Sesamoiditis

Lower Limb

Overview

Sesamoiditis is inflammation of the sesamoid bones beneath the first metatarsal head in the forefoot, commonly affecting the medial sesamoid. This condition results from repetitive micro-trauma, excessive pressure, or direct injury to these small bones embedded within the flexor hallucis brevis tendon, presenting with localized plantar pain and functional limitation.

Pathophysiology

The sesamoid bones act as a fulcrum for the flexor hallucis brevis tendon, distributing ground reaction forces across the first metatarsophalangeal joint during gait and propulsion. Repetitive stress, altered biomechanics, or direct trauma causes chronic inflammation of the bone, surrounding soft tissues, and the articulating surfaces. This leads to pain, swelling, and potential stress fracture or avascular necrosis if untreated.

Patient Education

Sesamoiditis typically improves with activity modification, proper footwear support, and graduated return to activity; avoiding walking barefoot and high-impact activities during acute phases is essential for recovery.

Typical Presentation

Site

Plantar aspect of the first metatarsal head, localized to the medial or lateral sesamoid; pain may radiate along the medial forefoot

Quality

Sharp, aching, or burning plantar pain with a dull underlying ache; may describe cracking or catching sensations

Intensity

Mild to moderate pain (3-7/10) initially, worsening with activity; intensity increases with weightbearing and push-off activities

Aggravating

Walking barefoot, high-impact activities (running, jumping, dancing), prolonged standing, tight footwear, repetitive forefoot stress, push-off phase of gait

Relieving

Rest, elevation, ice application, supportive footwear with cushioning and metatarsal pads, activity modification, strapping or taping

Associated

Swelling and tenderness over the sesamoid area, pain with dorsiflexion of the great toe, altered gait pattern favoring lateral foot, callus formation, clicking or catching sensation

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

First MTP Dorsiflexion Range

Procedure

Passively extend (dorsiflex) the big toe and compare the range with the other side.

Positive Finding

Pain under the first metatarsal head at end of extension, or reduced range.

Interpretation

Extension stretches the sesamoids forwards and can reproduce sesamoid pain. Pain at the top of the joint with stiffness points more to hallux rigidus.

Sources

No accuracy study

Sesamoid Palpation

Procedure

Extend the big toe to bring the sesamoids forward, then press directly on each sesamoid under the first metatarsal head. Move the toe gently and check that the tender spot moves with it.

Positive Finding

Focal tenderness over one sesamoid (usually the medial) that moves with the toe.

Interpretation

Supports sesamoiditis. Tenderness that moves with the toe localises it to the sesamoid rather than the metatarsal head. Persistent focal pain after running or jumping may be a sesamoid stress fracture; X-ray or MRI is needed.

Sources

No accuracy study

Great Toe Extension Stress Test

Procedure

Passively extend the big toe to end of range with the ankle dorsiflexed.

Positive Finding

Pain under the first metatarsal head.

Interpretation

Stretches the sesamoid complex. Not specific: plantar plate and joint problems also hurt in this position.

No accuracy study

Resisted Great Toe Flexion

Procedure

Ask the patient to push the big toe down against your finger.

Positive Finding

Pain under the first metatarsal head.

Interpretation

Contraction of flexor hallucis brevis, in whose tendons the sesamoids sit, loads the sesamoids and supports them as the pain source.

Sources

No accuracy study

First MTP Joint Palpation and Distraction

Procedure

Palpate around the first MTP joint, then gently pull the big toe away from the foot.

Positive Finding

Joint line tenderness that eases with distraction.

Interpretation

Helps separate a joint problem (hallux rigidus, synovitis) from sesamoid pain, which sits under the joint.

Not a diagnostic test

Single-Leg Stance or Weight-Bearing Tolerance Test

Procedure

Ask the patient to stand on the affected leg and rise onto the toes.

Positive Finding

Pain under the first metatarsal head when loading the forefoot.

Interpretation

A functional check that guides offloading (padding, stiff-soled shoes) and return to activity. Not a diagnostic test.

