Two pea-sized bones, called sesamoids, are embedded within the soft tissues under the main joint of the big toe. Even though they are small in size, the sesamoids play an important role in how the foot and big toe work. If the sesamoids are injured, they can be a source of severe pain and disability.
Sesamoiditis is a common ailment that affects the forefoot, typically in young people who engage in physical activity like running or dancing. Its most common symptom is pain in the ball-of-the-foot, especially on the medial or inner side. ...The term is a general description for any irritation of the sesamoid bones, which are tiny bones within the tendons that run to the big toe. Like the kneecap, the sesamoids function as a pulley, increasing the leverage of the tendons controlling the toe. Every time you push off against the toe the sesamoids are involved, and eventually they can become irritated, even fractured. Because the bones are actually within the tendons, sesamoiditis is really a kind of tendinitis - the tendons around the bones become inflamed as well.
There are three variances of sesamoiditis:
The first variance is turf toe,
(there is a seperate article at the foot of this page on Turf Toe)
an injury to the soft tissue around the big toe joint. The big toe joint is usually injured when extended past the normal range, immediately causing sharp pain and swelling. Turf toe most often affects the entire joint and limits its range of motion. Possible outcomes of turf toe include a sesamoid fracture or an injury to the soft tissue attached to the sesamoid. Patients may feel a “pop” when injury occurs.
The second type is either an acute or chronic fracture in the sesamoid bone. An acute fracture results from trauma as a direct hit or impact to the bone. Patients will immediately feel pain and swelling at the injured area, not the entire big toe joint. A chronic sesamoid fracture is a stress fracture that normally results from repetitive stress or excessive use. This fracture is accompanied by longstanding intermittent pain in the ball of the foot, beneath the big toe joint. Pain is often worsened by physical activity and relieved with rest.
The third type of sesamoid injury is sesamoiditis, resulting from overuse of the sesamoid bone. Sesamoiditis is an outcome of increased pressure to the sesamoids, and presents with chronic inflammation of the sesamoid bones and tendons. Patients often experience longstanding, intermittent pain beneath the big toe joint, normally aggravated by wearing certain shoes and partaking in dance
Sesamoid injuries of the foot can be treated with a combination of these non-surgical options. Non-surgical treatments may vary based on the type of injury and its level of severity:
Padding, strapping or taping may relieve the area of tension or inflammation. For example, a pad worn in the shoe would provide
strapping the toe can help relieve tension in the sesamoid area.
Immobilizing the foot in a cast or a removable walking cast may aid in healing of the injured sesamoid. Dr. Radovic may also recommend crutches to relieve weight from the foot.
Ibuprofen, aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) may help reduce pain and inflammation.
Physical therapy exercises and ultrasound therapy may be beneficial after a period of immobilization to strengthen, condition and increase range of motion of the sesamoid area.
Select cases may benefit from a cortisone injection in the joint to reduce pain and inflammation.
Custom orthotic inserts may be recommended as a long-term treatment for balance when walking and putting pressure on the ball of the foot.
What can be done for the condition?
Many cases of sesamoiditis can heal completely with careful treatment. There are two methods for treating sesamoid problems, nonsurgical treatment and surgery. Surgery is most often used as a last resort, when other forms of treatment aren't helping.
Doctors prefer to begin with nonsurgical treatment. Your doctor may recommend treating the inflammation and pain of sesamoiditis with nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Special padding in the shape of a J can be placed inside your shoe to ease pressure on the sesamoids as you stand and walk. You may need to limit the amount of weight placed on your foot when you're up and about. Shoes with low heels may also ease the pressure. Occasionally, doctors inject steroid medication into the soft tissues around the sesamoids to decrease the inflammation.
Some doctors place a patient with a fracture in a cast for about six weeks. Afterward, the patient must wear a stiff-soled shoe until the pain goes away. The stiff sole of the shoe keeps the toe steady and prevents it from bending while you walk. Other doctors prefer not to cast fractures. Instead, they have their patients wear a stiff-soled shoe right away.
Stress fractures are a bit more complicated. If a stress fracture doesn't heal, it becomes a nonunion fracture, an extremely painful condition that can cause significant disability. If the problem isn't better in eight to 12 weeks, surgery may be needed to remove the pieces of unhealed bone. To avoid the problems of a nonunion fracture, some doctors use a cast and require patients to avoid putting any weight on the foot for up to eight weeks.
If surgery becomes necessary, several procedures are available to treat sesamoid problems. Which one your surgeon chooses will depend on your specific condition.
Your surgeon may recommend removing part or all of the sesamoid bone. When bone is removed from only one sesamoid, the other sesamoid bone can still provide a fulcrum point for the toe flexors. However, if both of the bones are taken out, the toe flexors lose necessary leverage and can't function. When this happens, the big toe will either bend up like a claw or slant severely toward the second toe. Thus, surgeons usually try to avoid taking both sesamoids out.
