Big Toe Pain: Sesamoid Pathology
The sesamoids are two small round or oval bones situated in the thick soft tissue ligamentous plantar plate under the first metatarsaophalangeal (big toe) joint and provide attachments for multiple important ligaments and muscle-tendinous units that provide critical stability, strength, and function to the big toe during ambulation and propulsion. They fully ossify by the age of 7.
They usually ossify by multiple centers of ossification and rarely this bone can develop an incomplete fusion and bipartide sesamoids have been reported from 7-30% of the time and usually involve the tibial (medial and larger of the two bones) and are usually found to be bilateral. They are infrequently symptomatic however, their tortuous circulation make them prone to slow healing and potential for avascular necrosis when injured.
Types of Sesamoid Injuries
- Sesamoiditis
- Sesamoid fracture
- Sesamoid Stress Fracture
- Symptomatic Bipartide Sesamoids
- Irregular Shaped or Enlarged Sesamoids
- Osteochondritis
- Subluxation or Dislocation of the Sesamoids
- Sesamoiditis
Sesamoiditis is defined as inflammation and swelling of the peritendinous structures that inserts around the sesamoid bones. It often occurs in young adults and can be related to acute traumatic event or repetitive weight-bearing load during various exercises. Jumping or falling from a height, unsupportive or high-heeled shoes, excessive activity, or dancing have been reported to cause inflammtion to sesamoid bones. There can be a gradual or sudden onset of pain, swelling, and inflammation to the area under the big toe joint worse with or after periods of activity.
It is commonly a diagnosis of exclusion because early in the disease process routine foot x-rays will be normal. A bone scan or MRI can be beneficial to aid in the diagnosis. It is important to educate patients that symptoms usually resolve slowly with the below mentioned conservative therapy. If symptoms continue to be painful then surgical excision of the involved sesamoid may be warranted, however this does cause inherent imbalance of the big toe and deviation can occur.
Symptomatic bipartide fractures, and irregular or enlarged sesamoids usually became painful in a similar fashion and usually respond with conservative fashion. If they fail conservative measures the excision of the involved sesamoid may be warranted. Enlarged or prominent sesamoids can undergo complete excision or shaving of the invlolved bone.
Conservative Treatment
- Activity modification
- Supportive shoes
- Metatarsal pads
- Toe strapping
- Stiff soled, rocker bottom shoes with steel shank insert
- RICE
- NSAIDS
- Custom orthotics with pathology specific cutout design to decrease pressure under the sesamoids
Surgical or Invasive options
- Local steroid injections
- PRP injections
- Surgical excision of painful sesamoid
Sesamoid Fractures
Sesamoid fractures can develop from acute fracture or secondary to progression or un-treated stress fractures or osteochondritis. Acute fractures including fall from heights, big toe hyper-extension injuries, and other injuries can result in one or multiple fracture fragments of the involved sesamoid.
Recurrent micro-trauma such as running, dancing, sporting activities, can cause stress injuries to the bone and compromise circulation resulting in osteochondritis or stress fractures of the sesamoid bones. X-rays can demonstrate acute fractures, however if it is unclear between a bi-partide or sesamoid fracture then MRI and bone scan are beneficial. These pathologies are notorious to slow healing, and usually require an extensive healing period with at least prolonged protective weight bearing in a short leg fracture boot or non-weight bearing in a cast and crutches.
It is important to educate patients on the longer recovery with this diagnosis. The transition to a stiff soled shoe and/or custom functional foot orthotic to decrease pressure to the area is required for the following several weeks with activity modification to ensure proper healing. RICE, NSAIDS are encouraged as well. The use of a bone stimulator may be utilized as well in certain cases.
Surgical recommendation is recommended after failure of extensive conservative options as mentioned above. This can include partial excision of the small or large symptomatic fracture fragments or complete excision of the involved sesamoid bone. Again, it should be re-iterated that there are certain inherent muscle imbalances that develops after excision these bones and adjunctive procedures or further surgeries may be in order to maintain a normal position of the big toe.
University Foot and Ankle Institute
University Foot and Ankle Institute offers comprehensive care for sesamoid pain and fracture. From injection therapy and orthotic care to surgical treatment options, count on our experts to offer you state of the art care in a comfortable and friendly environment.
