- Sesamoiditis is inflammation of the two small sesamoid bones tucked beneath the big toe joint.
- It commonly affects runners, dancers, athletes who do repeated jumping, and people with high-arched feet.
- First-line treatment is offloading, activity modification, taping, and custom orthotics with a sesamoid pad.
- Sesamoid stress fractures need to be ruled out — they require longer protected weight-bearing than simple sesamoiditis.
- Most cases resolve with conservative care over 6–12 weeks.
What is sesamoiditis?
The sesamoid bones are two small bones, each about the size of a corn kernel, embedded in the tendon that runs under the big toe joint. They function like miniature kneecaps, providing leverage and absorbing some of the impact at the ball of the foot. When they become inflamed — usually from repetitive overload — the condition is called sesamoiditis.
Sesamoiditis is most common in runners, dancers, basketball players, and anyone whose sport involves repeated push-off through the big toe. Patients with high-arched feet are particularly prone because the forefoot bears proportionally more weight. It can also develop in people who suddenly increase forefoot impact or change to minimalist footwear.
Our podiatry team at Northwest Extremity Specialists treats sesamoiditis with a stepped, conservative-first plan. The most important step is offloading — taking pressure off the sesamoids — while the inflammation resolves. Most patients are significantly improved in 6–12 weeks with the right combination of taping, padding, orthotics, and activity modification. The first job at the initial visit is also to make sure it is not a sesamoid stress fracture, which has overlapping symptoms but requires longer protected weight-bearing.
See it in motion
Animations licensed from ViewMedica · Swarm Interactive
The two sesamoid bones — the tibial (inner) and fibular (outer) sesamoids — sit within the flexor hallucis brevis tendon, directly beneath the first metatarsal head. They are not connected to other bones by typical joints; they float within the tendon and slide forward and backward as the big toe moves. Their job is to act as a fulcrum, increasing the leverage of the tendon and protecting it from the bone. They take significant load with every step, run, or jump.
What it feels like
Sesamoiditis has a fairly specific pain pattern under the big toe joint:
- Aching or sharp pain under the big toe joint, especially with push-off
- Pain that gradually worsens over weeks rather than starting suddenly
- Tenderness when pressing directly under the big toe joint
- Pain that's worse with running, jumping, or going barefoot
- Swelling and sometimes bruising under the joint
- Difficulty bending the big toe up (limited motion)
- Pain when standing on tiptoe
Why it develops
Sesamoiditis develops from repetitive overload of the sesamoid bones:
- High-mileage running, especially on hard surfaces or in worn shoes
- Dance, basketball, soccer — any activity with repeated push-off
- Sudden increase in training volume or intensity
- High-arched (cavus) foot type that concentrates weight on the forefoot
- Switching to minimalist or low-stack footwear
- High heels, which shift weight forward onto the ball of the foot
- Acute injury (jumping landing) in some cases
How we diagnose sesamoiditis
A sesamoiditis exam focuses on the area directly under the big toe joint. Your provider will palpate each sesamoid individually, test big-toe range of motion, and watch you walk and rise onto your toes. Weight-bearing X-rays are taken in our office to evaluate the sesamoid bones — particularly to look for a fracture or for signs of avascular necrosis (loss of blood supply). MRI may be ordered if a stress fracture is suspected and X-rays are inconclusive. Most patients leave the same day with both a diagnosis and a plan.
Non-surgical care
The cornerstone of sesamoiditis treatment is offloading. Most cases resolve with several weeks of targeted conservative care:
- Activity modification — temporary reduction in running, jumping, and dance
- Custom orthotics with a sesamoid cutout to offload the inflamed area
- A dancer's pad or felt padding placed behind the sesamoids
- Stiff-soled shoes or rocker-bottom shoes to limit big-toe motion
- Big-toe taping for additional support
- Anti-inflammatory medication for acute flares
- A short period in a walking boot for severe cases
- Corticosteroid injection in selected resistant cases
Surgical care
Surgery is uncommon for sesamoiditis and is reserved for cases that have failed extensive conservative treatment, persistent sesamoid fracture nonunion, or significant avascular necrosis. Sesamoidectomy (surgical removal of one sesamoid) is a careful decision — removing both sesamoids is rarely done because it permanently weakens the big toe push-off.
- Partial or complete sesamoidectomy of one affected sesamoid
- Bone grafting in selected nonunion cases
- Repair of associated soft-tissue structures
After a sesamoidectomy, most patients are non-weight-bearing for 2–4 weeks, then progress through a walking boot for several more weeks. Return to athletic shoes typically takes 8–12 weeks, with return to running and sport at 3–6 months. Recovery is gradual and benefits from coordinated physical therapy.
When to see a specialist
- Pain under the big toe joint that has lasted more than 2 weeks
- Pain that limits your ability to run, dance, or play sport
- Sudden severe pain or swelling under the big toe after an injury (could be a fracture)
- Pain that doesn't respond to rest and over-the-counter measures
- Bruising or visible swelling under the big toe
Sesamoiditis is treated by our sports medicine team — Dr. Todd Galle in Wilsonville and Dr. Manny Moy at Cedar Mill — as well as any of our other board-certified podiatrists. Surgical sesamoidectomy, when needed, is performed by Dr. Mia Horvath or Dr. Thomas Melillo at our Tigard Locust office.