Sesamoids and accessory ossicles seen in the foot vary widely in their prevalence and appearance. Occasionally, these bones may be associated with painful syndromes, due to various pathologies, including trauma, infection, inflammation, degeneration and others. However, symptomatic accessory and sesamoid bones are rare, and search for additional pathology should be performed. Although the clinical significance of these osseous structures is probably minor, clinicians very commonly ask about these bones, which may originate an unnecessary work-up. Therefore, knowledge of their presence and morphological variations is important to prevent misinterpreting them as fractures—a common error. Finally, it may be very difficult to distinguish between incidental variants and truly symptomatic ones. Radiological studies provide insight regarding the presence and pathology involving these bones. This review describes an overview of the anatomy of sesamoids and accessory ossicles in the foot, and provides a pictorial review of their pathological conditions, including trauma, sesamoiditis, osteomyelitis, osteoarthritis and pain syndromes. Radiological studies including radiography, ultrasound, scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) provide useful information which should be used in concert with clinical findings to guide patient management.Teaching points• Sesamoids and accessory ossicles seen in the foot vary widely in their prevalence and appearance.• Pathology of these bones includes trauma, sesamoiditis, infection, osteoarthritis and pain syndromes.• Radiography, ultrasound, scintigraphy, CT and MRI provide information regarding the pathology of these bones.