If you would like more information about treatment options for sesamoid injuries, please call us at (877) 736-6001 or visit us at www.footankleinstitute.com.
Dr. Baravarian has been involved in athletics his entire life and played competitive tennis in high school and college. He has an interest in sports medicine, arthritis therapy and trauma/reconstructive surgery of the foot and ankle. He servers as a consultant to the ATP (Association of Tennis Professionals) tour, multiple running organizations and several shoe manufacturers. He is also fluent in five languages (English, French, Spanish, Farsi and Hebrew),
Podiatrist Dr. Bob Baravarian is available for consultation at the Santa Monica, Sherman Oaks and UCLA Westwood offices.
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My stress fracture is not healing, after the doctor used a pad so my sesamoid fracture could heal. But, its not working and its been 3 months. What other things can I do so it would help to heal? Can it still heal?
Hi Emily,
I am so sorry to read about your condition. Unfortunately we cannot give medical advice via a blog to someone we have never seen, or reviewed her medical records or even seen any of her films. So sorry about that. 🙁
But what I can say is you should go back to your doctor, plain and simple. At the very least, the peace of mind alone should be worth the “price of admission.” And if something is not healing properly then jumping on the problem earlier rather than later is a great idea. I hope this helps!
Oh my goodness! Incredible article dude! Many thanks.
i am 13 and i have a sesamoid fracture. i had it for over 5 years before going to the docter for it and i have been “healing” for almost 6 months and i can’t do it anymore. at this point it isn’t ruining all good things in my life and i would rather have them just cut off my leg. Please help me
Hannah,
We are so very sorry to read about you situation, and we understand how frustrating it can be, but please don’t be chopping of your leg! That would be an even bigger mistake for sure.
I do not know where you live, but I think you have to get your folks to take you back to the doctor so he/she can understand how much this is getting in the way of your enjoying some of the best years of your life.
If you are near us, you are more than welcome to ask your folks to bring you to see us. If you are looking for a reference to another doctor near you (no guarantees we can recommend someone, but maybe we can), please ask your folks to email me at webhelp@footankleinstitute.com.
Please take good care of yourself!
Steven
I am having a dull to sharp pain under my big toe in the area between the two joints. Both x-rays and MRI show no fracture or abnormalities, however the pain is there every time i walk. It hurts as i step off my big toe even while wearing custom over-pronation orthotics. Hurts the worst if i walk barefoot on wood floors. I feel some stiffness in the toe while resting and soreness when i wake up in morning. I have tried icing under and above big toe before walking and that doesn’t help. Any ideas on what else we could look for?
Mike,
So sorry to read about what is going on. You asked if we have “any ideas on what else we could look for” and I would suggest another doctor if you are thinking you have hit a dead end with yours. If not, then please go back and see him/her and see what you can do. If you are near us, please come see us, if not, you can let me know where you live and I can see if we know anyone near-ish you.
Unfortunately we cannot begin to give advice without seeing a patient. Well, technically, seeing your foot and your records and films, but you get the idea.
Please take care of yourself!
A very helpful web site; couldn’t make it without ya!
I was told I have sesamoiditis in my right foot about a year ago. We did the arch pad sleeve, the insole taping, bought more rigid exercise shoes. I have stopped running completely, modified exercises so I don’t stretch that big toe much (no lunges and similar exercises). I had a bone scan and x rays done and there was some highlight of the big toe area on the bone scan but there was more concern with the ankle/ tibia meet. So with all of the padding and support, modifications to my exercise routines, ibuprofen and ice and rest my foot still hurts. What options remain for such a chronic issue that will ease the pain and allow me more freedom in my daily life and ability to perform regular exercises again?
Hi Katie,
It is impossible to give you specific advice without seeing you or having a virtual consultation and doing a medical record review of your condition do if you are not able to see us in person (which you can request here:https://www.footankleinstitute.com/request-a-virtual-consultation).
But here a few things you can consider:
1) Orthotic with cutout region
2) Stiff soles shoes to avoid bend in toe
3) Possibly removal of sesamoid if damaged
I hope this helps
Dr. Bob Baravarian
Assistant Clinical Professor
UCLA School of Medicine
Director and Fellowship Director:
University Foot and Ankle Institute
Los Angeles, California