When a sesamoid bone is fractured in a sudden injury, surgery may be done to remove the broken pieces. To remove the sesamoid on the inside edge of the foot, an incision is made along the side of the big toe. The soft tissue is separated, taking care not to damage the nerve that runs along the inside edge of the big toe. The soft tissues enclosing the sesamoid are opened, and bone is removed. The tissues next to the sesamoid are stitched up. Then the soft tissues are laid back in place, and the skin is sewed together.
Surgery is similar for the sesamoid closer to the middle of the foot. The only difference is that the surgeon makes the incision either on the bottom of the big toe or in the web space between the big toe and the second toe.
For patients diagnosed with stubborn plantar keratosis, surgeons generally perform surgery to scrape off the extra tissue. Your surgeon may decide to shave off only the affected part of the bone. The bottom half of the sesamoid is cut off, and the rough edges of the remaining part of the bone are filed with a special tool to leave a smooth shell. This surgery is easier on the body than procedures that completely remove the sesamoid.
When patients continue to have problems with nonunion stress fractures, a bone graft may help the parts of the bone heal together. Surgeons mostly use this type of surgery for high performance athletes to keep the fulcrum point intact. The surgeon makes an incision along the inside edge of the main joint of the big toe. This exposes the sesamoid bone. The surgeon gathers small bits of bone from a nearby part of the big toe bone. The bone fragments are then packed into the unhealed area of the sesamoid. The soft tissue surrounding the sesamoid is stitched closed. Then the soft tissues are laid back in place, and the skin is sutured together.
What should I expect after treatment?
Patients with sesamoid problems may benefit from four to six physical therapy treatments. Your therapist can offer ideas of pads or cushions that help take pressure off the sesamoid bones.
Treatments directed to the painful area help control pain and swelling. Examples include ultrasound, moist heat, and soft-tissue massage. Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area.
If simple modifications are made to your shoes you may be allowed to resume normal walking immediately. But you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside. More aggressive treatment may require you to use crutches for several weeks to keep weight off the foot.
After a surgical procedure to shave or remove bone, patients are generally placed in either a rigid-soled shoe or a cast for two to three weeks. Most are instructed to use crutches and to limit the weight they put on the foot during this period.
Treatment is more cautious after bone graft surgery. Patients usually wear a cast for up to four weeks. Then they wear a short walking cast for another two months, at which time active exercises can start.
About 12 weeks after surgery, surgeons begin computed tomography (CT) scans on a regular basis to keep track of how the bone graft is healing. The CT scan uses X-rays that are interpreted by a powerful computer to create images that appear as slices through the body. With a CT scan the surgeon can see the bones of the sesamoid better to determine if it is healing.
Read more: Foot Disorders Forum - Sesamoiditis
Typical treatments include physical therapy, local steroid injections,
padding, NSAIDs, orthoses, non-weightbearing or, in cases of failed
conservative treatment, surgical excision of the tibial sesamoid.
Complications arising from surgical excision may include infection,
nerve damage, tendon tear, hallux abducto valgus deformity and/or other
We have used ESWT for chronic tendinopathies and sesamoiditis for many
years and have achieved excellent resolution of the pain without the
need for surgical excision or any type of surgical repair.
In this particular case study, a professional football player had failed
conservative therapy for chronic sesamoiditis. Failed conservative
therapies included orthoses, taping, stretching, heel cups and deep
tissue massage. His last episode of sesamoiditis was six weeks in
duration and he was unable to play football without pain.
We decided to try ESWT. We did not use an anesthetic nerve block for the
ESWT treatment. We used the Dornier Epos Ultra (Dornier Medtech) to
identify the flexor tendon at the level of the tibial sesamoid bone. We
treated all hypoechoic areas at 0.21mj/cm2. The total joules applied
were 960 joules. We performed two ESWT sessions with the sessions being
two weeks apart.
Foot injuries are one of the most common injuries for athletes. Specifically, among all the joints and bones of the foot, the first metatarsophalangeal joint with its sesamoid complex is the most commonly affected. It is usually clear when an athletic injury involves the first metatarsophalangeal joint complex. However, identifying the specific injured structures and arriving at a precise diagnosis can be difficult.
Two hallucal sesamoids are situated under the first metatarsal head. The
medial (tibial) sesamoid tends to be larger, oval-shaped and presents in
a bipartite or multipartite form in 10 to 33 percent of feet. The
lateral (fibular) sesamoid is smaller and rounder. Each sesamoid has an
articular surface of hyaline cartilage, allowing it to articulate with
the plantar aspect of the distal first metatarsal. While sesamoids
elsewhere in the body occur variably, the hallucal sesamoids are
virtually constant. These sesamoids function as an integral part of the
The hallucal sesamoids play an important role in great toe function as
they absorb weightbearing pressure, reduce friction and protect tendons.
