Sesamoiditis Michigan | Ball of Foot Pain Treatment | Balance Foot & Ankle

Activity / Sport	Risk Level	Mechanism	Prevention
Ballet / Dance	Highest	Constant demi-pointe forces sesamoids against MT head	Proper technique, dancer orthotics, rest
Running (forefoot striker)	High	Repetitive push-off load on 1st MTP	Sesamoid offloading orthotic, cadence adjustment
Basketball / Jumping	High	Landing impact concentration on forefoot	Metatarsal pad, cushioned court shoes
Golf	Moderate	Weight shift + pivot on lead foot	Golf-specific orthotic, softer spike sole
Walking (flat shoes / barefoot)	Low-Moderate	Inadequate cushioning under 1st MTP	Cushioned footwear, avoid hard surfaces barefoot

Offloading Method	How It Works	Best For	OTC or Custom
J-Pad (dancer’s pad)	Horseshoe-shaped pad surrounds sesamoids without touching them	All sesamoiditis — immediate first-line	OTC foam or custom
Metatarsal Pad	Proximal to sesamoids; transfers load to met shafts	Associated metatarsalgia	OTC (stick-on)
Morton’s Extension Orthotic	Stiff forefoot extension limits 1st MTP dorsiflexion	Sesamoiditis with hallux rigidus component	Custom only
Full-Length Custom Orthotic with Sesamoid Relief	Total arch support with excavated sesamoid window	Recurrent / chronic sesamoiditis	Custom only
Cam Boot	Total offloading of forefoot / sesamoids	Acute exacerbation or sesamoid fracture	Medical device

What Are the Sesamoids and Why Do They Hurt?

The sesamoid bones are two small ossicles — the medial (tibial) sesamoid and the lateral (fibular) sesamoid — embedded within the two heads of the flexor hallucis brevis (FHB) tendon just beneath the first metatarsophalangeal joint. They function analogously to the patella in the knee: repositioning the FHB tendon to increase its mechanical advantage for toe plantarflexion and absorbing compressive forces beneath the first metatarsal head during gait and activity.

Because the sesamoids bear substantial load with every step — particularly during push-off and impact sports — they are susceptible to cumulative stress injury. The medial (tibial) sesamoid is injured approximately twice as frequently as the lateral, likely due to its larger size and more direct weight-bearing position.

Types of Sesamoid Pathology

Dr. Biernacki evaluates sesamoid injuries across a clinical spectrum:

Sesamoiditis (Stress Reaction)

Acute or chronic inflammation of the sesamoid bone and surrounding soft tissue without fracture. Presents as aching, localized tenderness directly beneath the first metatarsal head with activity. Common in runners, dancers, and activities involving high forefoot loading. MRI shows bone marrow edema (stress reaction) without fracture line.

Sesamoid Stress Fracture

Repetitive loading overwhelms the sesamoid’s remodeling capacity, producing a fatigue fracture. Stress fractures of the sesamoids are often misdiagnosed as sesamoiditis or bipartite sesamoid on plain x-ray — MRI or bone scan is required for definitive diagnosis. Treatment requires offloading, and healing may take 3–6 months of strict immobilization.

Bipartite Sesamoid

Approximately 10–30% of people have a bipartite (two-part) medial sesamoid — a developmental variant where the ossification center failed to fuse, resulting in two bone fragments joined by cartilage. Most bipartite sesamoids are asymptomatic. When symptomatic — from acute trauma or repetitive stress — the fibrocartilaginous junction between the two parts becomes inflamed. Distinguishing a symptomatic bipartite sesamoid from an acute fracture requires imaging and clinical correlation.

Sesamoid Avascular Necrosis (AVN)

Disruption of blood supply to the sesamoid leads to bone death (osteonecrosis) with progressive bone collapse and fragmentation. AVN can follow acute trauma, steroid injection, or develop insidiously in high-demand athletes. MRI shows characteristic signal changes confirming AVN. Advanced AVN typically requires surgical sesamoidectomy.

