The FHB tendons contain the two sesamoid bones of the first MTP joint, providing their unique function — not only flexing the great toe but bearing up to 50-60% of first metatarsal head ground reaction force through the sesamoids. Sesamoiditis, sesamoid fracture, and avascular necrosis of the sesamoids all manifest as plantar first MTP pain beneath the sesamoid footprint.
Great toe MTP plantarflexion; sesamoid positioning for first metatarsal head load distribution
FHB dysfunction from sesamoid pathology produces first MTP plantar pain during toe-off. The medial sesamoid is more commonly symptomatic (higher load). MRI distinguishes acute sesamoid fracture (bone marrow oedema) from chronic non-union (sclerotic margins). Sesamoid excision (last resort) requires meticulous FHB tendon repair to maintain first ray function.
FHB sesamoid inflammation from first metatarsal head overload producing plantar MTP pain managed with offloading and sesamoid excision as last resort.
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