Sesamoid Fracture of the Foot: Causes Diagnosis and Recovery for Big Toe Sesamoid Injury

What Are the Sesamoid Bones?

The sesamoid bones are two small, pea-shaped bones embedded within the flexor hallucis brevis tendon on the plantar (bottom) surface of the first metatarsal head — directly beneath the big toe knuckle joint. They function as a pulley for the flexor tendons, increasing their mechanical advantage for plantarflexion of the big toe during push-off, and as a weight-bearing cushion beneath the first metatarsal head. The medial (tibial) sesamoid is slightly larger and bears more weight; the lateral (fibular) sesamoid is smaller and positioned beneath the lateral surface of the metatarsal head.

At Balance Foot & Ankle, we diagnose and treat sesamoid fractures and sesamoiditis in athletes and active patients throughout Southeast Michigan, providing both conservative management and surgical consultation when needed.

How Sesamoid Fractures Occur

Sesamoid fractures can be either acute or stress fractures. Acute sesamoid fractures result from a direct blow or sudden forceful plantarflexion — such as a landing from height that hyperextends the big toe — that applies more force to the sesamoid than the bone can withstand. Stress fractures of the sesamoid are far more common and occur from repetitive loading that cyclically stresses the sesamoid beyond its healing capacity. Runners, ballet dancers, basketball players, and other athletes who perform repetitive forefoot loading on hard surfaces are at highest risk for sesamoid stress fractures.

A confounding factor in sesamoid diagnosis is the bipartite sesamoid — a sesamoid that naturally develops from two ossification centers and remains in two separate parts in approximately 10 to 30 percent of people. Bipartite sesamoids are bilateral in 25 percent of cases and can be misidentified as fractures. Smooth, rounded edges on imaging suggest a bipartite sesamoid; sharp, irregular edges suggest acute fracture. Bone marrow edema on MRI differentiates symptomatic bipartite sesamoid from asymptomatic bilateral variant.

Symptoms and Diagnosis

Pain directly beneath the first metatarsal head at the sesamoid region is the hallmark symptom. The pain is worse with weight bearing and with push-off during walking and running, and is exquisitely tender with direct palpation from the plantar surface of the foot. Ballet dancers and runners describe progressive forefoot pain that initially limits certain positions and progressively limits all activity. Swelling and bruising beneath the metatarsal head may be present with acute fractures.

Weight-bearing X-rays in multiple views are the first imaging step. MRI is the gold standard for confirming sesamoid stress fracture, evaluating fracture extent, excluding bipartite sesamoid confusion, and assessing avascular necrosis in delayed presentations.

Conservative Treatment

Non-displaced sesamoid fractures are managed conservatively for 6 to 12 weeks. A CAM boot or rigid-soled shoe eliminates the sesamoid loading of normal gait. A sesamoid offloading orthotic with a dancer pad — a donut-shaped pad around the sesamoid — redistributes pressure away from the fracture zone. Complete avoidance of barefoot walking, push-off activities, and first MTP joint hyperextension is essential during healing. Recovery is frustratingly slow — the poor blood supply of the sesamoid slows healing significantly compared to most other foot bones.

When Surgery Is Considered

Surgical options for sesamoid fractures include excision of the involved sesamoid for fractures that fail to heal after prolonged conservative management. Sesamoid excision reliably relieves pain and allows return to activity, though it requires careful technique to avoid altering hallux alignment or weakening flexor tendon function. Most surgeons prefer conservative management exhausted over 4 to 6 months before recommending excision.

If you have persistent big toe joint pain beneath the ball of the foot, contact Balance Foot & Ankle for evaluation. We serve Southeast Michigan with same-week appointments.

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Frequently Asked Questions

How is a sesamoid fracture diagnosed?

Diagnosis combines clinical examination with X-rays and MRI. MRI is particularly useful to distinguish fracture from sesamoiditis, stress reaction, or avascular necrosis. Ultrasound can also identify soft tissue involvement.

How long does a sesamoid fracture take to heal?

Acute fractures typically heal in 6-8 weeks with immobilization, offloading, and activity modification. Stress fractures may take 12 weeks or longer. Non-unions can persist indefinitely without intervention.

Will I need surgery for a sesamoid fracture?

Most sesamoid fractures heal without surgery. Sesamoidectomy is reserved for non-unions, avascular necrosis, or chronic pain that fails conservative care. Removing only one sesamoid preserves most big toe function.

Your Board-Certified Podiatrists

Dr. Tom Biernacki, DPM

Board-Certified · FACFAS

Dr. Carl Jay, DPM

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Dr. Daria Gutkin, DPM

Podiatrist

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.