Sesamoid Bone Pain 2026: Causes & Treatment | DPM

Sesamoid Condition	Cause	Pain Pattern	X-ray Finding	MRI/Bone Scan Finding
Sesamoiditis	Repetitive stress; overuse; cavus foot; dancer/runner	Dull ache under 1st MTP; worse with push-off; gradual onset	Normal or mild irregularity	Bone marrow edema; periosteal reaction
Acute sesamoid fracture	Single traumatic event; fall; jamming big toe	Sudden sharp pain; point tenderness; swelling	Fracture line (linear); compare with contralateral	Fracture gap; surrounding soft tissue edema
Stress fracture of sesamoid	Cumulative repetitive loading; running volume increase	Insidious onset; worse with activity; no single event	May appear normal early; sclerosis late	Bone marrow edema; fracture line on MRI before X-ray positive
Bipartite sesamoid (normal variant)	Congenital two-part sesamoid (10–33% of people)	Usually asymptomatic; can become painful with overuse	Two rounded smooth fragments (smooth edges differentiate from fracture)	No marrow edema if truly asymptomatic variant
Sesamoid AVN (osteonecrosis)	Disrupted blood supply; post-fracture; steroid use	Persistent deep aching; failure to heal; worse with all weight-bearing	Sclerosis; fragmentation; density change	Loss of normal bone signal; necrotic core
Sesamoid chondromalacia / OA	Articular cartilage wear; post-inflammatory	Chronic pain; 1st MTP joint stiffness; activity-related flare	Joint space narrowing; osteophytes	Cartilage thinning; subchondral edema

Treatment	Indication	Duration	Expected Outcome	Escalation If Failed
Dancer’s pad / sesamoid offloading orthotic	Sesamoiditis; bipartite sesamoid pain; mild stress reaction	6–12 weeks minimum; permanent for recurrent cases	60–70% resolution with compliant offloading	Custom orthotic + metatarsal bar; cortisone injection
Stiff-soled shoe / rocker bottom	All sesamoid conditions — limits 1st MTP dorsiflexion loading	During active symptoms	Immediate load reduction; pain reduction within days	Surgical shoe / walking boot if inadequate
CAM boot / non-weight-bearing	Acute fracture; stress fracture; AVN	6–8 weeks NWB; 4–6 weeks CAM boot after	Fracture healing in 8–12 weeks if blood supply intact	ORIF / sesamoidectomy for non-union
Cortisone injection (periosteal / peritendinous)	Sesamoiditis failing conservative care; bipartite pain flare	1–2 injections; limit due to fat pad atrophy risk	50–70% pain relief for 3–6 months	PRP injection; surgical sesamoidectomy
PRP (platelet-rich plasma) injection	Sesamoiditis / stress reaction; AVN early stage	1–3 injections	Emerging evidence for bone healing; 60–70% response	Sesamoidectomy
Sesamoidectomy (partial or total)	AVN; non-union fracture; chronic refractory sesamoiditis	Outpatient; 6–8 week recovery	85–90% pain relief; hallux valgus risk with medial sesamoid removal	Reconstructive surgery if HV develops post-op

Pain under the ball of the big toe — particularly at the base of the first metatarsal head — has a specific set of causes that are different from general forefoot pain. The sesamoid bones are two small, pea-sized bones embedded within the flexor hallucis brevis tendon that runs under the first metatarsophalangeal joint. They act as pulleys to improve the mechanical advantage of the big toe push-off. When they’re inflamed, fractured, or undergo avascular necrosis, the pain they cause is very specific, very focal, and often very persistent if not managed correctly.

In our clinic, sesamoid injuries are most commonly seen in dancers (especially ballet dancers who spend significant time on relevé), runners with forefoot striking patterns, and athletes in sports requiring explosive push-off (basketball, baseball, tennis). We also see them in patients who’ve simply made a sudden change in footwear — going from supportive shoes to flat sandals creates a dramatic increase in first ray loading that can overload the sesamoids quickly.

What Are the Sesamoid Bones

The sesamoids are two small bones — the medial (tibial) sesamoid and the lateral (fibular) sesamoid — located plantar (underneath) the first metatarsophalangeal (MTP) joint. Unlike most bones, they are embedded within the substance of the flexor hallucis brevis tendon rather than connected to adjacent bones via joints in the traditional sense. Their purpose is to act as a pulley: by displacing the tendon away from the joint axis, they increase the mechanical advantage of the flexor hallucis brevis, making big toe push-off more powerful and efficient.

The medial sesamoid bears more load than the lateral and is consequently injured more often. The blood supply to the sesamoids is limited and enters primarily from the distal end — which means fractures, particularly of the medial sesamoid, have inherent poor healing potential due to watershed blood supply to the proximal fragment. This is why sesamoid fractures are treated more aggressively and for longer than most other small bone fractures.

