I have had several runners and one roller derby player come to the office recently having sesamoiditis. The sesamoids are two small bones which are embedded in the tendon directly underneath the big toe joint. They act as a stabilizer of the big toe, keeping the toe moving up and down as opposed to side to side.
Sesamoids can occasionally fracture or be bipartate. Bipartate means that an individual sesamoid which normally starts out as two pieces and fuses together doesn’t fuse, leaving the two pieces separate, which the image below shows.
High-arched feet have a greater tendency to develop sesamoiditis than flat feet. Excessively worn, poor fitting or improperly designed shoes can also cause sesamoiditis.
Medical treatment depends on the severity of pain include icing, anti-inflammatory medications (Advil/Aleve), cortisone injections into the joint, immobilization and orthotics.
Shoe treatments include wearing a shoe that doesn’t flex at the forefoot or have a thin, non-shock absorptive sole. In a running shoe, this means no flex groove directly under the big toe joint where the sesamoid is inflammed.
Going barefoot is also not a good idea until the area heals.
Since the sesamoids bear weight with every step, this condition can take several weeks to months to improve. If however, the pain remains unchanged in spite of the treatment, then MRI should be used to make sure there’s no fracture. Fractured sesamoids require non-weight bearing immobilization with cast and crutches and occasionally surgical removal of the sesamoid.
If you have pain under the big toe joint that doesn’t improve with reduced activity and rest then you may have a fracture. Whether or not you have big toe discomfort of pain, it’s important to see a podiatrist for evaluation. Waiting to seek treatment can make this condition worse.
Dr. Jenny Sanders Shoe Blog 
Excellent information, you really know your stuff!
This one strikes close to home!
Hi Dr. Sanders, just found your blog. Great post. I do think you ought to mention that adding padding to shoes (a “reverse morton’s extension” or “metatarsal bar”), either with moleskin on an over-the-counter shoe insert or a custom-fitted one, is often quite effective. It certainly was for me.
Great comment John. Many runners probably don’t know what a reverse Morton’s extension or metatarsal bar is, so I will post a quick video explanation and link to it for reference. I’m equally impressed with your blog and have added it to my blog roll. Keep up the good work!
Hi Dr. Sanders,
Can you recommend any resources for how to tape this injury to minimize discomfort while skating? I’m waiting on orthotics but would really hate to put my roller derby career on hold until I have them.
Cheers!
Emily
Great question. Just posted an answer Roller Derby – Ball Of The Foot Pain.
I recently tried forefoot running and developed sesamoiditis. I have high arches, so I must be a text book case for this injury when I tried forefoot running. I am looking to change shoes now. Would you have any recommendations?
Thanks
R T
Not knowing whether you have a wide or narrow foot, my general guideline would be to look for shoes that exhibit the following:
1)Thick, inflexible forefoot
2) No flex groove across the forefoot in area of pain
3) Correct heel-to-ball size.
If a shoe change doesn’t provide relief, I would seek treatment with a sports medicine podiatrist. Many of the new forefoot runners I am treating, are developing stress fractures due to this change in running style.
Thank you. I am on the mend, having taken time off from running for 2 weeks. Now, it feels more like a nibble, than the immobilizing pain it was earlier.
I have wide feet. Would you have specific recommendations for shoes? What is considered correct heel to ball size?
Thanks again
I would go to a specialty running shoe store (Fleet Feet etc.) and have them measure and size you properly.
Can anyone suggest a specific shoe to workout in for this problem?
Saucony Guide 6, Brooks Addiction 11, Brooks Ariel, Brooks Adrenaline 13, New Balance 940, New Balance 1340 and Adidas Supernova Sequence are a few models that are inflexible in the forefoot which is the main criteria you want to search for. A specialty running shoe store should also be able to help you with styles. The heel-to-ball fit also has to be perfect https://drshoereviews.com/2007/12/05/size-matters-heel-to-ball-vs-heel-to-toe/ and you will want to do the 3-Point Test to evaluate your shoes.
I have broken sesamoid on the left. I have been in the hard Darko surgical shoe with a cut out for the bone the last 8 weeks. There is not a lot of pain now, some at times but can walk on it OK around the house. The last xray a few weeks ago the podiatrist said he thinks is on the way to healing. However the swelling is still about the same as when it broken, is that a worry? Surgery big fear for me.
Fractured sesamoids can be very difficult to heal. The definitive way to assess healing is with ultrasound or MRI. If there is still swelling, I would opt for MRI. If MRI shows healing, I would progress to regular shoes and activity very slowly. If MRI does not show healing, I would fully immobilize with cast/crutches to completely off-weight the forefoot. I have also had very good success with bone stimulation to expedite sesamoid fracture healing. Bone stimulation is low frequency ultrasound that is used twice per day throughout healing and for several months thereafter. Here’s a link of my how-to video on its use.
Unfortunately, even with the above treatments, there is still a chance the fracture won’t heal in which case surgical excision will be necessary. Fortunately, if not completely healed yet, you still have options. Also fortunately, if surgery is required, the recovery and return to activity is short and the complications are low.