Practical Pearls For Treating Sesamoiditis In Athletes
Sesamoiditis can be a frustrating condition for both the patient as well as the treating physician. Making the injury even more complicated is the debate over the true cause of the pathology. The literature describes the condition as being related to a bipartite sesamoid or resulting from a fracture.1 One can order a bone scan as well as magnetic resonance imaging (MRI) to further discern between the two. If there is a fracture, clinicians can emphasize immobilization in a walking boot for six weeks or longer, and use symptoms as an indicator of improvement as radiographs sometimes do not demonstrate a complete osseous union.1
I would like to discuss the success I have had in treating sesamoiditis in my practice by identifying the cause of the injury. While we know the cause can be a bipartite or fractured sesamoid, radiographs in my practice on these patients frequently reveal a normal appearing sesamoid complex. It is also not uncommon to see bipartite sesamoid bones bilaterally yet only one side is symptomatic. In these cases, as with the majority of my patients with sesamoiditis, I tend to focus on their activities.
The most common cause that I see with these patients is excessive propulsion forces on the involved metatarsophalangeal joint (MPJ). One of the most common examples is volleyball players who jump off of their dominant leg. I also see a high incidence of sesamoiditis in those participating in the popular P90X exercise as the repetitive activities result in very excessive force to the MPJ. Weightlifters also inflict enormous amounts of force on the sesamoids during certain movements involved in powerlifting.
So what do you tell these patients? Many of them come to me after already attempting therapy with orthotics and shoegear modifications including dancer pads and doughnut-type pads. Their usual question is, “Isn’t there another type of pad we can try? These kind of worked but the pain keeps coming back.”
After reviewing their history and activities, I try to find the source of the increased force. As I mentioned previously, there are sport-specific activities that increase the force to the MPJ that result in sesamoiditis. Running can also increase the force of those who heel strike on an outstretched leg. This occurs as heel strikers need to have their entire body then pass over their foot, which requires an increased amount of dorsiflexion and stress to the MPJ of the great toe. Once we identify the source in these patients, I try to stress to them that we need to remove the source of force initially to allow the sesamoid to heal and then alter the force to prevent it from returning. This can be very challenging.
In the case of a volleyball player, an example would be to have the player propel or jump off the entire foot as opposed to the MPJ of the great toe. Plyometric strengthening activities performed barefoot can help teach this as well as increase the activation of the lesser toes, which will assist in jumping. It is important for patients to learn the activity barefoot as one’s proprioception is higher and this feedback is crucial. Athletes often can feel the pain in the great toe, notice when they are placing too much pressure there and learn to activate the lesser digits.
A paper published in August 2014 stresses the importance of doing calf raises barefoot and grasping a towel with the lesser digits to treat plantar fasciitis.2 I routinely use this now in my practice. You can also gain a wealth of knowledge in barefoot strengthening activities from fellow podiatrist Emily Splichal, DPM (www.evidencebasedfitnessacademy.com ).
By increasing the strength of the lesser toes by activating the extensor digitorum longus and brevis muscles, the foot can become stronger and take some of the load off the extensor hallucis longus and brevis tendons. In my clinical experience, I have found that strengthening the flexor hallucis longus, flexor hallucis brevis, extensor digitorum longus and extensor digitorum brevis muscles can relieve the pain within the sesamoid complex. It is without a doubt a frustrating and longstanding injury that can sometimes take months to overcome. However, I have had much more success with changing the activity and force than with padding or offloading.
As for surgical excision, I really make every attempt to avoid removing these bones, especially the entire sesamoid bone, from any runner or athlete. Taking the smaller or usually distal fracture fragment can sometimes help but more often, I am able to resolve the pain by leaving the fragment intact. The photo below is from a runner who transitioned from a heel strike gait to a midfoot strike pattern, and was able to decrease the force to the sesamoids during what many call the toe-off or propulsion phase of gait. You can see there are fragments of both the tibial and fibular sesamoid. This individual has been pain-free for five years with no surgical removal of the sesamoids.
