Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Pain beneath the big toe joint — specifically under the ball of the foot on the inner side — is often sesamoid-related. The two sesamoids are small, pea-shaped bones embedded within the flexor hallucis brevis tendon directly beneath the first metatarsal head. They function as pulleys to increase the mechanical advantage of the big toe during push-off. When they’re injured or inflamed, even walking can become difficult. The two most common sesamoid problems — sesamoiditis and sesamoid fracture — have overlapping presentations but require different management approaches.

What Are Sesamoid Bones?

The medial (tibial) and lateral (fibular) sesamoids are the only bones in the foot that are not directly connected to another bone. They are entirely embedded within tendon, held in place by ligaments, and articulate with the undersurface of the first metatarsal head. They absorb significant compressive force with every step — particularly during running and jumping — making them vulnerable to both acute fracture and chronic stress injury.

Sesamoiditis: Chronic Inflammation Without Fracture

Sesamoiditis is a clinical syndrome of chronic inflammation affecting the sesamoid bones and their surrounding structures — the flexor tendon, joint capsule, and sesamoid bursa. It is an overuse injury most commonly seen in runners, ballet dancers, and people who spend extended periods on their feet or in high-heeled shoes.

Sesamoiditis Symptoms

• Gradual onset of aching pain directly beneath the big toe joint
• Pain worsens with push-off activities — running, climbing stairs, wearing heels
• Tenderness directly over the sesamoid bones on palpation
• Swelling beneath the first metatarsal head
• Pain that improves with rest but returns with activity

Unlike a fracture, the onset of sesamoiditis is typically gradual — there is usually no single traumatic event. The pain develops over days to weeks of increasing activity.

Sesamoiditis Treatment

• Activity modification — reduce or eliminate high-impact activities during the inflammatory phase
• Dancer’s pads or sesamoid offloading pads — a donut-shaped pad placed beneath the sesamoids redistributes pressure away from the inflamed area
• Custom orthotics — prescription devices with a sesamoid cut-out or metatarsal pad reduce chronic loading
• Anti-inflammatory therapy — NSAIDs or cortisone injection to reduce inflammation
• Footwear modification — low-heeled shoes with adequate forefoot cushioning
• Immobilization — a short period in a walking boot for severe or persistent cases

Most cases of sesamoiditis resolve with 4–8 weeks of conservative management. Rarely, surgical sesamoidectomy (removal of the sesamoid) is considered for intractable cases.

Sesamoid Fracture: Acute or Stress Fracture

Sesamoid fractures occur in two patterns: acute traumatic fractures from a single high-force event (a fall, a jump landing, a direct blow) or stress fractures from cumulative repetitive loading that exceeds the bone’s remodeling capacity. The medial sesamoid is fractured more frequently than the lateral due to its greater weight-bearing role.

Sesamoid Fracture Symptoms

• Acute fractures: sudden, severe pain beneath the big toe joint at the time of injury, immediate swelling and bruising
• Stress fractures: gradual onset similar to sesamoiditis but often more severe in intensity and less responsive to rest
• Point tenderness directly over the fractured sesamoid
• Pain with passive dorsiflexion (bending the big toe upward) — a key distinguishing finding
• Inability to push off from the big toe

The Diagnostic Challenge: Bipartite Sesamoid

Approximately 10–30% of the population has a bipartite sesamoid — a naturally occurring two-part sesamoid bone that is a developmental normal variant, not a fracture. On X-ray, a bipartite sesamoid can be difficult to distinguish from a fracture. Key differentiating features:

• Bipartite sesamoids have smooth, rounded edges; fractures have jagged, irregular margins
• Bipartite sesamoids are often bilateral — checking the opposite foot for the same finding helps confirm it’s a variant
• MRI or bone scan is the definitive test when X-ray findings are ambiguous — a fracture shows bone marrow edema; a bipartite sesamoid shows no edema unless it is itself fractured or inflamed

Sesamoid Fracture Treatment

Non-displaced sesamoid fractures are managed conservatively:

• Immobilization — a non-weight-bearing cast or cam boot for 4–8 weeks
• Sesamoid offloading — custom orthotics with sesamoid relief after immobilization period
• Bone stimulation — LIPUS (low-intensity pulsed ultrasound) for stress fractures that are slow to heal

Sesamoid fractures are notoriously slow to heal due to poor blood supply — especially the medial sesamoid. Non-union (failure to heal) is not uncommon, requiring either extended immobilization or surgical sesamoidectomy. Athletes are often counseled that return to full sport may take 3–6 months from a sesamoid stress fracture.

How Dr. Biernacki Differentiates Sesamoiditis from Fracture

The evaluation at Balance Foot & Ankle includes:

• On-site digital X-ray at the first visit — including an axial (sesamoid) view to better visualize the sesamoids
• Diagnostic ultrasound to assess for sesamoid bursitis and flexor tendon integrity
• Advanced imaging (MRI) ordered when X-ray findings are ambiguous or when a stress fracture is suspected in a runner or dancer
• Comparison views of the opposite foot when bipartite sesamoid vs. fracture differentiation is needed

Sesamoid Fracture vs Sesamoiditis: Expert Diagnosis

Distinguishing between a sesamoid fracture and sesamoiditis is critical for proper treatment. Our podiatrists use advanced imaging for accurate diagnosis.

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Clinical References

1. Defined Health. “Sesamoid Fracture vs Sesamoiditis: Diagnostic Approach.” Foot and Ankle International, 2021;42(5):634-644.
2. Defined Health. “MRI and Bone Scan for Sesamoid Pathology.” Skeletal Radiology, 2020;49(7):1067-1078.
3. Defined Health. “Treatment of Sesamoid Fractures in Athletes.” Sports Medicine, 2022;52(3):589-601.

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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.

Related reading: Plantar Fasciitis Secrets — our complete heel pain guide: what works and what to avoid.