Sesamoiditis: pain under the big toe joint, and how to offload it
Under the big toe joint sit two pea-sized bones, the sesamoids, which work like pulleys for the big toe tendons and take a lot of weight as you push off. Sesamoiditis is irritation of these bones and the tissues around them: pain under the ball of the foot behind the big toe, worse walking, rising on tiptoe and bending the toe back. The honest headline: no trial has tested any treatment, so the advice rests on case series and expert consensus, and one-spot bone pain here can be a stress fracture that heals slowly.
Offloading does most of the work: low heels, stiff or rocker soles, a pad that takes weight around the sore spot, and taping the big toe slightly down. This guide starts with the signs that need an X-ray or scan, explains why a split sesamoid on an X-ray is often normal, and gives a staged plan with 3D demos for a gradual return to running and jumping.
Exercise is for pain that has been checked or is clearly mild and settling.
Get urgent medical help if
Call 999 or go to A&E: after an injury, you heard a crack, the foot or ankle has changed shape or points at an odd angle, a bone is sticking out, there is a bad cut over it, you're in severe pain, or the toes look blue or white, feel numb or are cold to touch. These can mean a broken bone. Don't drive yourself.
Contact NHS 111: severe pain in the ball of the foot, not being able to walk, a foot that has changed shape, a snap, grinding or popping noise at the time of an injury, feeling faint, dizzy or sick from the pain, a foot that is hot, swollen and painful, or pain with feeling hot, cold or shivery. These might be signs of a broken bone or an infection.
Same day: a sudden, very painful, hot, swollen, red joint, often the big toe, especially with a high temperature, feeling shivery or being unable to eat. It may be gout, but it could be a joint infection (septic arthritis), which is urgent.
Same day: you have diabetes and a new foot problem, such as an ulcer or wound, signs of infection, or a hot, swollen foot with a change in colour, even if it doesn't hurt. Contact your diabetes foot team or GP: the National Institute for Health and Care Excellence (NICE) asks for these to reach a specialist foot service within 1 working day, and a suspected Charcot foot is kept off weight until it has been checked.
See a doctor or physiotherapist if
Pain in one spot under the big toe joint that hurts with every step and later at rest or at night, especially after a rise in training: a possible stress fracture of a sesamoid, which heals slowly. Take the load off it until it has been checked.
Pain that started when the big toe was forced backwards, or you can't push off: a possible fracture or a sprain of the joint, which the turf toe guide covers.
You can't put weight through the ball of the foot, or the pain is severe without any injury: a podiatry consensus advises referral for further assessment.
Tingling or numbness along the big toe or in the foot: see a GP.
See a GP if pain in the ball of the foot is stopping you doing normal activities, is getting worse or keeps coming back, or hasn't improved after 2 weeks of treating it at home.
Signs that you're not eating enough for your training (relative energy deficiency in sport, or RED-S), such as periods that have stopped or become irregular, or repeated stress injuries: a podiatry consensus lists these as a reason to refer, as they raise the risk of stress fractures.
Any foot pain if you have diabetes: foot problems can be more serious.
Understand it
What it isStrong evidence
Two pea-sized bones, the sesamoids, sit under the head of the long bone behind the big toe (the first metatarsal), inside the tendon of a short big toe muscle. They work like pulleys for the tendons that bend the big toe, spread the load under the joint and help you push off. They carry up to half your body weight, and more than three times it as you push off. The inner one takes more load and is more often painful.
Sesamoiditis means irritation of these bones and the tissues around them. It is a diagnosis made once other causes have been ruled out, and the pain may come from the cartilage behind the bones or from the tissues around the tendons. The big toe's long tendon (flexor hallucis longus) runs between the two bones.
It is common in ballet dancers, runners and baseball catchers, in young active people, and in sports that load the front of the foot or bend the big toe back, such as running and jumping. A review describes it as typical of younger women, but in a Korean series of athletes 78% were men, so the pattern varies with the sport. Contributors include sudden increases in activity, high heels, unsupportive or flexible shoes, high arches or flat feet, weight gain and a large sesamoid.
Pain under the big toe joint when walking, especially when the toe bends up, with weight-bearing and pushing off; it eases off the foot. The area is tender to press and may be swollen, and people often walk on the outer edge of the foot to avoid it. A clinician checks for tenderness right over each sesamoid and how the big toe moves.
