The TLDR (too long/didn’t read) version: Foot/Ankle concern? = Refer to Podiatry/See a Podiatrist
What is Sesamoiditis?
Sesamoiditis is an overuse injury in which prolonged, high impact forefoot loading causes irritation and subsequent inflammation of the peritendinous structures in which the sesamoid bones are located.
The reasons why this overuse occurs can range from particular gait patterns during high impact activity to poor footwear choices. The exact reason must be determined via a thorough clinical assessment.
How does it present?
Typically pain is localised to the underside of the big toe joint but can often radiate throughout the entire great toe joint.
Symptoms are often worse on weight bearing, particularly activities that place the big toe joint in an extended position (such as a plank or lunge position). Explosive weight-bearing activities can further exacerbate symptoms (jumping, hopping, running).
What to do
See a podiatrist or refer to a podiatrist ASAP. Any delay in therapy can lead to risks relating to further damage. Being a chronic overuse injury, if the causative overload is not redirected away from the sesamoid, the risk of stress fracture or avascular necrosis development is heightened.
Symptom guidance can be advised upon to manage whilst awaiting podiatry assessment and intervention. As the reason(s) for developing sesamoiditis are specific to each case, not everyone will respond in the same manner.
While awaiting podiatry assessment therapeutic advice that is unlikely to cause harm and potentially be beneficial is:
- Education: Pain education, reassurance, avoidance of nocebic language.
- NSAIDS topically (Voltaren Gel). If safe to proceed, systemically can be beneficial in reducing local inflammation.
- Avoid exercise that places the big toe under increased pressure (such as a plank, push up or lunge position).
- Wear shoes you feel MORE comfortable in
- Footwear can increase or decrease sesamoid loading (even runners can inc/dec loads)
- Refer to or see a podiatrist:
"The podiatrist will assess you and give a clear diagnosis, work out why it is happening and plan to get you back to where you want to go. They will look at capacity, loading and plan accordingly. You might need to change your shoes, do appropriate exercises, use devices like orthotics to manage loading. They will advise you what is needed for your sore feet."
What not to do
- Delay. If appropriate offloading measures are not implemented in a timely manner, the risk of further injury development is significantly increased.
- Nothing. It is not a self-limiting condition. Doing nothing is a clinical decision that is related to short/long term harm.
Want to Know More? Here's a more in-depth look at Sesamoiditis
What is it?
An irritation of the peritendinous structures surrounding the sesamoids bones of the great toe. These bones are contained within the Flexor Hallucis Brevis tendon as well as a portion of the plantar plate. The medial or tibial sesamoid is typically more prone to injury as compared to the lateral or fibular sesamoid due to its smaller size and more central location under the 1st metatarsal head (Atiya et al).
The sesamoid’s function is to stabilise the first ray, increase mechanical advantage during propulsion as well as protect the 1st metatarsal head by dispersing direct compressional force. When a person is standing in a static position, the sesamoids reside proximal to the 1st MTPJ. As the first ray dorsiflexes, during the propulsive phase of gait, the sesamoids move distally to act as the main weight bearing focus under the 1st MTPJ. This results in as much as 300% bodyweight force being transmitted through the sesamoids during high impact activity such as running.
Chronic, repeated stress causes compressive forces between the sesamoid and metatarsal head and is further contributed by tensile forces from vigorous, high impact forefoot loading; resulting in sesamoiditis.
Typically painful and sharp. Patients generally present with insidious onset activity-related medial forefoot pain, that eases on rest. Pain is exacerbated by weight bearing and upon dorsiflexion of the 1st MTPJ. Most patients will describe acute/severe pain on the propulsive phase of gait, and will typically load the lateral column of the foot to avoid weight bearing over the 1st MTPJ.
Further symptoms will typically include a restricted and painful range of motion at the 1st MTPJ, tenderness upon direct compression of the affected sesamoid and reduced plantar flexion strength at the 1st MTPJ.
In chronic cases, a callus may be present underlying the 1st MTPJ and a burning pain may remain on rest from weight-bearing activity. Nocturnal pain should not be apparent in most cases. If this presents, it is important to rule out the possibility of a stress fracture of the sesamoid or metatarsal head.
Myths, falsehoods and quarter truths
“A cortisone injection will fix it”
Mostly, no. Although the anti-inflammatory effect may be beneficial in the short term for pain management, it is important to consider that this is an overuse condition due to repetitive focal stress. Without biomechanical modification of loading distribution, it is likely that this condition will further degenerate. Furthermore, a cortisone injection should not be administered in the presence of a stress fracture or avascular necrosis, so it is important to ensure that the condition has not yet progressed to this stage (Sims & Kurup).
“A CAM boot is required”.
In most cases, no. Although the offloading achieved via a CAM boot will ease painful symptoms in the short-term unless biomechanics are addressed it is likely that the condition will return upon return to normal activity. Furthermore, the muscular deconditioning from the global offloading of a CAM boot can further add to focal forefoot loading. Necessary force redistribution can be achieved whilst keeping the patient active and engaged with their injury management plan.
“You cannot wear high heels anymore.”
Although it is true that an increased heel height can in turn increase forefoot loading, it is not necessary to rule out high heels forever. Sesamoiditis is largely seen within a younger active female population: significantly limiting footwear options may negatively impact their buy-in to the overall treatment plan (Waldman). Instead, it may be beneficial to discuss low-heeled supportive footwear options as an interim treatment method and then look to load modifications, via the help of a podiatrist, in the future so that high heeled shoes can remain a regular fashion choice.
As it is an overload on the tissue, doing less, in theory, could be an option. But not a good one. Doing less on our feet has significant deleterious effects on our health, mood, lifestyle and sporting performance.
Treatment should focus on three aspects. Load optimisation, capacity building and education.
Load optimisation is where we work out what loading is essential and what is potentially pathological. The main focus for the sesamoids is to encourage soft tissue recruitment and activation to reduce focal compression on the bone itself as well as the non-contractile tissues that surround it.
We do this via:
- Gait Training (for runners)
Capacity building is taking the fixed capacity of work that the surrounding musculature is currently doing, and increasing it. This can be done with resistance training as well as activation repatterning.
Education here really means pain education. When we take the time to talk through pain in terms of nociception it empowers our clients to take charge of their musculoskeletal complaints. This is particularly important when making a return to higher level activity to reduce the likelihood of pain expectancy.
We also take the time to explain to every client the exact reason for their sesamoiditis, their symptoms and allow opportunities for discussion and questions. This leads to the critical step of goal setting.
There’s also the 5% ‘ers. This can include pain modulation with NSAID’s, massage, and icing. As discussed above, cortisone has been shown to be useful for short term pain relief (similar to strapping and orthotics) but no better long term (+ side effects).
Such an overlooked yet critical aspect of health care, actually asking what our clients want and why. A client suffering from sesamoiditis symptoms for only a short period of time vs. those with chronic symptoms will have different goals and expectations although almost always pain relief will be there. Goal setting in the short, medium and long term provides a useful framework to fall back on when compliance/adherence or life gets in the way of best-made plans.
1. Sesamoiditis of the metatarsophalangeal joint. OA Orthopaedics (2013). Atiya S, Quah C, Pillai A.
2. Painful sesamoid of the great toe. World Journal of Orthopaedics (2014). Sims A, Kurup H.
3. Sesamoiditis. World Atlas of Uncommon Pain Syndromes (2014). Waldman S.