Sesamoid bone disorders are a rare cause of metatarsal pain and can be difficult to diagnose. This article describes an atypical case of avascular necrosis of the fibular sesamoid in a 62-year-old male. Avascular necrosis of the sesamoid is an infrequent and incompletely defined process. The case described in this report is somewhat atypical as this condition is usually associated with female sex, adolescence, or a precipitating factor of minor trauma. Level of Clinical Evidence: 4. (The Journal of Foot & Ankle Surgery 48(2):203-207, 2009)