A stress fracture of a sesamoid is a high-risk stress fracture. Like those of the navicular and the base of the fifth metatarsal, it is prone to slow healing and to not healing at all (non-union), because of the high load and a poor blood supply.
A break from a sudden injury hurts straight after the big toe is forced backwards, while sesamoiditis builds gradually. A stress fracture builds gradually too, so the clues are pain in one spot with every step, later at rest or at night, often after an increase in training. In a case series of 58 young athletes with sesamoid fractures (average age 15, 51 of them girls), 83% were stress injuries, mostly from dance, running and gymnastics.
A sprain of the big toe joint after it is forced back (turf toe), big toe arthritis or a bunion (each has its own guide), gout, loss of blood supply to a sesamoid, infection, an inflamed fluid sac, a trapped nerve with tingling along the big toe, or a painful patch of hard skin under the joint. Irritation of the big toe's long tendon where it runs between the sesamoids is another: in one surgical series, 3 of 23 cases were at that spot.
What X-rays and scans do and don't showMixed evidence
A split sesamoid on an X-ray is often normal, a normal X-ray doesn't rule out a stress fracture, and a scan matters when pain is in one spot, follows an injury, or doesn't settle. The numbers:
A sesamoid in two or more parts (a split, bipartite or partite sesamoid) is a normal variant. Most large X-ray series find it in 7 to 15% of feet: 12.7% of 3,994 feet in a general population study, 14.3% of 671 and 14.6% of 474 X-ray series, and 6.8% of 7,946 feet. One series of 1,651 X-rays found it in about 2%, and reported rates range from about 2 to 33%.
Whether split sesamoids usually occur in both feet is disputed: older reports say 80 to 90% are in both feet, but in the 474-foot series one-sided splits were more common. That is why a clinician sometimes X-rays the other foot.
A split sesamoid has smooth, rounded edges, and the normal gap between the parts is 0 to 2 mm. A fracture has sharp, uneven edges whose pieces don't fit back together.
X-rays are often normal in sesamoiditis. A bone scan or an MRI (magnetic resonance imaging) scan shows bone irritation or a stress fracture that X-rays miss; in 5 athletes with stress fractures, bone scans and CT (computed tomography) scans were more reliable than MRI.
In 14 athletes still in pain after non-surgical care, 6 (43%) had no abnormality in the sesamoid itself on MRI, only changes in the soft tissues around it.
The American Academy of Orthopaedic Surgeons (AAOS) says most sesamoid problems settle without surgery, but recovery can take a long time. The figures all come from case series or reviews of them:
A case series of 27 athletes with sports-related pain under the inner sesamoid and no injury: a stepped 3-month plan relieved pain in 48%. Younger age, a higher body mass index (BMI) and a split inner sesamoid went with pain that persisted.
A review of case reports and series (59 people treated without surgery): about two-thirds had pain relief, pain often came back, and about half of the athletes returned to sport without pain.
A case series of 58 young athletes with sesamoid fractures: 85% returned to sport, taking 161 days on average from diagnosis to being pain-free or cleared for sport.
The evidence: case series and expert consensus, no trialsMixed evidence
No randomised trial of any treatment for sesamoiditis exists. The evidence is a 2025 review that pooled 59 patients from 11 case reports and series, a 2024 case series of 27 athletes, older case series, reviews, and a 2024 consensus in which 16 experienced podiatrists agreed on 62 recommendations. That consensus is expert opinion, not trial evidence.
Rest from the activity that hurts. Wear low heels and stiff-soled shoes, clogs or a rocker sole so the big toe bends less, and avoid high heels, thin flexible soles, flip-flops and backless slippers. A felt pad with a U- or J-shaped cut-out (a dancer's pad) takes pressure off the sore sesamoid, and taping the big toe so it stays slightly bent down limits bending back.
The podiatry consensus kept ready-made orthoses with offloading changes, such as cut-outs or an extension under the joint, in its recommendations, but not custom-made ones. In a case series of 10 athletes, custom orthoses relieved pain in 8 and let them keep training. If symptoms continue, AAOS suggests a removable short-leg brace or walking boot for 4 to 6 weeks.