A bipartite sesamoid — a normal anatomic variant in which the sesamoid has two separate ossification centers that never fused — is present in approximately 10–30% of people. It’s critical to distinguish a bipartite sesamoid from a fracture on imaging, as they look similar on X-ray. Key distinguishing features: bipartite sesamoids are typically bilateral (same finding in both feet), have smooth, well-corticated margins, and the gap between the pieces is rounded rather than jagged.

Sesamoid Conditions — Not All the Same

Several distinct pathologies affect the sesamoids, each requiring different treatment and carrying a different prognosis:

Symptoms of Sesamoid Pain

The hallmark of sesamoid pain is focal tenderness directly under the first metatarsal head — specifically under the ball of the big toe, not the big toe joint itself or the plantar fascia insertion at the heel. Patients can typically point with one finger to exactly where it hurts, which is diagnostically helpful.

Common symptom features: pain that worsens with barefoot walking, especially on hard floors; pain with push-off during walking or running (late stance/toe-off phase); pain when wearing flat, unsupportive shoes (sandals, flip-flops); worsening with high-impact activities (jumping, sprinting, dancing); and possible mild swelling under the first MTP joint. A clinical finding unique to sesamoid injury: pain is markedly worsened by extending (pulling up) the big toe — this loads the sesamoid apparatus under tension. Pain that is worse with toe extension than with direct pressure is highly suggestive of sesamoid pathology.

Causes and Risk Factors

Sesamoid bone pain results from overloading of the first metatarsal head region. The primary risk factors in our patient population include: athletic activities requiring forceful toe push-off or prolonged time on the ball of the foot (ballet, basketball, baseball, gymnastics, distance running with forefoot strike pattern); sudden footwear changes from cushioned to minimalist or flat shoes; high-arched (cavus) foot which transfers load to the first and fifth metatarsal heads; prominent first metatarsal head that projects more plantarly than usual (plantar-flexed first ray); bony prominences or hyperkeratosis under the sesamoid region; and direct trauma (turf toe with sesamoid involvement or a fall landing on the ball of the foot).

Diagnosis

Weight-bearing X-rays in standard AP, lateral, and sesamoid axial views are the starting point. X-rays identify frank fractures, displacement, and avascular necrosis (sclerosis/fragmentation pattern). However, X-rays miss stress fractures in early stages and cannot distinguish sesamoiditis from stress fracture. X-rays can also appear to show a bipartite sesamoid that is actually a stress fracture — comparison views of the opposite foot help, but are not definitively diagnostic.

MRI is the gold standard for sesamoid pathology. It detects bone marrow edema (sesamoiditis and early stress fracture), AVN (loss of normal marrow signal), cartilage damage, and associated tendon or capsule injury. In any patient with sesamoid pain persisting beyond 4 weeks without clear X-ray diagnosis, we order MRI. Bone scan was historically used but MRI provides superior anatomic detail with no radiation. Diagnostic local anesthetic injection (lidocaine under the sesamoid) confirms the sesamoid as the pain source when multiple forefoot conditions are present simultaneously.

Treatment Options

Dancer’s Padding / Sesamoid Offloading

The cornerstone of sesamoiditis treatment is redirecting plantar pressure away from the sesamoid bones. “Dancer’s padding” is a J-shaped or donut-shaped felt or foam pad that creates a protected zone around — not over — the sesamoid. This single intervention can reduce sesamoid pain dramatically within 1–2 days and forms the foundation of all conservative sesamoid management. The pad is applied to the insole or directly to the foot, with the open center precisely over the tender sesamoid. Correct placement is critical and is something we teach patients in our clinic.

Activity Modification

All activities that load the sesamoids through toe push-off or forefoot strike must be significantly reduced or eliminated during treatment. This includes running (especially forefoot strike), dancing, jumping, and sports with aggressive directional changes. Low-impact alternatives: cycling (moves push-off to midfoot), swimming, and pool running maintain fitness without sesamoid loading. Return to activity is guided by symptoms — typically 4–6 weeks for sesamoiditis, 8–12 weeks for stress fracture.

Footwear and Orthotic Management

Transition to rigid-soled or stiff-soled shoes during treatment — these prevent the toe extension moment at push-off that stresses the sesamoid. A shoe with a rocker bottom sole is ideal. Custom orthotics with a Morton’s extension cutout (a recess under the first metatarsal head) provide precise offloading and are particularly useful for patients with a plantar-flexed first ray or recurrent sesamoid problems.

Corticosteroid Injection

A carefully placed corticosteroid injection adjacent to the painful sesamoid provides significant short-term pain relief and allows rehabilitation to progress. We use ultrasound guidance for precision. Indicated for sesamoiditis that hasn’t responded adequately to 4–6 weeks of conservative management. Not appropriate for stress fractures — corticosteroids may impair bone healing. Repeat injections are limited (typically no more than 2–3 lifetime) due to potential for tendon weakening and avascular necrosis risk with repeated injections.