⚠ Red Flags

  • •Acute severe pain with inability to weightbear following trauma
  • •Signs of systemic infection (fever, spreading erythema, lymphadenopathy)
  • •Suspected sesamoid fracture with neurovascular compromise
  • •Progressive neurological symptoms or loss of foot sensation
  • •Unrelenting pain unresponsive to 6-8 weeks conservative management
  • •History of previous sesamoid surgery with recurrent symptoms

⚡ Yellow Flags

  • •High athletic demands with pressure to return to activity prematurely
  • •Perfectionist or overly competitive personality affecting compliance with activity modification
  • •Frequent barefoot walking due to lifestyle choices or cultural practices
  • •History of eating disorders or bone health concerns
  • •Low mood or depression affecting self-management
  • •Poor understanding of condition leading to non-compliance with offloading strategies

Osteopathic Techniques

Pain under the big-toe sesamoids has several causes: acute and stress fractures, nonunion, osteonecrosis, chondromalacia and inflammatory sesamoiditis. Conservative care with orthotics and immobilisation comes first; surgery ranges from fixation to removing a sesamoid. No trials of osteopathic techniques in sesamoiditis were found.

Safety: Sesamoid stress fractures are high-risk: they are more likely to progress to non-union and often do not respond to conservative care. X-rays are unreliable for stress fractures, so MRI is recommended when one is suspected.

Region

First MTP surrounds, plantar arch and medial foot

Technique

Soft tissue, foot and ankleNo trials found

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the toe joints and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Sesamoiditis

Searched 25 Oct 2026: no trials of soft tissue technique in sesamoiditis.

Sources

Region

First metatarsophalangeal joint

Technique

Articulation, ankle and foot
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in sesamoiditis. In hallux limitus, one trial found sesamoid mobilisation with strengthening and gait training improved pain and big-toe extension.

Rationale

Gentle glides of the toe, midfoot and ankle joints to restore foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Sesamoiditis

Searched 25 Oct 2026: no trials in sesamoiditis. Indirect: Shamus 2004 (clinical trial, functional hallux limitus): sesamoid mobilisation, flexor hallucis strengthening and gait training gave more first MTP extension, flexor strength and pain relief than a control group after 12 sessions.

Region

Plantar fascia and forefoot tender points

Technique

Counterstrain, foot and ankle tender pointsNo trials found

Rationale

Gentle indirect technique: tender points in the foot and ankle are eased by passive positioning.

How it's done, cautions & evidence

How it's done

Find a tender point in the foot, ankle or calf. Passively move the foot and ankle into the position where the tenderness and tissue tension ease most, and hold it for about 90 seconds while monitoring the point. Return slowly to neutral and re-check.

Cautions

Do not use over an acute fracture, or in a patient who cannot give feedback.

Evidence in Sesamoiditis

Searched 25 Oct 2026: no trials of counterstrain in sesamoiditis.

Region

Gastrocnemius-soleus (calf)

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Sesamoiditis

Searched 25 Oct 2026: no trials of calf muscle energy technique in sesamoiditis.

Rehabilitation Exercises

Great Toe Dorsiflexion and Plantarflexion - Active

Range of MotionBeginner

Plantar Fascia Stretch - Standing with Towel Roll

StretchingBeginner

Calf Stretch - Lunge Position

StretchingBeginner

Foot Intrinsic Exercises - Towel Scrunching

StrengtheningBeginner

Great Toe Flexion Against Resistance - Seated

StrengtheningIntermediate

Single-Leg Stance on Firm Surface

StrengtheningIntermediate

Proprioceptive Training - Single-Leg Balance on Foam

BalanceIntermediate

Foot Arch Activation - Short Foot Exercise

PosturalBeginner

Calf Raises - Double Leg to Single Leg Progression

StrengtheningIntermediate

Ankle Circles and Mobilization - Seated

Range of MotionBeginner

Heel-Toe Walking - Forward and Backward

BalanceIntermediate

Pool Walking or Swimming - Low-Impact Conditioning

CardiovascularBeginner

Referral Criteria

  • •Suspected sesamoid fracture confirmed on imaging or clinical examination
  • •Symptoms persisting beyond 8-12 weeks despite appropriate conservative management
  • •Significant functional limitation affecting activities of daily living or quality of life
  • •Signs of avascular necrosis or degenerative changes on imaging
  • •Need for advanced imaging (MRI, bone scan) to confirm diagnosis
  • •Consideration of injection therapy or surgical intervention by orthopedic surgeon
  • •Concurrent inflammatory arthropathy or systemic disease contributing to symptoms
  • •Neurological symptoms or suspected nerve compression requiring specialist assessment