Working Diagnosis:
1. Chronic right first MTP region pain and effusion
2. Bipartite tibial sesamoiditis
3. Medial hallucal neuritis without neuroma

Treatment:
At initial evaluation, the patient already received three weeks of immobilization with a CAM boot, metal shank insertion, topical ice, non-guided corticosteroid injection, and activity modifications.

We opted to resume immobilization in her CAM boot to further offload her forefoot and decrease inflammation. We employed regular ice massage and a short course of oral anti-inflammatory medication.

At initial follow-up, we performed an ultrasound-guided right first MTP intra-articular corticosteroid injection. She was instructed to continue icing and offloading with her CAM boot and axillary crutches. We recommended non-weight bearing for four weeks. We considered orthopedic referral to discuss sesamoidectomy if symptoms progressed.

Outcome:
The patient tolerated ultrasound- guided injection well. She successfully off-loaded her affected right foot with non-weight bearing status for four weeks duration. She was able to successfully discontinue the CAM boot and crutches with complete symptom resolution. She reported successful increase in her activities including use of an elliptical, bicycling, and light jogging for 1/2 mile intervals without recurrence of her pain. She was successfully released for gradual return to her strength and conditioning program and sport-specific activities per her collegiate athletic training staff.

At follow-up, we recommended gradual increase in treadmill jogging until reaching ideal mileage, followed by a progressive increase in running distance and intensity. Subsequently, she was to jog intermixed with lower-impact elliptical or bicycling for five days per week until resuming Spring lacrosse practice. We recommended a motion-control/stability shoe, topical ice for new-onset pain, and immediate decrease in activity for recurrence of previous symptoms.

Author's Comments:
- Tibial sesamoiditis and medial hallucal neuritis can both result in forefoot and great toe pain in athletes.
- Non-operative management is the mainstay treatment for
sesamoiditis.
- Diagnostic and/or therapeutic injections can provide a
management option for refractory cases prior to surgical
consultation.
- Ultrasonography provides a high yield modality for both
diagnostic and interventional management of forefoot pain in the athlete.

Editor's Comments:
As the old adage says, "sesamoiditis is a diagnosis of exclusion." The authors ruled out fracture/diastasis of the bipartate sesamoid prior to ultrasound-guided injection. Consider medial hallucal nerve injury in the athlete with paresthesia to the medial great toe.

References:
1. Boike, A., M. Schnirring-Judge, and S. McMillin, Sesamoid disorders of the first metatarsophalangeal joint. Clin Podiatr Med Surg, 2011. 28(2): p. 269-85, vii.
2. Wempe, M.K., et al., Feasibility of First Metatarsophalangeal Joint Injections for Sesamoid Disorders: A Cadaveric Investigation. Pm&R, 2012. 4(8): p. 556-560.
3. Chou, L.B., Disorders of the first metatarsophalangeal joint - Diagnosis of great-toe pain. Physician and Sportsmedicine, 2000. 28(7): p. 32-+.
4. Dedmond, B.T., J.W. Cory, and A. McBryde, The hallucal sesamoid complex. Journal of the American Academy of Orthopaedic Surgeons, 2006. 14(13): p. 745-753.
5. Richardson, E.G., Injuries to the hallucal sesamoids in the athlete. Foot Ankle, 1987. 7(4): p. 229-44.
6. Tallia, A.F. and D.A. Cardone, Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician, 2003. 68(7): p. 1356-62.
6. Delfaut, E.M., et al., Imaging of foot and ankle nerve entrapment syndromes: from well-demonstrated to unfamiliar sites. Radiographics,
2003. 23(3): p. 613-23.
7. Schon, L.C., Nerve entrapment, neuropathy, and nerve dysfunction in athletes. Orthop Clin North Am, 1994. 25(1): p. 47-59.
8. Dietzen, C.J., Great toe sesamoid injuries in the athlete. Orthop Rev, 1990. 19(11): p. 966-72.
9. Cohen, B.E., Hallux sesamoid disorders. Foot Ankle Clin, 2009. 14(1): p. 91-104.

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