Sesamoid syndrome/sesamoiditis

Quick overview

• Typical complaints: stabbing or pressing pain under the ball of the big toe, especially a. when rolling and on hard floors
• Common triggers: increased training, forefoot running, high heels, hallux misalignments, hollow feet/overpronation
• Diagnostics: clinical examination, X-ray (including sesamoid tangential image), if necessary MRI if a stress reaction/edema is suspected
• Therapy initially conservative: activity adjustment, padding (Dancer's Pad), suitable shoes/insoles (e.g. Morton Extension), physiotherapy, short-term NSAIDs
• Splints/walkers or forefoot relief in case of severe irritation or suspected stress fracture
• Surgery should only be carried out in the case of persistent symptoms or special findings (e.g. displaced fracture, nonunion) after careful consideration

Anatomy: The sesamoid bones of the big toe joint

There are two small bones under the metatarsophalangeal joint of the big toe - medial (tibial) and lateral (fibular) sesamoid. They are embedded in the tendons of the flexor hallucis brevis muscle and are part of the so-called sesamoid apparatus.

• Function: Increase the lever arm of the big toe flexors, improve power transmission during push-off
• Protection: distribution of pressure forces in the forefoot, buffer effect when rolling
• Surroundings: Ligaments, tendons and the plantar plate stabilize the metatarsophalangeal joint of the big toe

Due to this special position, high forces act on the sesamoid bones when running, jumping or dancing - the result is overload and irritation.

Symptoms: How do you recognize sesamoiditis?

• Localized pressure pain under the ball of the big toe (plantar)
• Pain when rolling, standing on tiptoes or changing direction quickly
• Start-up pain, which can worsen with further stress
• Sometimes slight swelling or warming in the area of ​​the big toe joint
• Feeling like walking on a pebble
• In the case of an acute injury (e.g. fracture): sudden shooting pain and significant inability to bear weight

Discomfort can occur on one or both sides and can worsen with hard soles, thin cushioning or high heels.

Causes and risk factors

It is usually an overload reaction of the sesamoid bones and surrounding soft tissues. Repeated microtrauma leads to irritation, bone edema or, in isolated cases, stress fractures.

• Sports load: running (forefoot running), jumping and dance sports, sprints
• Shoe factors: high heels, hard/flexible thin soles without rocker component
• Misalignments/anatomy: Hallux valgus/rigidus, hollow foot, overpronation, metatarsus primus varus, bipartite sesamoid bone (congenitally divided)
• Hard ground, sudden increases in training, inadequate regeneration
• Rare: acute fracture, nonunion, avascular necrosis (circulatory disorder)

Diagnosis: This is how we proceed

At the beginning there is an anamnesis and a detailed examination: localization of pressure points, testing of rolling and big toe mobility, gait and shoe analysis.

• X-rays in multiple planes, including a special sesamoid tangential image
• MRI to show bone edema, stress reactions or soft tissue involvement
• CT if a fracture/pseudarthrosis is suspected to assess the bone structure
• Ultrasound to assess bursae/soft tissues

It is important to differentiate between sesamoiditis, stress fracture and a bipartite (split) sesamoid bone. The latter usually shows smooth, regular edges and often exists on both sides - a fracture is more likely to have jagged, uneven edges and a corresponding history of pain.

Conservative treatment: The standard route

Most cases can be calmed down conservatively. The aim is to relieve pain, reduce inflammation and redistribute the load in the forefoot.

If there is severe pain or a stress reaction, temporary immobilization may make sense.

Forefoot relief and immobilization

Depending on the findings, a forefoot relief shoe, a rigid walker boot or short-term partial weight-bearing with forearm crutches are possible (typically 2-6 weeks). The goal is to allow the irritation to subside and promote healing.

The load is increased gradually according to symptoms and medical recommendations. A structured return-to-run program minimizes relapses.

Physiotherapy and exercises

• Stretching the calf muscles (gastrocnemius/soleus) to relieve the rolling process
• Gentle mobilization of the big toe joint in low-pain areas
• Strengthening the foot muscles (e.g. “short foot”, cloth claws), stabilizing the leg axis
• Gait training, adjustment of running technique if necessary, controlled return to work
• Manual techniques for tissue calming and load distribution

Physical measures such as ice and relieving tapes can ease acute phases. Evidence for shock wave or therapeutic ultrasound in sesamoiditis is limited; they can be discussed on a case-by-case basis.

Injections and regenerative procedures: only selective

Injections are used cautiously. Cortisone injections can relieve pain in the short term, but carry risks (fatty tissue atrophy, tendon weakening, rarely circulatory problems). If so, then preferably ultrasound-targeted and according to strict indications.

Preparations such as PRP are considered in individual cases for chronic tendon or soft tissue irritation. The data specifically on sesamoiditis is limited. We discuss opportunities and limitations transparently and initially prefer tried and tested conservative measures.

Surgery: When does it make sense?

Surgery is the exception. It is an option if symptoms persist despite consistent therapy over several months or if there are special findings such as a displaced sesamoid fracture, painful nonunion or avascular necrosis.

• Sesamoidectomy (partial or complete removal of a sesamoid bone) – Risk: Change in big toe position/strength
• Osteosynthesis/refixation of fresh fractures in selected cases

Post-operatively, a phase of relief, subsequent physiotherapy and a gradual increase in load are important. An individual benefit-risk comparison is essential in advance.

Course and prognosis

Many patients achieve significant improvement within a few weeks to a few months with conservative therapy. In the event of a stress reaction or fracture, the healing time may be longer.

Relapses are possible, especially if training increases too quickly, persistent shoe problems or untreated misalignments. Consistent load control and suitable insoles/shoes reduce the risk.

Self-help in everyday life

• Cushioning, well-fitting shoes with a wide toe box and possibly a rocker sole
• Dancer’s pad or soft forefoot pads, correctly placed
• Increase the load slowly, plan breaks, vary the surface
• Alternative training (cycling, swimming) during the recovery phase
• Stretch regularly (calf) and strengthen foot muscles
• cooling after exercise; Heat only if it is perceived as pleasant and there is no acute inflammation

Prevention: How to prevent it

• Gradual increase in training (e.g. 10% rule)
• Technical training and sufficient regeneration between intensive units
• Shoes with sufficient cushioning and stability; timely replacement of expired models
• Insoles/correction for axial deviations or overpronation after orthopedic assessment
• Weight and load management, especially with high forefoot loads

When should you seek medical advice?

• Sudden, severe pain under the ball of the big toe after trauma
• Persistent pain at rest, pain at night, significant swelling/warmth
• Increasing misalignment of the big toe or noticeable “cracking” when rolling
• Numbness, tingling or problems with wound healing
• Diabetes or circulatory disorders with plantar pressure points
• No improvement despite protection and measures over 2-3 weeks

Differential diagnoses: What can look similar?

• Hallux rigidus (arthrosis of the big toe joint)
• Hallux valgus with secondary overload
• Metatarsalgia of other rays
• Morton's neuroma (nerve irritation between the metatarsals)
• Stress fracture of the 1st metatarsal bone
• Bursitis, gout or inflammatory rheumatic diseases
• Avascular necrosis of a sesamoid bone, nonunion
• Bipartite sesamoid bone (variant, not pathological - but can cause problems)

Your orthopedics in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, we examine forefoot problems in a structured manner and treat them according to current orthopedic standards - conservatively first and with an eye on your individual goals, whether everyday life, work or sport.