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A 24 year old woman complained of pain and swelling plantar surface of her right great toe after spending many hours dancing in a night club. This was her principal social activity. Although tall, she wore high heels. Examination revealed tenderness localised to the fibular sesamoid and radiography (fig 1) confirmed a longitudinal fracture of this bone. Symptoms settled rapidly with conservative treatment including use of flat soled trainers.
Tibial and fibular sesamoid bones occur within the tendon slips of flexor hallucis brevis beneath the first metatarsal head; they increase the mechanical advantage of this muscle during the `toe-off' phase of locomotion and may also share weight bearing.1 Fractures and sesamoiditis, most commonly of the tibial sesamoid, are seen in professional dancers2 and athletes,3 probably caused by compressive forces between sesamoid and metatarsal head but possibly by repeated tensile forces from vigorous “toe-off” activity.
High heels flex the first metatarsophalangeal joint and increase compressive forces on the sesamoids. This, and many hours of vigorous dancing probably combined to cause the injury reported here. Widespread use of recreational drugs that enhance mood and energy and might persuade a person to ignore skeletal discomfort may also contribute to this “club foot”. Clubbing culture shows no signs of abating and we believe this injury will be recognised increasingly in future with the accident and emergency department as probable first site of presentation.