References
1. Jones JL, Losito JM. Tibial sesamoid fracture in a softball player. J Am Podiatr Med Assoc. 2007; 97(1):85-88.
2. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2014; epub Aug. 21.
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About The Author
Dr. Nick Campitelli
Dr. Campitelli is a podiatrist in Akron, OH specializing in foot and ankle surgery with an interest and enthusiasm for running as well as helping runners with injuries. For the past several years he has been treating running injuries in patients by fixing their form and transitioning them to minimalist shoes. Having treated runners with all types of injuries through conservative measures with orthotics and shoe gear changes to reconstructive foot and ankle surgery, Dr. Campitelli has brought what works best and is most current to his practice as well as the Akron and Cleveland running communities.
Good day Dr Nick,
Good article. I’ve read your other article and some of the comments, and you say that changing running gait to more proper mechanics (foot lands below you) and doing intrinsic foot exercises is a good way to help/cure sesamoiditis. I believe that is true. Right now, I’ve had sesamoiditis (i think that’s what it is) for about 12 days. On day 4, I started using crutches and currently do as well everywhere I go. (trying to take as few steps as possible with my injured foot) So I’ve been on crutches for 9 days now and the pain has definitely decreased maybe even significantly. My injured foot is always slightly bigger then my other foot around the area of my sesamoids, i dont think it’s swelling. it looks like the roundy bumpy around around my sesamoids has depressed or something, as if the floating sesamoids have actualy depressed themselves. And I never noticed any swelling for this condition at all.
I iced it a few times when i got ses, but now i heat the area using a hot gel pack. is that safe? I notice that any pain from weight bearing but especially touching the area AFTER using a heated gel pack 2-3x for10 mins each makes the pain almost, if not completely gone, for some hours if I try to poke around the area for pain (very interesting). do you know why this is?
and the pain area, its strange, it looks/feels like its not the sesamoids (the ball of the big toe?), it looks/feels like its medial and posterior to the sesamoids in ONE small spot, its like quite a bit on the edge of the foot on the medial side, (like its at the base of the ball of the big toe but medial) After heating using gel pack, poking it i feel no/little pain, but standing the pain is like there but maybe a bit less. Either way I feel no pain from poking the top/highest part of the round bumpy part (the ball of the big toe?) where I think my sesamoids are. But it does look somewhat thicker than my other foot.
I haven’t seen a specialist yet I just immediately went to crutches after I diagnosed myself with ses, not even sure if it is, I compete in track. My running form has been bad, foot landing way ahead of me. I’ll change that. Also, I’ve been doing lots of massaging my injured foot’s sole (except the around around my sesamoids) with a golf/lacrosse ball and also a Foot Rubz ball.
When standing, I feel some pain but its not bad, but the pain is more prominant when i rotate the foot inwards where my toes become more vertical or the medial edge of my foot is in contact with the ground more ( so eversion or pronation of the foot? can’t decide). any comment on that?
I will start doing eccentric and intrinsic foot exercises in around 6 days while still using crutches. I know crutches are bad but I think its best to stay off the foot for some time and then strengthen it. Then I will slowly start jogging and running with proper form.
I started taking calcium pills. I also roll my calf and peroneal muscles. I have a flat arch/foot, live in canada.
Also, is stretching or flexing the big toe bad? I’ve heard mixed things. Sorry for the long article and questions. I really do need to get back into sport asap. I think my condition of whatever it is, is not a severe condition.
Thanks for for great free knowledge from your articles. Very much appreciate it being an athlete.
I would try to rest 2-3 weeks and bike or water jog and see if it resolves. Also should see someone to get an X-ray to confirm that there is no fracture. If there is those could take longer to resolve. Even as you change your form you need to let this heal. They can be stubborn.
Thanks got it.
So update: Now I can walk pain free, if not there mite be a tiny bit of pain when walking but its not barely noticeable, might not even be there. Still using crutches.
My question is: For foot exercises, how often can I should I do them? like towel crunches, and some other intrinsic and eccentric exercises. Once everyday, twice every day, or like once every 2 days?