Anti-inflammatory painkillers such as ibuprofen can ease pain, if they suit you. A steroid injection, ideally guided by imaging, can help, but shouldn't be used if there's a fracture or a loss of blood supply to the bone. In the review of case series, injections and orthoses were the options used most and appeared to help, but pain often came back. In the 27-athlete case series, the stepped plan was 3 weeks of less activity, anti-inflammatories and stiff offloading insoles, then an ultrasound-guided steroid injection, then a walking boot with crutches.
No trial has tested exercise. The podiatry consensus supports a gradual return to loading as tolerated and strengthening of the big toe and the muscles that curl the toes; it didn't support general foot-muscle strengthening. An NHS podiatry page lists calf and towel stretches, heel raises, foot-muscle work and low-impact exercise such as swimming.
Because bending the big toe back loads and squeezes the sesamoids, our plan leaves out the sole stretch, kneeling on tucked toes and full tiptoe until late. That choice is ours, and stricter than the NHS page.
Sesamoid stress fractures need a clinicianEmerging evidence
Treatment is often a cast or boot without putting weight through the foot for 6 to 8 weeks at first, or a stiff-soled shoe or short-leg brace with a J-shaped pad, and 2 to 6 months of non-surgical care before surgery is considered. In the case series of 58 young athletes, 90% were treated without surgery. A systematic review of return to sport found that fixing the fracture with a screw gave the best return rates of the operations.
Removing one sesamoid: across 10 studies (196 feet), pain fell from 6.5 to 1.2 out of 10, and 94% of people returned to sport (90% at their previous level) at about 12 weeks, but complications occurred in 22.5% and 3% needed a second operation. In a case series of 24 people with sesamoid fractures, 92% returned to activity at about 12 weeks, and 1 developed a bunion after the inner sesamoid was removed. Removing both sesamoids is avoided, because it can leave a clawed or cocked-up toe.
Other operations include shaving a prominent sesamoid and fixing or grafting a fracture that hasn't healed. Podiatrists in the consensus said they hesitate to refer for surgery because of complications such as the big toe drifting out of line, stiffness and weak push-off.
Keep it mild under the big toe joint; one-spot bone pain is a stop signEmerging evidence
An NHS podiatry page advises using a 0 to 10 scale, staying in the mild pain zone by pacing your activities, and cutting back if the pain is severe.
Our suggested rule is stricter than this site's usual 5 out of 10: pain under the big toe joint no more than about 2 to 3 out of 10 during walking and exercise, settled within an hour, and no worse the next morning. That is our editorial choice, because the joint takes your weight with every step and a sesamoid stress fracture heals slowly. Elsewhere, in the calf or the hips, the usual rule applies.
Pain in one spot on the bone that comes with every step or at night means stop the loading and get it checked. During the return to running and jumping, any pain under the joint that is still there the next day means go back a step (our suggestion, matching the stress fracture guide).
Start at the first stage. Each move opens a full guide with a 3D demo.
Stage 1
Offload the big toe joint (about weeks 0 to 3, or longer as your team advises after a fracture)
Stiff-soled or rocker-soled shoes with a low heel, a pad with a cut-out around the sore sesamoid, and the big toe taped slightly down (the steps are below). No tiptoe work, kneeling on tucked toes, deep squats onto the toes, hopping or sprinting. If a stress fracture is suspected or confirmed, follow the clinic's plan instead. Doses are editorial unless marked.
Move on when: Walking in your offloading shoes and pads is pain-free or mild (no more than about 2 out of 10 under the joint), and pressing under the joint is less tender.
Follow along: a timer, a cue and the next move, one step at a time.
Stage 2
Strength without bending the big toe back (about weeks 3 to 8)
Strengthen the calf and foot while the big toe stays flat or only part-way up. Doses are editorial unless marked.
Move on when: 15 half-height calf raises and 30 minutes of brisk walking cause no pain under the joint during or the next day, and pressing under the joint no longer hurts.
Follow along: a timer, a cue and the next move, one step at a time.
Stage 3
Return to push-off, running and jumping (from about week 8, or once a fracture has healed and your team allows)
A gradual return to loading as you can tolerate it, as the podiatry consensus advises. Before running, check (our suggestion, borrowing the stress fracture guide's checks): no tenderness pressing under the joint, 30 minutes of brisk walking without pain, and 20 single-leg calf raises and 10 hops on the sore side without pain. Doses are editorial.
