Sesamoid Problems in the Foot: Sesamoiditis, Fractures, and Avascular Necrosis

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

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The Sesamoids: Two Small Bones With Big Problems

The sesamoid bones — two small, pea-sized bones embedded in the flexor hallucis brevis tendon beneath the first metatarsal head — are important but frequently overlooked sources of forefoot pain. Despite their small size, the sesamoids bear significant compressive and tensile loads during push-off, and dysfunction at this location can be profoundly disabling, particularly for runners, dancers, and anyone who performs repetitive forefoot loading. At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, we see sesamoid problems regularly and approach them with the detailed evaluation this complex anatomy requires.

Sesamoiditis: Inflammation Without Fracture

Sesamoiditis — inflammation of the sesamoid bones and their surrounding structures — produces chronic, aching pain beneath the first metatarsal head that is worse with barefoot walking, high heels, and activities loading the forefoot. On examination, direct plantar palpation of the sesamoids (particularly the medial tibial sesamoid) reproduces the pain. X-rays are normal (the sesamoids appear intact), and MRI shows bone marrow edema without fracture. Treatment: offloading with a dancer’s pad (padding that relieves direct sesamoid pressure), stiff-soled footwear, corticosteroid injection for inflammatory flares, and activity modification. Recovery is measured in months rather than weeks for established sesamoiditis.

Sesamoid Stress Fractures and Acute Fractures

The tibial sesamoid (medial of the two) is far more commonly fractured than the fibular sesamoid. Bipartite sesamoid — a normal developmental variant where the sesamoid bone consists of two separate pieces united by fibrocartilage — is present in 10-30% of people and can be mistaken for a fracture on X-ray. Distinguishing features: acute fracture shows irregular, non-corticated edges; bipartite sesamoid shows smooth, corticated margins. MRI confirms fracture by showing bone marrow edema at the fracture site. Treatment: non-weight-bearing in a boot for 6-8 weeks, followed by gradual return to activity with sesamoid offloading. Fractures that don’t heal (non-unions) may require surgical sesamoidectomy (removal of the involved sesamoid).

Avascular Necrosis of the Sesamoid

Avascular necrosis (AVN) — death of sesamoid bone tissue from loss of blood supply — occurs as a complication of sesamoid fractures, corticosteroid injection, or idiopathically. MRI shows characteristic signal changes of bone death. Conservative treatment (offloading, activity modification) can allow some cases to stabilize; progressive AVN with collapse and persistent pain requires sesamoidectomy. Sesamoidectomy has functional consequences — particularly affecting toe-off mechanics — and is reserved for cases that fail conservative management. Contact Balance Foot & Ankle at (810) 206-1402 for systematic evaluation of sesamoid pain with appropriate imaging and a conservative-first treatment approach.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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When to See a Podiatrist for Sesamoid Problems

Sesamoid injuries — affecting the two small bones under the big toe joint — cause persistent ball-of-foot pain that limits pushing off and jumping. At Balance Foot & Ankle, Dr. Tom Biernacki diagnoses sesamoiditis, sesamoid fractures, and avascular necrosis with imaging and provides targeted conservative and surgical treatment.

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Clinical References

1. Richardson EG. Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 1999;7(4):270-278.
2. Bichara DA, Hsu AR, Giza E. Sesamoid fractures of the hallux. Foot Ankle Spec. 2012;5(5):325-332.
3. Cohen BE. Hallux sesamoid disorders. Foot Ankle Clin. 2009;14(1):91-104.

Your Board-Certified Podiatrists

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When to See a Podiatrist

If foot or ankle pain has been bothering you for more than a few weeks, home care alone may not be enough. Balance Foot & Ankle offers same-week appointments at our Howell and Bloomfield Hills clinics — no referral needed in most cases. Bring your current shoes and a short list of symptoms and we’ll build you a treatment plan in one visit.

Call Balance Foot & Ankle: (810) 206-1402  ·  Book online  ·  Offices in Howell & Bloomfield Hills

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.