I can do them pain free,
Thanks
Hi Dr. Campitelli, thank you for the article. I had sesamoiditis for a year and I actually was able to greatly heal it after reading your blog and try barefoot running of my own. It really helped the sesamoiditis and I can’t remember the last time I had pain there! However, I did an extensive amount of walking during a vacation last year, and now I have tendonitis of the extensor hallucis longus and brevis tendons which I have had for a year. I find that it is very hard to find information on how to heal this kind of injury, especially for people open to minimalist footwear. I find that it hurts so much when I try and go minimalist that I have resorted to wearing supportive shoes, and strengthen when I can. But my foot has become so weak now that any kind of shoe is uncomfortable to wear. Have you had any success treating other patients with this kind of tendonitis? I would be very grateful to hear your feedback. Every podiatrist I have seen has told me simply to wear orthotics but that doesn’t help! And the barefoot running unfortunately just seems to aggravate it. I would be very grateful to hear your perspective 🙂
That’s a rare area to get tendinitis which lasts that long. May need a MRI to confirm if it’s a year old. Could have nerve entrapment there as well. If it’s truly tendinitis and has not resolved, you would have to be overusing it someway or somehow.
Hello Dr. Nick,
After three years of reading your blog, I have something I would like to share.
I have walked barefoot in the house for most of my life, have done multiple martial arts on bare feet and when I started to become interested in running, I noticed I developed pain in my lower back and in my knees when using “traditional” running shoes. I read about minimalist running and bought a pair of vibrams (bikila LS). After a year of building up, I managed to run for over an hour straight. I am not someone to do things hastily and am not someone that “needs” to run in order to feel good. So I did things slow and steady.
In juli 2014, i went for a run and came across a dirt road, covered with lots of small pebbles. At first I thought: lets not go in here, but I still wanted to try something new (normally I run on asphalt roads).
I stepped on a little stone with my left foot, just where my sesamoïd bones are (I didn’t even know what sesamoïd bones were at that time), and although it felt a bit sore, I went off the dirt road back onto the asphalt and was able to complete my run.
Only the next day when I woke up, did my big toe feel very stiff and sore (although no apparent swelling occurred, or any redness was visible). For a month I walked very little/careful (having summer vacation and all it was no problem to just sit and relax in the sun) and the pain faded away. After a total of four weeks of rest, I went for some careful test walks and test runs and all seemed O.K. During that week I slowly build up my walking distances and never felt any pain. After a week of careful walks (turning into two hour walking trips and doing some careful 20 minute running laps), I went on a big hike with some friends and when we arrived back at our appartment, I felt that stiffness and soreness coming back.
I went to see my doctor at the end of sepbemter and she gave me the advice to wear shoes with stiff soles as not to flex the tendons in my foot too much. It did not help much and in december 2014 I went to the hospital and got an x-ray of my left foot (nothing to be seen luckily). In January i went to a podotherapist who told me i should just rest and it would go over eventually. I asked if he thought orthotics might be nescessary to help relieve stress on the tendon. He told me orthotics could help, but were not needed per sé and I had a good chance of healing without them.
Most of the times when I read about sesamoïditis, it seems a chronical issue, coming from repetitive stress by walking or running a lot in a wrong way. In my case however, I got injured by stepping on a sharp stone. I have the complaints of someone with sesamoïditis (stiffness of the big toe when trying to pull it upwards, sometimes I have a “clicking” feeling underneath the joint of my big toe when standing/walking). However, I do not feel typical tendon pain (which, so I read, occurs mostly when resting after a lot of use), but more so when walking through town. Since the return of my injury in august, I have not ran and keep walking to a bare minimum.
Is this truly sesamoïditis, or could it also very well be a different sort of injury in the same area? Should I keep rest much longer, or should I try to ease back into running?
Very in-depth post here on the way you treat sesamoiditis. I think it emphasizes how exercising in regular ways can help more than just losing weight! It is important to one’s overall health.