Acute Sesamoid Fracture

Direct trauma — landing from a height, a single hyperextension injury at the first MTP — can fracture a sesamoid acutely. Acute fractures present with immediate point tenderness and swelling. Treatment depends on displacement, pain severity, and patient activity demands.

Symptoms of Sesamoid Injury

The classic presentation of sesamoiditis and sesamoid pathology includes:

• Localized pain and tenderness directly beneath the first metatarsal head (at the ball of the foot, on the plantar surface under the big toe joint).
• Pain with push-off — worsened by walking barefoot on hard floors, running, dancing, or ascending stairs.
• Pain with great toe extension — dorsiflexing the big toe loads the sesamoids through the FHB tendon.
• Swelling and bruising in acute injuries.
• Callus formation beneath the first metatarsal head from chronic pressure.

Diagnosis: Imaging and Examination

Accurate sesamoid diagnosis requires systematic evaluation:

• Weight-bearing foot radiographs — axial (sesamoid) view directly profiles the sesamoids and identifies fracture, fragmentation, or AVN. Bipartite appearance is visible but cannot distinguish symptomatic from incidental bipartite.
• MRI — the most sensitive modality for sesamoid pathology. Bone marrow edema confirms stress reaction; fracture lines are visible; AVN produces characteristic signal changes. Essential when x-ray is inconclusive.
• Bone scan (technetium-99) — high sensitivity for metabolically active stress fractures and AVN; used when MRI is contraindicated.
• Ultrasound — evaluates adjacent soft tissue pathology (FHB tendinopathy, plantar plate, bursa).

Non-Surgical Treatment

The majority of sesamoid conditions are managed non-surgically with a combination of:

• Sesamoid padding and dancer’s pads — felt or foam padding that offloads the sesamoid region transfers pressure to adjacent metatarsal heads.
• Custom orthotics with sesamoid accommodation — a custom foot orthosis with a cut-out or Morton’s extension beneath the first ray unloads the sesamoid while supporting the rest of the forefoot.
• Rigid-soled footwear — limiting first MTP dorsiflexion (the motion that loads sesamoids) reduces pain during healing.
• Activity modification — reducing or eliminating push-off loading activities. Barefoot walking on hard surfaces is the worst loading scenario.
• Immobilization — for stress fractures and acute injuries, a boot walker or non-weightbearing cast may be prescribed for 6–8 weeks.
• Corticosteroid injection — ultrasound-guided injection to the sesamoid region for acute sesamoiditis reduces inflammation. Used cautiously in stress fractures where injection may impair healing.

Sesamoid stress fractures and AVN require longer conservative management — 3–6 months of protected loading — than simple sesamoiditis. Compliance with offloading is essential for healing.

Surgical Treatment: Sesamoidectomy

Surgery is considered when:

• Conservative care has failed after 6–12 months of compliant treatment.
• Avascular necrosis has produced significant bone collapse or fragmentation.
• Intractable pain from symptomatic bipartite sesamoid not responsive to conservative measures.

Sesamoidectomy involves surgical excision of the damaged sesamoid through a plantar or dorsal approach. The medial sesamoid can be removed without significant functional deficit in most patients. Removing both sesamoids simultaneously risks hallux valgus deformity and is avoided unless absolutely necessary. Recovery from sesamoidectomy involves protected weightbearing for 4–6 weeks, with full return to activity at 3–6 months.

High-Risk Populations and Prevention

Sesamoiditis is particularly common in ballet dancers, runners with high-arched cavus feet, athletes in forefoot-loading sports (soccer, basketball, gymnastics), and patients with prominent first metatarsal heads. Prevention strategies include proper footwear with adequate cushioning, sesamoid padding for high-risk athletes, and custom orthotics for cavus foot types that increase sesamoid loading.

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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 expert evaluations and advanced in-office care.