Move on when: Running, hopping and your sport cause no pain under the joint during or the next day. Keep the shoe and pad changes that helped for sport. If pain keeps coming back, see a sports medicine doctor or podiatrist about orthoses, a scan or an injection.
Follow along: a timer, a cue and the next move, one step at a time.
What to change for now
Taping and padding (written steps)
Taping and padding can't be shown on the 3D figure. The principles come from AAOS, a specialist review and the podiatry consensus; the exact method below is our suggestion, and a podiatrist or physiotherapist can show you.
1. Pad: stick a felt pad to the insole or the foot with a U- or J-shaped cut-out, so the sore sesamoid sits in the gap and the pad takes your weight around it. A pharmacist or podiatrist can cut one.
2. Tape: with the big toe resting slightly bent down, run a strip of rigid tape under the big toe and back along the sole behind the ball of the foot, so the toe can't bend far back, and anchor it with a strip around the middle of the foot. AAOS describes taping the toe so that it stays slightly bent downwards.
3. Check your skin and circulation after taping, and take the tape off if the toe goes numb, pale or tingly.
4. Shoes: a stiff sole or a rocker reduces how far the big toe bends, and a low heel reduces the load on the front of the foot.
Soft, cushioned, lower-heeled shoes with a stiff sole that curves up at the toe reduce bending of the big toe, as an NHS podiatry page advises; flexible soles, high heels and hard, flat or unsupportive shoes add stress. An ice pack on the sore area for up to 20 minutes every 2 to 3 hours can ease the pain, wrapped so it isn't directly on the skin.
After a sesamoid fracture, the clinic's plan comes first: often weeks in a cast, boot or stiff shoe, then a gradual return over months. Start this guide's last stage only when your team allows.
Irritation of the two small sesamoid bones under the big toe joint, or the tissues around them. They work like pulleys for the big toe tendons and take a lot of load as you push off.
What does sesamoiditis feel like?
Pain under the ball of the foot behind the big toe, worse walking, rising on tiptoe and bending the big toe up, often with tenderness and some swelling. It usually builds gradually.
Is it sesamoiditis or a stress fracture?
A stress fracture hurts in one spot with every step and later at rest or at night, often after a rise in training, and a break from an injury hurts straight after the toe is forced back. Sesamoid stress fractures heal slowly, so get one-spot pain checked.
My X-ray shows a split sesamoid. Is it broken?
Not necessarily. In most X-ray studies, about 7 to 15% of feet have a sesamoid in two or more parts, a normal variant with smooth edges. A clinician looks at the edges and the gap, sometimes X-rays the other foot, and may order a scan.
What helps sesamoiditis?
Offloading: low heels, stiff or rocker soles, a pad with a cut-out around the sore spot, and taping the big toe slightly down. Orthoses with a cut-out can help, and a walking boot is an option if it won't settle.
Where does a dancer's pad go?
Around the sore sesamoid, with the cut-out under it, so the pad takes your weight around the bone rather than on it. A podiatrist can cut and place one.
What exercises can I do with sesamoiditis?
Cycling with the arch on the pedal, calf stretches with the big toe flat, and strength work that doesn't bend the big toe back, such as seated calf raises and lifting the front of the foot. Leave out full tiptoe, kneeling on your toes and hopping until it settles.
Can I run with sesamoiditis?
Not while it hurts under the joint. Once walking and half-height calf raises are pain-free, build back with hops and walk-jog intervals, adding time before speed.
How long does sesamoiditis take to heal?
It varies, and the figures come from case series. In one, about half of athletes had less pain after a 3-month stepped plan, and pain often comes back. Sesamoid stress fractures in young athletes took about 5 months on average to clear.
Will a steroid injection help?
It can, once a fracture and loss of blood supply to the bone have been ruled out, and it's usually guided by imaging. It was part of the plans that helped in case series, but pain often came back.
Is sesamoiditis the same as turf toe?
No. Turf toe is a sprain of the big toe joint after it is forced back, often in field sports, while sesamoiditis usually builds gradually under the joint. Our turf toe guide covers the sprain.
Will I need surgery?
Rarely: most sesamoid problems settle without it. Removing one sesamoid got 94% of people back to sport in about 12 weeks across 10 studies, but 22.5% had complications, so it is a last resort.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