Hi, I’m German, in June last year started to run minimal injury in the lower back and reading about the art I saw that I could work and it was, disappeared these pains, but at 5 months, and “making Donkey “without adequate transition ran many kilometers without a progressive and appropriate adaptation, injuring me and after going to the podiatrist, as I told him (finger numbness, burning in the metatarsal area especially the first, and pain the first metatarsal, which appeared to 4/6 kms race, and progressively increased, but disappeared as soon as I stopped running and I took off my shoes) said he had Sesamoiditis acute phase after a eco spelling in which no inflammation, some infiltrations traumeel in the area, templates after studying tread (which was seen in the right foot, where I have the injury, the area of maximum impact and contact appreciated is the first metatarsal by far remarkable only in this up and see that there was dysmetria) I made templates, after trying two podiatrists who recommended me, two templates, test with well cushioned shoes, the pain has not disappeared, the same, after a long rest, the latter days, to try, I tried again with minimalist shoes and no pain after tell, wanted to ask for an opinion from someone who knows the minimalism, it would be advisable to make a now smooth transition and run minimalist although whether or not Sesamoiditis it I have. Many thanks in advance, I write to you from the despair of six months and much money spent later trying to find some light. A greeting.
Do you only get pain while running? Is there still numbness and tingling and burning or is it just pain. If you squeeze your foot from the sides does it hurt? Do you feel like you’re walking on a stone or your sock is bunched up but it’s not?
only hurts when I run and take about 20 minutes begins and progressively increases, rather it is numbness and burning, but very uncomfortable. as I was barefoot and stretch your fingers or I just stop running barefoot or in seconds that feeling disappears completely, which resumes if continuous running.
May be a neuroma
do you recommend (as I’ve rested months) try running with vibram five fingers and barefoot, because although I’m running with minimalist shoes (Merrell), I protect something and leave me totally feel the ground, could be a solution ?
Hi Dr Campitelli, thank you for the great article. I injured my right foot a little over a year ago. At first I took two weeks off and tried to run again, two different times, and in 6 weeks I was in so much pain I couldn’t walk on my foot. After an X-ray, a podiatrist diagnosed me with sesamoiditis, gave me a dancer’s pad, and recommended orthotics. I used the dancer’s pad and took a break from running for a couple months. I was skeptical about the orthotics because I had read so many accounts of them not working for others with this condition. I was pregnant at the time, so when I started running again, it was for short distances at a very easy pace. I still experienced some pain, but it wasn’t bad. I totally quit running (due to pregnancy) in April and I figured the few months off would be good for my foot, give it time to heal. I started running again in November and after only five walk/runs of very short distances, the pain was back. I was very discouraged. I sought the help of a local physical therapist who specializes in running injuries. He also practices FDM. My first visit he manipulated my sesamoid area, using the FDM technique, and the “rock” I had been walking on for over a year was instantly gone! I was elated! After a few sessions, I am running again, trying to run with proper form, landing midfoot. I have also changed my shoes, going from 8mm drop New Balance neutral shoes to Altra stability zero drop shoes. My question for you is this: I still experience some aching in that general area, nothing like the pinpoint pain of sesamoiditis, but kind of a residual soreness. I have been doing foot strengthening exercises too. Is this pain a normal part of building up my foot muscles again? Is there anything you would recommend? I am taking my running super slow, doing walk/jogging short intervals for now, hoping to build up to 5k in 6 weeks. I used to run 15-17 miles a week pre-injury.
