Osteochondritis of the first metatarsal sesamoid

Osteochondritis of the first metatarsal sesamoid is rare. The principal symptoms are pain on weight bearing and sharply localized tenderness over the involved sesamoid. Routine anteroposterior and lateral roentgenograms are of little value and only an axial view of the sesamoid-metatarsal joint demonstrates the characteristic multifragmented appearance of the sesamoid. Conservative treatment is usually unsuccessful and the sesamoid has to be excised. We describe a typical case of Ilfeld's disease in a 23-year-old man with three months of pain over his right fore-foot on weight bearing. There was no history of trauma. Examination revealed tenderness on pressure over the tibial sesamoid and pain on acute passive extension of the great toe. Anteroposterior roentgenograms showed slight irregularity of the tibial sesamoid and the axial view demonstrated the characteristic multifragmentation of the tibial sesamoid. There was no radiographic evidence of any change of the articular surface of the sesamoid or of the metatarsal head. Since conservative treatment was unsuccessful, we followed the recommendations of Gianestras and excised both sesamoids. The surgical specimen revealed an irregular, shaggy cartilaginous surface of the tibial sesamoid in contrast to the smooth, shiny cartilaginous surface of the fibular sesamoid. Three weeks after operation weight-bearing was allowed and the patient was free of symptoms and signs. Only 17 cases of Ilfeld's disease have been reported in the literature of the western world. This typical case demonstrates the importance of axial roentgenograms as a diagnostic aid without which the cause of metatarsalgia is easily overlooked.