What I have learned about treating sesamoiditis.
|Read my latest blog post featured in Podiatry Today below.
I have been intrigued by sesamoiditis since I suffered from it as a resident. I lived with the condition for 10 years before finally realizing I was creating the problem by the way I was running and walking.
After making this discovery, my outlook on treating sesamoiditis changed. I no longer relied on treating it through inserts and offloading devices. I began focusing on strengthening the foot, proper walking and running form, and shoe gear.
I realized I was placing excessive force on my first metatarsophalangeal joint (MPJ). Contrary to my previous belief, when I began experimenting with barefoot running on a treadmill, I put less strain on the joint and my painful sesamoids. This was because I had adapted a shorter stride and began landing with a flatter, more midfoot and forefoot type of foot strike. I was landing more laterally (as I should be) so there was direct force to the first MPJ.
More importantly, I had eliminated the propulsion phase of gait. I realized that it was during the propulsion phase that I felt pain in my sesamoid complex. I was focusing on heel striking laterally and then allowing my foot to pronate and toe off during propulsion. I no longer accept this as a proper phase of gait.
When teaching running form, I advocate landing with a midfoot strike. Instead of pushing off with the forefoot, one should drive the knee forward and use the momentum from a forward lean at the ankles. The propulsion will come from the entire foot and spring mechanism of the leg (Achilles and quadriceps) with a lesser degree of flexion on the first MPJ.
It takes many weeks of running with this form to see a reduction in pain. I typically will introduce a period of rest and anti-inflammatories before commencing this, depending on the severity of the injury. If patients can run without severe pain that would be changing their form, I will allow them to run easy with no speed workouts and only slow base training. If they can’t run pain-free, then the rest period continues until they can demonstrate a relatively pain fee gait, one that doesn’t alter form to relieve the pain.
I have also noticed that many patients who present to me with either sesamoiditis, a bipartite or fractured sesamoid perform some type of propulsion activity for the forefoot. This is usually from playing volleyball or watching exercise videos such as the infamous P90X or the Insanity workout. Doing repetitive dynamic planks can really load the MPJ excessively, creating pain. Treating these patients with rest, casting and orthotics may help. However, once patients return to the activity that places force on the MPJ, the pain reoccurs.
I also advise modifications in walking and standing. Taking long strides on rigid dress shoes with a solid heel can also increase the force to the MPJ as the body needs to pass over the foot and the force ends up on the first MPJ that is now behind the body passing over it. With a shorter stride or smaller step, the foot does not end up behind the body and the stress to the MPJ is undoubtedly minimized.
Even standing can play a role. Instead of standing in a relaxed posture leaning back onto a cushioned heel, one should disperse the weight over the feet with a slight lean toward the forefoot, which will recruit foot intrinsics to stabilize one’s posture. This obviously takes time and patients cannot learn it overnight.
Do you mean that in the toe off phase you push your knee forwards, not your whole body? Or should there be no push with toes at all?
Correct. The great toe should not pushing the entire body off. It’s not efficient mechanics and it leads to abnormal force loads.
Have you considered the role of trunk counterrotation — particularly movement of the pelvis in both the transverse and frontal planes — in reducing load on the MPJ while still allowing a long stride?
Hi Dr. Nick,
Hope all’s well. I have a chronic sesamoiditis in my left big toe, although if rested, and off my feet it’s pain free, in fact it’s more the dorsiflexion of the toe that really hurts. If I rest the toe for extended time it feels completely normal but due to the nature of my profession it returns. I play professional rugby, a position called prop, are main role is scrummaging. It’s basically wrestling of the ball of your feet, exaggerated dorsiflexion. On top of this we are the most heavily built people on the pitch, I weigh 120 kg, about 260lbs. So my question to you is does minimalist shoe theory apply to a man my size as nature did not intend for us to be this big surely? I don’t believe it’s awfully that bad. But it really hurts, basically I’ve tried orthotics and strapping, but would realigning my toes help do you think? It’s very difficult playing rugby atm. Electro corporeal short wave therapy?
It sounds to me like you have a classic case of excessive dorsiflexion of your great toe joint leading to the cause of your pain. I see this a lot in my practice in volley ball players (repetitive jumping off of one foot), those doing P90x, and weight lifters who put a tremendous amount of force on the ball of their feet.
The challenge is to stop this excessive dorsiflexion. Wearing a minimalist shoe usually helps runners because there is a lack of heel cushioning and this forces the runner to alter their gait and reduce the propulsion force at the great toe. Basically by increasing the cadence and landing under the center of gravity the change occurs.
Yes a man of your size can benefit from a minimalist shoe but I think in your case the challenge will be to stop the excessive DF force to your great toe.
Try experimenting with short runs in a pair. 3-4 minutes a day and increase a few minutes weekly. Allow 6-8 weeks to reach 3 miles of running.
Thanks for the question. Hope this helps!
This sounds like what I’m experiencing, I do not do P90x…but HIIT training videos on cement flooring. I spend a LOT of time in burpee mode, plank stance, jump rope and Plyometric exercises. So excessive flexion of the big toe (left in particular) Is it also a symptom to have the top of foot from the big toe on back when flexed sore in addition to pain at the base as shown in your diagram? do you recommend a shoe that would better support these types of daily activities with this type of ongoing injury – I’m going to try your running advice, but what about general fitness use? I imagine I’ll have to take a break for a bit and let it heal? How long does inflammation last in this area when rested. Any thoughts would be appreciated. Thanks much Dr. Nick.
Dear Dr.
hoe you are doing well
i have suffered from sesamoiditis ” inflamation of the tendon without fracture” for 7-8 month.
after that i have developed algodystrophy aka complex regional pain syndrome. luky me 🙂
however my CRPS was the type that heals , so my pain started reducing and after 8 month now i am pain free in my foot with the exception of the famous sesamoid site.
actually RSD makes bone demineralization , so i have to wear orthotics until they hoepfully heals,,,:( i only can walk 15 minutes barefoot before they become painful.
anyway i have this issue with orthotics , as i have tried 9 different pairs with several different shoes ,,, some orhtotics are handmade other ready made…ect
i have a problem that when i stand for 10-15 minutes , i feel like i have been standing for hours and need to sit for a while before i can walk-stand again, and that is in both , healthy and RSD feet so it’s not RSD related.
kindly advise :
1- is it normal to have such pain when wearing orthotics.
2- is there’s any stretching i can do to avoid this ?
Hi Dr. Nick
My right big toe is swollen n very painful…i drive alot…sometimes n swelling go down n the pain will ease up n sometimes it will relaps…I would love to know the reason for this problem….