Sesamoiditis.
What is sesamoiditis?
Sesamoid bones are small bones embedded within tendons rather than connected to other bones by joints in the conventional sense. In the foot, two sesamoid bones — the medial and lateral sesamoids — sit within the flexor hallucis brevis tendon beneath the first metatarsophalangeal joint (the big toe joint), where they function as a pulley system that improves the mechanical advantage of the flexor hallucis longus tendon during push-off, and as a load-bearing structure that distributes weight across the forefoot during walking and running.
Sesamoiditis refers to inflammation of one or both of these bones and their surrounding soft tissues — the tendons, bursae and periosteum immediately adjacent to the sesamoids. It is characterised by pain and tenderness directly under the first metatarsophalangeal joint that worsens with activities requiring toe push-off and weight-bearing through the forefoot.
Sesamoiditis versus sesamoid stress fracture
This distinction matters enormously for management and is one of the most common diagnostic errors in forefoot pain assessment. Both conditions produce localised tenderness under the big toe joint and pain with forefoot loading, making clinical differentiation difficult. However their management is quite different — sesamoiditis is an inflammatory/overuse condition that responds well to load modification and physiotherapy, while a sesamoid stress fracture requires more extended rest and offloading, and if inadequately managed can progress to avascular necrosis and require surgical removal of the bone.
Conservative treatment remains the primary approach for sesamoiditis, though there are no standardised guidelines for its management — a systematic review of individual-level data across published studies highlights that load modification, orthotic management and activity modification form the evidence-supported core of conservative care. X-ray helps identify acute fractures but misses stress fractures, which require MRI for confirmation. If there is diagnostic uncertainty, MRI is the appropriate imaging investigation
Who gets sesamoiditis?
Sesamoiditis is most common in athletes whose sport requires repetitive forefoot loading and push-off — dancers (particularly ballet and contemporary), runners, footballers, netballers and any athlete performing significant jumping and landing. It frequently develops from a gradual increase in physical activity rather than a single acute event. High-arched feet increase sesamoid loading by reducing the natural shock absorption of the arch. Forefoot varus deformity, hallux valgus (bunion), and tight calf muscles that limit ankle dorsiflexion and increase forefoot compensation all predispose to sesamoid overload.
What are the symptoms?
Pain and tenderness localised directly under the first metatarsophalangeal joint — specifically the plantar surface at the medial or lateral sesamoid — is the hallmark finding. The pain is typically aggravated by activities requiring push-off and forefoot loading: walking barefoot on hard surfaces, running, dancing, climbing stairs and wearing high heels. Swelling over the plantar aspect of the big toe joint may be visible in more acute presentations. Pain on passive dorsiflexion of the big toe — which stretches the structures around the sesamoids — is a characteristic clinical finding.
How can physiotherapy help?
The primary goal of physiotherapy for sesamoiditis is reducing the load through the sesamoids while maintaining as much activity as possible, and then systematically rebuilding forefoot load capacity as symptoms settle. Physiotherapists assess the condition thoroughly and develop a customised treatment plan based on its severity and the patient's specific needs.
Offloading is the most immediately effective intervention. Dancer's padding — a sesamoid relief pad with a cut-out directly under the affected sesamoid — redistributes plantar pressure away from the inflamed bone and provides significant symptomatic relief during the healing phase. Custom or semi-custom foot orthotics with sesamoid offloading built into the design provide more durable relief for ongoing activity. Supportive footwear with ample cushioning and a wide toe box reduces stress on the sesamoid bones and should be consistently worn during the rehabilitation period.
Padding and taping the big toe joint alleviates pressure on the sesamoid bones during activity, and rigid taping that limits toe dorsiflexion is particularly effective for reducing the loading peak at push-off.
For the underlying biomechanical contributors — calf tightness, intrinsic foot weakness, altered gait mechanics — physiotherapy addresses these systematically to reduce the long-term sesamoid loading that will perpetuate or recur the problem if not corrected. Intrinsic foot strengthening, calf stretching and eccentric calf loading, and gait retraining to reduce the compensatory forefoot loading pattern are the exercise priorities.
Neural mobilisation of the medial and lateral plantar nerves is useful when neurogenic pain is contributing to the symptom picture — nerve sensitivity is a common feature of chronic sesamoiditis that is frequently undertreated.
If conservative treatments are ineffective, corticosteroid injection may be considered to reduce pain and inflammation. Surgical removal of the sesamoid is reserved for cases that have genuinely failed all appropriate conservative management — it is a last resort given that sesamoid removal permanently alters forefoot mechanics.