Surgical Sesamoidectomy

Surgical removal of one sesamoid (sesamoidectomy) is reserved for: AVN with refractory pain, stress fractures that fail 6+ months of conservative treatment, and acute displaced fractures. The medial sesamoid can be removed without significant functional deficit in most patients. Removing the lateral sesamoid must be done with caution — losing both sesamoids causes hallux valgus deformity. Recovery from sesamoidectomy: 6–8 weeks with gradual return to activity by 3–4 months. Good outcomes in properly selected patients.

For sesamoid evaluation, dancer’s padding fitting, custom orthotic fabrication, and injection therapy in Howell or Bloomfield Township, MI: Call (810) 206-1402 or book at new-patient-information.

Healing Timeline

Sesamoiditis without fracture: with consistent offloading and activity restriction, pain typically improves significantly within 2 weeks and resolves by 4–6 weeks. Incomplete treatment (continuing provocative activities) can perpetuate sesamoiditis for months. Sesamoid stress fracture: 8–12 weeks of strict offloading in a non-weight-bearing cast or CAM boot. The limited blood supply to the sesamoids makes healing slower than other small bones. Complete fracture/AVN: 6 months to 1 year for conservative management, or 3–4 months after sesamoidectomy. Prognosis for AVN managed conservatively is variable — many patients achieve acceptable function, but some require eventual surgery.

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Frequently Asked Questions

How long does sesamoid pain take to heal?

Sesamoiditis without fracture: 4–6 weeks with consistent offloading and activity restriction. Sesamoid stress fracture: 8–12 weeks in a non-weight-bearing boot or cast. Avascular necrosis: 6 months to 1 year for conservative management or 3–4 months post-sesamoidectomy. Patients who continue provocative activities during treatment dramatically extend recovery timelines — the most common cause of prolonged sesamoid pain is inadequate rest compliance.

What is the difference between sesamoiditis and a sesamoid fracture?

Sesamoiditis is inflammation without a fracture — the sesamoid bone is intact. Symptoms improve more quickly with rest (days to a few weeks). A sesamoid stress fracture is a hairline crack requiring strict non-weight-bearing for 2–3 months. The two cannot be reliably distinguished on clinical exam or even standard X-ray — MRI is the definitive test. If sesamoid pain hasn’t improved after 3–4 weeks of rest and offloading, assume fracture until proven otherwise by MRI.

Can I run with sesamoiditis?

Running with active sesamoiditis significantly delays healing and risks fracture. Forefoot strikers load the sesamoid with 3–4× body weight at toe-off; this is exactly the mechanism that caused sesamoiditis in the first place. We recommend zero running during the first 4–6 weeks of treatment. Pool running (deep-water running with flotation belt) and cycling maintain fitness without sesamoid loading. Return to running begins with a gradual walk-to-run program only after 4+ weeks of symptom-free walking.

When should I see a podiatrist for ball-of-big-toe pain?

See a podiatrist if: the pain is directly under the base of the big toe (not the joint itself), is worse with toe extension and push-off, has been present for more than 2 weeks, or occurred after a jumping or push-off injury. Sesamoid injuries are frequently under-diagnosed at urgent care and the ER because sesamoid-specific X-ray views are often not taken. At Balance Foot & Ankle, we take targeted sesamoid views and have MRI referral available for same-week evaluation. Call (810) 206-1402.

Does insurance cover sesamoid treatment?

Yes. Evaluation, X-rays, orthotics, and injection therapy for sesamoid pain are covered by Medicare and most private insurance plans when medically indicated. MRI is typically covered after conservative treatment has been attempted. Sesamoidectomy is a covered surgical procedure. Our team at Balance Foot & Ankle verifies your coverage before your appointment. Call (810) 206-1402.

Sources

1. Biedert R, Hintermann B. “Stress fractures of the medial great toe sesamoids in athletes.” Foot Ankle Int. 2003;24(2):137–141.
2. McBryde AM Jr, Anderson RB. “Sesamoid foot problems in the athlete.” Clin Sports Med. 1988;7(1):51–60.
3. Richardson EG. “Hallucal sesamoid pain: causes and surgical treatment.” J Am Acad Orthop Surg. 1999;7(4):270–278.
4. Amaranath J et al. “Diagnosis and management of sesamoid disorders of the first metatarsophalangeal joint.” Foot Ankle Spec. 2016;9(6):533–541. doi:10.1177/1938640016667310
5. Dedmond BT, Cory JW, McBryde A Jr. “The hallucal sesamoid complex.” J Am Acad Orthop Surg. 2006;14(13):745–753.

AAOS: Sesamoid Pain

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your sesamoiditis, our podiatry team at Balance Foot & Ankle can help with same-week evaluations and advanced in-office care.