The functional complexity and anatomic location of these small bones
make them vulnerable to injury from shear and loading forces.
During running, more than half the weightbearing force travels through
the great toe complex. Forces up to three times the athlete’s body
weight may be transmitted across the sesamoids. The medial sesamoid
bears most of this force and thus is more prone to injury than the
lateral sesamoid. Injury to the hallucal sesamoids can cause
incapacitating pain. Although you usually can diagnose traumatic
injuries easily, you may overlook other pathologic conditions caused by
Careful physical and radiographic examinations (including bone scans)
may be necessary to determine the structures damaged, extent of damage
and the optimal treatment plan. Sesamoidal injures are divided into
acute and chronic injures. Acute injuries are traumatic
fracture/dislocations of the sesamoids and sesamoidal apparatus caused
by trauma to the first MPJ complex. Chronic injuries of the sesamoids
can be divided into three groups: Stress fractures, osteochondritis and
How To Detect And Treat Acute Injuries
Fracture dislocation of the sesamoids and sesamoidal apparatus is
relatively rare. It usually results from a high-impact force like a
fall, an injury which the pathological force of hyperextension of the
The hallux is dorsiflexed, causing stretching of the plantar joint
capsule. This causes distal distraction of the sesamoids due to their
strong attachments to the plantar base of the proximal phalanx. As
pathologic dorsiflexion continues, the capsule ruptures from its
insertion at the plantar metatarsal neck. The hallux, with the sesamoids
attached to the base of the proximal phalanx, dislocates dorsally to
override the metatarsal head. The metatarsal head is then driven
plantarly. The pathologic dorsiflexion may dislocate the sesamoids
dorsally with the intersesamoidal ligament still intact. It also may
result in either rupture of the intersesamoidal ligament or a transverse
fracture of one of the sesamoids.
Jahss classified two types of first MPJ dislocation. Type I is a dorsal
dislocation of the proximal phalanx and sesamoids on the first
metatarsal head with the intersesamoidal ligament still intact. You
cannot reduce this type of dislocation by closed means because of the
intact intersesamoidal ligament. However, you can often use closed means
to reduce the two groups of Type II dislocations. Type IIA is a dorsal
dislocation of the proximal phalanx and sesamoids on the first
metatarsal head with rupture of the intersesamoidal ligament, which
results in wide separation of the sesamoids. Type IIB shows a transverse
fracture of one of the sesamoids.
What About Sesamoid Stress Fractures?
As far as treatment goes, you would emphasize rest and use a 1/4- to
3/8-inch weight dispersion felt padding or a specially modified foot
orthosis with a sesamoid “cutout” that decreases stress on the sesamoid
while transferring weight along the shaft of the first metatarsal. Using
a rigid soled shoe is also helpful. If the fracture has not united after
six months of treatment and symptoms are sufficiently severe, you should
consider surgical treatment. This may include performing open reduction
with internal fixation of the fractured sesamoid or excising the
What To Look For In Osteochondritis Of The Sesamoids
Osteochondritis or avascular necrosis of the sesamoids may occur as a
primary disorder, possibly related to recurrent stress, or as a
secondary problem following a stress fracture and subsequent
fragmentation. Be aware sesamoidal osteochondritis is less commonly a
complication of traumatic fracture and more often the result of chronic
stress. In either case, resulting avascular necrosis may lead to
fragmentation and collapse of the sesamoid. You should treat such
lesions conservatively for at least six months with splinting and
How To Relieve Sesamoiditis
Sesamoiditis is a clinical diagnosis usually related to repetitive
stress to the hallucal sesamoids. It occurs more frequently in the high
arch or cavus foot type. In diagnosing sesamoiditis, keep in mind that
it is marked by point tenderness on one or both of the sesamoids in the
absence of radiographic evidence of a specific bony abnormality such as
stress fracture or avascular necrosis.
Turf Toe comes under the Sesamoid section
The question asked was about Turf Toe.The simplest
definition of turf toe is that it is a sprain of the main joint of the
big toe. Here is some more detailed information gleaned for you. Turf
toe is not a term you want to use when talking to a head football coach
about his star running back or the ballerina before her diva debut.
“Turf toe” is the common term used to describe ...a sprain of the
ligaments around the big toe joint. Although it’s commonly associated
with football players who play on artificial turf, it affects athletes
in other sports including soccer, basketball, wrestling, gymnastics, and
dance. It’s a condition that’s caused by jamming the big toe or
repeatedly pushing off the big toe forcefully as in running and jumping.