Hello. I have read a lot about sesamoiditis, yet feel I know very little about it. My 12 year old daughter is currently suffering from sesamoiditis. She isn’t very sports active but does play recreational soccer and basketball. She got an X-ray 2 months ago which showed her big toe joint was very bright white (she couldn’t really bend it at the time) and no break in the sesamoids. She was put in a walking boot which did not help reduce the sesamoid pain. After a month in the boot and no improvement in pain (in fact it got worse) she finally got an MRI. Officially diagnosis: marrow edema in the medial sesamoid consistent with acute sesamoiditis. There was no specific event tied to the pain. It had been bothering her for months until one day she could barely walk on it. She is now able to bend her big toe joint but still has sesamoid pain and pain along where the tendons run through her arch to the ankle area. Currently she is wearing the boot but has been using crutches for the past 3 weeks. She still has pain and swelling though the swelling has reduced some. I feel she needs someone more specialized to treat her injury but not sure who would be in her best interests. (Currently seeing a sports medicine doc). Because she’s still growing, in fact going through a growth spurt now, I feel like a pediatric orthopedic doctor is our best option. But then I also feel a podiatrist may be a better option. Is there anything unusual about her symptoms/injuries that makes you suspect a more complex diagnosis? How unusual is this injury for a 12 year old to have? The doctor seemed to think removal of the bone may be necessary. I am unsure about that course of action and feel therapy or other options should be explored. Any thoughts you have would be appreciated. Please.
I have a similar but different issue with my 10 year old daughter. She is a competitive cheerleader, tumbler and dancer. She has been on the cheer squad for 3 years and has only really focused on tumbling with regularity this past year. One evening she complained that the ball of her left foot was sore. No swellling or bruising; she only complained of it briefly and didn’t say much else about it. I had just made an appt for her sister and I to see a new podiatrist for new orthotics. I added her to the appt figuring that maybe she was due to be seen for orthotics as well. I mentioned it to the podiatrist. The podiatrist took xrays and declared that she had a fractured seismoid. She was treated with taping of toe, strapping w pad and orthopedic shoe and moved to a boot for greater stabilizatio. Symptoms improved but the fracture did not appear to be healing over the course of 6 weeks; the podiatrist started talking about the possible use pf a bone stimulator or removal if non union continued after sufficient time. As a nurse, this didn’t make sense to me and I was not at all comfortable with the idea of a bone stimulator on such a young child (no research that I could find supporting its use). In researching this, I came upon bipartite seismoid as a varient and the higher incidence of seismoiditis in those with bipartite. This made much more sense to me. I took her for a second opinion with a pediatric orthopedist (who has a specialty in the treatment of congenital foot malformations) and she confirmed that it was bipartite w/seismoiditis. She recommended 1 more month in boot and to return if symptoms return. Cheer season is over and all she is doing is a rec dance class but she will want to get back to tumbling. I am thinking that it would be best to give her the winter off of tumbling to allow it to futher heal. I know that prevention of a return of the seismoiditis is essential and will be a life long issue. My next step and where I am hoping for help, is how do I do this and who best to work with. I just paid for 3 new orthotics out of pocket for myself and my 2 daughters. The 10 year old only tried them yesterday and they were made prior to bipartite discovery, so I am not sure if they will need to be altered with this in mind or not. I am also thinking that I should possibly try dancer’s pads with her but don’t know. Your recommendations are for runners and at least one volleyball player. I am not sure how to apply these to her situation. She is not a fan of any sport where she has to run and I have always noticed that she has a somewhat unusual gait. She loves cheer, tumbling and dance! I am concerned that she will become a real couch potato if I can’t figure out how to manage the healing of her foot and prevent future injury. Thank you very much for your time and consideration!!
