begin within eight weeks after surgery. Gradually return to activities with pain as your guide. Understand that your level of activity prior to the injury was somewhere above your foot’s threshold to withstand the forces and stress of that activity. Increase your workouts slowly, and if pain returns, decrease the intensity and duration of your walks, runs, or other physical activities.

Rehabilitation

Formal physical therapy may not be necessary after surgery to remove your sesamoid. Many patients can adequately restore motion and strength in their big toe with a regular cardiovascular exercise program. Most patients can return to sports and activities within two or three months after surgery. Begin exercising with short walks and increase the duration and intensity as pain allows. Start lightly stretching your big toe about two to three weeks after surgery, as instructed by your physician. You may be able to use stationary cycles or swim without causing much pain in your foot three to four weeks after the injury. When your pain is gone, start with low impact exercises. Progress to light jogging before sprinting, jumping, and cutting. More vigorous running and exercise typically can begin within eight weeks after surgery. Gradually return to activities with pain as your guide. Understand that your level of activity prior to the injury was somewhere above your foot’s threshold to withstand the forces and stress of that activity. Increase your workouts slowly, and if pain returns, decrease the intensity and duration of your walks, runs, or other physical activities.

The best way to prevent reinjury in your big toe is to be sure that it is flexible and strong before you begin repetitive running, jumping, and cutting motions. Though are not at risk of reinjuring your sesamoid after it has been removed, you do need to prevent what is called post-operative drift or migration of your big toe out of position. Continue taping your big toe daily for up to eight weeks after surgery. It is a good idea to continue toe taping when exercising or engaging in activities for three or four months after surgery. To prevent loss of range of motion and strength in your big toe, you should make stretching and weight bearing aerobic exercise part of your everyday routine. The risk of injuring your remaining sesamoid is small. However, returning to activities before your pain has gone away and increasing your activity level too quickly may cause pain and symptoms to flare up. Remember the level of exercise you were performing when the initial injury occurred and slowly work your way back. Proper footwear, designed for your particular sport or activity, can help protect your foot against abnormal strain in your big toe joint. Avoid wearing old, worn-out shoes when you are running or participating in activities that pound your feet. In general, shoes with higher heels put more strain on the ball of your foot and should be avoided. Depending on the shape of your foot, you may benefit from orthotic devices molded to decrease the strain that passes through the ball of your foot when you walk or run. Your physician typically has these molded for you if necessary. If you plan on returning to competitive sports or rigorous activities, you may benefit from visiting a physical therapist. Therapists can help teach you plyometric training techniques, such as jump training with boxes or steps. Proprioceptive training, which includes balancing on a BAPS board atop a round ball, also can help improve the resiliency and coordination of the muscles that move your big toe.