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

What Are the Sesamoid Bones?

Beneath the first metatarsal head — the ball of the foot behind the big toe — lie two small bones called the sesamoids. Embedded within the flexor hallucis brevis tendon, these pea-sized bones act like tiny pulleys, enhancing the mechanical advantage of the muscle that bends the big toe downward. They also serve as weight-bearing pads that absorb the significant forces generated during push-off with each step. When the sesamoids are stressed, inflamed, or fractured, the result is pain directly under the big toe joint that can be remarkably disabling.

Sesamoiditis vs. Sesamoid Fracture: What’s the Difference?

Sesamoiditis refers to inflammation and stress reaction within the sesamoid bones without frank fracture — the bone equivalent of a bruise or early stress injury. A sesamoid fracture involves an actual break through the bone, which may occur acutely from direct impact or develop gradually as a stress fracture from repetitive loading. Many sesamoid bones are bipartite — naturally in two pieces — which can be mistaken for a fracture on X-ray. Comparison views, bone scans, or MRI help distinguish bipartite sesamoids from true fractures.

Who Gets Sesamoid Problems?

Dancers, runners, basketball players, and anyone who spends extended time in high heels or thin-soled shoes is at elevated risk for sesamoid injuries. High-arched feet (cavus foot) direct more weight onto the ball of the foot and specifically the first metatarsal head, predisposing to sesamoid overload. Turf toe — an acute hyperextension injury of the first metatarsophalangeal joint — can acutely fracture a sesamoid or initiate a stress reaction pattern. Patients with bunions who have altered first metatarsal mechanics are also vulnerable.

Symptoms

The hallmark symptom is pain directly under the first metatarsal head, in the pad of the forefoot just behind the big toe. The pain worsens with push-off, going up stairs, wearing heeled shoes, and activity in general. There may be swelling, bruising, and marked point tenderness over the sesamoid. Unlike metatarsalgia affecting the lesser metatarsals, the pain is specifically underneath the big toe joint rather than in the central forefoot.

Conservative Treatment

Rest and offloading are the cornerstones of treatment. A stiff-soled shoe or surgical shoe that reduces forefoot flex reduces the lever arm stresses on the sesamoid. Custom orthotics with a sesamoid cut-out or dancer’s pad distribute weight away from the inflamed area. A short course of oral anti-inflammatory medication reduces acute inflammation. In more severe cases, a short walking boot provides more complete offloading. Physical therapy addresses the intrinsic weakness and gait compensation patterns that develop around the painful area.

When Conservative Treatment Fails

Corticosteroid injection around (not into) the sesamoid can provide significant pain relief in cases that haven’t responded to 4 to 6 weeks of conservative care. True stress fractures with persistent pain despite 3 to 4 months of conservative treatment may ultimately require surgical excision of the fractured sesamoid. Sesamoidectomy — removal of one sesamoid — is effective for relieving pain but requires careful technique to avoid damaging the flexor hallucis brevis tendon and causing a hallux valgus (bunion) or cock-up deformity.

Expected Recovery

Sesamoid injuries notoriously take longer to heal than patients expect. Even sesamoiditis without fracture may require 6 to 12 weeks of strict offloading for complete resolution. Stress fractures with bony healing require 3 to 6 months. Patience and compliance with orthotics are essential to prevent re-injury.

If you have persistent pain under your big toe joint, a podiatrist at Balance Foot & Ankle can evaluate whether sesamoid pathology is the cause and create a targeted treatment plan to get you back to full activity.

Foot or Ankle Pain? We Can Help.

Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Sesamoid Injury Treatment in Michigan

Sesamoiditis and sesamoid fractures cause pain under the big toe joint that makes walking and pushing off difficult. Dr. Tom Biernacki provides specialized sesamoid treatment at Balance Foot & Ankle in Howell and Bloomfield Hills.

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Clinical References

1. Cohen BE. “Hallux sesamoid disorders.” Foot Ankle Clin. 2009;14(1):91-104.
2. Kadakia AR, Molloy A. “Current concepts review: traumatic disorders of the sesamoid complex.” Foot Ankle Int. 2011;32(8):834-839.
3. Bichara DA, et al. “Sesamoiditis and hallux sesamoid fractures.” Foot Ankle Spec. 2012;5(6):388-395.

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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.