Dr Nick – I am desperate after seeking help for 5 yrs with chronic pain. I began having problems after a night of wearing dress boots w/ a 2″ heel. My feet hurt in the great toe/sesamoid area, however, in trying to complete my tasks, I pushed through the pain. I have never been a frequent wearer of high heels. Initially my R foot hurt the most. X-rays showed “perhaps the beginning of some arthritis” and a slight bunion. An air cast for 6 wks resolved it temporarily. Soon I found I could no longer tolerate brisk walking, which was my form of regular exercise (toe off was too painful). I was then diagnosed with bilateral sesamoiditis. Cortisone injections were not effective. Bilateral surgery was recommended to correct the bunions, which I was told were throwing off my biomechanics & causing the sesamoiditis. As he could not say exactly what he would do “until I get in there,” I declined and went with new custom orthotics.. The orthotics provided some relief initially, and ultimately bought me another 2 yrs. However, I was never able to return to my previous level of activity and eventually became so limited that I sought the opinion of the chief of podiatric surgery at Mass General Hospital. He would not perform surgery, citing hyper mobility of my great toe joint as a factor that would cause the bunion correction to ultimately fail. He also recommended orthotics. After another year, the orthotics no longer helped and I sought the opinion of another foot/ankle surgeon. Daily chronic pain was becoming unmanageable. He did not feel the bunions had anything to do with the sesamoiditis (they were, by now, slightly worse, but never really bad and in and of themselves never painful). MRI showed L medial sesamoid bone as partially arthritic. He recommended correcting bunions (one foot at a time) with lapidus procedure and removing medial sesamoid bone of L foot. 16 wks later I’m still in a boot (after protective dressing, cast & non WB = 8 wks). Currently in my 4th wk of PT 2 x/wk honestly to just resolve issues of stiffness and weakness secondary to surgery/immobilization. Despite iontophoresis to the sesamoid area, the pain persists and now also have significant tendon pain in bottom of my foot and into ankle. Please advise me where to turn next. I am just 52, and way too young and (normally) fit to be so limited now. Please help me get my life back, Dr Nick.
Honestly sounds like you’ve been immobilized way too long. I walk my lapidus procedures 1 week post op and they’re out of boot at six weeks. Your recovery was a bit on the conservative side, which is ok. I would think once you get things moving again your pain will improve. You need aggressive joint mobilization now. See if you can get a Dynasplint to increase your great toe ROM. Assuming the arthrodesis healed and there’s adequate fusion at metcuneiform joint. But I can’t really give advice since this is online. This is how I approach mine. Each case is different.
Hi, I am a keen runner who performs to a high level. I am in my early 20s. I was recently diagnosed with a necrotic medial sesamoid. It causes me constantly pain and has stopped me from running at all. I’d really love to return to running some day. What do you think my options are, the doctor treating me just said to leave it as it is basically. Thanks
How long have you been dealing with it? How do you know it’s necrotic ? I.e. What tests were done?
It’s been 8 months now, I had an MRI which said there is osteonecrosis of the medial sesamoid.
My almost 15 year old daughter has been suffering from sesamoiditis for almost a year now. She has only had x-rays which showed a bipartite sesamoid, No MRI or bone scan. She still has pain and swelling when she does too much. She plays basketball, tennis and wants to run cross country this fall, so she is very active. We were told that she can do whatever she wants as long as she can handle the pain, that she would not do any more damage to the foot. She has continued to play her sports through the pain. I am concerned that she could in fact cause more damage. I have been doing some reading and am worried about tendon damage as well as the bone becoming necrotic. Should I request an MRI or bone scan? What are your thoughts about getting her to heal? Complete inactivity? Thank you so much in advance, we are at our wits end with this foot!!!
Hi Dr. Campitelli,
I had a fracture to sesamoid bone February 2017 and I’m sure indoor rock climbing caused my injury. Saw a podiatrist in early April and had a post op shoe on for 6 weeks and wore stable tennis after for 2 more weeks. I slowly got back into stretching the big toe and working out. Slowly added lunges as much as my foot would allow me. In November 2017, I started climbing again, doing lunges, and occasionally running on the treadmill. From this my sesamoid bone has been aching more frequently. I’ve been paying attention to my form when climbing ensuring I’m not placing the ball of my foot on foot holds during climbs. What would you recommend on strengthening the foot? I don’t want to give up climbing as I enjoy that as my hobby. I put superfeet insoles in my tennis shoes and winter boots but after reading your other blog posts, I wonder if that is the best method to fully recover the foot.
Thanks!
Do you have an email in which I could contact you? I have a stress fracture in my left sesamoid and am looking for advice. I can also post here if you prefer that. Thanks for your time!
You can post here
Are there programs/guides for strengthening the muscles you mentioned and learning to mid-foot strike? I started doing the barefoot calf raises and towel exercises described but am not clear what other ex are helpful here or how to re-train gait. Looked at EBFA website but those resources seemed oriented towards providers rather than patients. Thank you!