Our physiotherapists Eliane Machado, Mauricio Bara and Emma Cameron both have experience in forefoot and foot pain conditions and are members of the Australian Physiotherapy Association. Eliane's research background in lower limb biomechanics is directly relevant to the gait and forefoot loading analysis that underpins sesamoid rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Sesamoid bones are small bones embedded within tendons rather than connected to other bones by joints in the conventional sense. In the foot, two sesamoid bones — the medial and lateral sesamoids — sit within the flexor hallucis brevis tendon beneath the first metatarsophalangeal joint (the big toe joint), where they function as a pulley system that improves the mechanical advantage of the flexor hallucis longus tendon during push-off, and as a load-bearing structure that distributes weight across the forefoot during walking and running.
Sesamoiditis refers to inflammation of one or both of these bones and their surrounding soft tissues — the tendons, bursae and periosteum immediately adjacent to the sesamoids. It is characterised by pain and tenderness directly under the first metatarsophalangeal joint that worsens with activities requiring toe push-off and weight-bearing through the forefoot.
Sesamoiditis versus sesamoid stress fracture
This distinction matters enormously for management and is one of the most common diagnostic errors in forefoot pain assessment. Both conditions produce localised tenderness under the big toe joint and pain with forefoot loading, making clinical differentiation difficult. However their management is quite different — sesamoiditis is an inflammatory/overuse condition that responds well to load modification and physiotherapy, while a sesamoid stress fracture requires more extended rest and offloading, and if inadequately managed can progress to avascular necrosis and require surgical removal of the bone.
Conservative treatment remains the primary approach for sesamoiditis, though there are no standardised guidelines for its management — a systematic review of individual-level data across published studies highlights that load modification, orthotic management and activity modification form the evidence-supported core of conservative care. X-ray helps identify acute fractures but misses stress fractures, which require MRI for confirmation. If there is diagnostic uncertainty, MRI is the appropriate imaging investigation
Who gets sesamoiditis?
Sesamoiditis is most common in athletes whose sport requires repetitive forefoot loading and push-off — dancers (particularly ballet and contemporary), runners, footballers, netballers and any athlete performing significant jumping and landing. It frequently develops from a gradual increase in physical activity rather than a single acute event. High-arched feet increase sesamoid loading by reducing the natural shock absorption of the arch. Forefoot varus deformity, hallux valgus (bunion), and tight calf muscles that limit ankle dorsiflexion and increase forefoot compensation all predispose to sesamoid overload.
What are the symptoms?
Pain and tenderness localised directly under the first metatarsophalangeal joint — specifically the plantar surface at the medial or lateral sesamoid — is the hallmark finding. The pain is typically aggravated by activities requiring push-off and forefoot loading: walking barefoot on hard surfaces, running, dancing, climbing stairs and wearing high heels. Swelling over the plantar aspect of the big toe joint may be visible in more acute presentations. Pain on passive dorsiflexion of the big toe — which stretches the structures around the sesamoids — is a characteristic clinical finding.
How can physiotherapy help?
The primary goal of physiotherapy for sesamoiditis is reducing the load through the sesamoids while maintaining as much activity as possible, and then systematically rebuilding forefoot load capacity as symptoms settle. Physiotherapists assess the condition thoroughly and develop a customised treatment plan based on its severity and the patient's specific needs.
Offloading is the most immediately effective intervention. Dancer's padding — a sesamoid relief pad with a cut-out directly under the affected sesamoid — redistributes plantar pressure away from the inflamed bone and provides significant symptomatic relief during the healing phase. Custom or semi-custom foot orthotics with sesamoid offloading built into the design provide more durable relief for ongoing activity. Supportive footwear with ample cushioning and a wide toe box reduces stress on the sesamoid bones and should be consistently worn during the rehabilitation period.
Padding and taping the big toe joint alleviates pressure on the sesamoid bones during activity, and rigid taping that limits toe dorsiflexion is particularly effective for reducing the loading peak at push-off.
For the underlying biomechanical contributors — calf tightness, intrinsic foot weakness, altered gait mechanics — physiotherapy addresses these systematically to reduce the long-term sesamoid loading that will perpetuate or recur the problem if not corrected. Intrinsic foot strengthening, calf stretching and eccentric calf loading, and gait retraining to reduce the compensatory forefoot loading pattern are the exercise priorities.
Neural mobilisation of the medial and lateral plantar nerves is useful when neurogenic pain is contributing to the symptom picture — nerve sensitivity is a common feature of chronic sesamoiditis that is frequently undertreated.
If conservative treatments are ineffective, corticosteroid injection may be considered to reduce pain and inflammation. Surgical removal of the sesamoid is reserved for cases that have genuinely failed all appropriate conservative management — it is a last resort given that sesamoid removal permanently alters forefoot mechanics.
Our physiotherapists Eliane Machado, Mauricio Bara and Emma Cameron both have experience in forefoot and foot pain conditions and are members of the Australian Physiotherapy Association. Eliane's research background in lower limb biomechanics is directly relevant to the gait and forefoot loading analysis that underpins sesamoid rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
