Sesamoiditis is pain and irritation around the two small “pea-shaped” bones (sesamoids) that sit underneath the big toe joint. These bones act like pulleys inside the tendons that bend your big toe, helping your foot push off the ground efficiently. When they become overloaded, the area can get sore, swollen, and very sensitive to pressure, especially during walking, running, jumping, dancing, or wearing tight or high-heeled shoes.
Most people describe sesamoiditis as a deep bruise-like ache under the ball of the foot at the base of the big toe. It often starts gradually after a change in training, footwear, or activity.
Physiotherapy for sesamoiditis focuses on:
- Identifying why the sesamoids are being overloaded
- Reducing that load while the area settles
- Creating a program to build it back up.
Key Facts
- Sesamoiditis has been reported to account for 2.2% of all foot injuries and 18.3% of first metatarsophalangeal joint injuries in athletic populations. 🔗
- After sesamoidectomy (surgery to remove one sesamoid), an average return to sport of 10.5 weeks has been reported, with 86% returning to pre-injury levels in the summarised literature. 🔗
- A 4-year incidence of 4.2% has been reported for sesamoiditis in athletes. 🔗
Risk Factors
- Sports with high forefoot loads: running, sprinting, dance, basketball, netball, soccer, gymnastics.
- Rapid increases in training volume or intensity, especially adding hills or plyometrics.
- High heels, minimalist shoes, very flexible shoes, or shoes with poor forefoot cushioning.
- Foot posture patterns that overload the inner or outer forefoot.
- Calf weakness or reduced ankle dorsiflexion that shifts load forward during gait.
- Previous forefoot injuries, including turf toe, sesamoid stress reactions, or metatarsalgia.
Symptoms
- Pain under the ball of the foot at the base of the big toe, often described as a deep bruise.
- Pain that is worse during push-off (the “toe-off” phase of walking or running).
- Tenderness when pressing directly under the big toe joint (often more on the inner side).
- Swelling, warmth, or a “puffy” feeling under the big toe joint.
- Pain rising onto your toes, jumping, sprinting, lunging, or going up stairs.
- A feeling of stiffness or reduced movement at the big toe joint due to pain.
Aggravating Factors
- Running, jumping, sprinting, court sports, or dance that increases forefoot loading.
- Repeated big toe “bend back” positions (big toe extension), such as lunges and planks.
- Barefoot walking on hard floors, especially first thing in the morning or after training.
- Tight, thin-soled, or very flexible shoes that do not cushion or offload the forefoot.
- High heels or shoes with a narrow toe box that concentrate pressure under the big toe.
- Sudden training changes (more hills, speed work, plyometrics, extra sessions).
- Long periods on your feet at work, especially on hard surfaces.
Causes
Sesamoiditis is usually caused by repeated overload of the sesamoid bones and the surrounding soft tissues under the big toe joint. This overload can build up when your activity demands increase faster than your body can adapt. It is common after changes like starting a running program, adding court training, returning to sport after time off, increasing dance hours, or doing more hill running and jumping.
Biomechanics (how your body moves) often largely contributes to the development of seasamoiditis. If your big toe does not bend well, your body often “cheats” by pushing off harder through the ball of the foot, which can overload the sesamoids, but if your big toe bends too much, it repeatedly squashes the tendon. If your foot rolls in or out more than normal, pressure can get focused on one sesamoid, rather than sharing the load across two. Foot wear that is thin and flexible (like thongs) often increase pressure under the forefoot, and high heels shift body weight forward, increasing sesamoid compression. Worn-out runners can lose shock absorption and allow more forefoot loading. Weak calve, quads, hamstrings, and glutes can increase the load placed on the foot, and poor control of small foot muscles reduce capacity to spread load throughout the foot.
How Is It Diagnosed?
Sesamoiditis is diagnosed through a combination of your history and a targeted clinical examination. A physiotherapist will ask about training changes, footwear, surfaces, and whether symptoms came on gradually or after a specific incident. Pain that builds over time with forefoot loading, plus tenderness directly under the big toe joint, strongly suggests a sesamoid-related problem.
Your physio will check:
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Exact pain location (medial sesamoid, lateral sesamoid, or both)
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Big toe joint range of motion
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Swelling, heat, and sensitivity to direct pressure
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Gait and running mechanics
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Calf strength, ankle mobility, foot intrinsic control, and hip control
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Footwear assessment
Because sesamoiditis can look like stress fracture, plantar plate injury, or arthritis, imaging may be recommended when symptoms are severe, persist despite good sesamoiditis rehab, or if there was a clear traumatic event.
Investigations & Imaging
- X-ray
- Helps rule out obvious fracture, arthritis, or structural variants (like a bipartite sesamoid). Often normal in early overload.
- Magnetic resonance imaging
- Shows bone marrow oedema and surrounding soft tissue irritation, and helps distinguish sesamoiditis from stress fracture or other joint pathology
Physiotherapy Management
Exercise
Sesamoiditis physiotherapy exercises need to be chosen carefully so you strengthen the foot without repeatedly compressing the painful area. Early on, your physiotherapist may start with isometric (static) big toe and foot intrinsic work that builds capacity without high irritation. As pain settles, your sesamoiditis rehab progresses to calf strengthening (often a key driver of forefoot load), then to controlled big toe and forefoot loading, and eventually hopping and running drills when tolerated/relevant. The program also addresses hip and trunk control so your foot is not forced to “do the braking” alone during landing, cutting, and direction changes.
Activity Modification
A physiotherapist will help you reduce the specific loads that keep provoking your sesamoiditis while keeping you active. That might mean temporarily avoiding hills, speed sessions, plyometrics, and barefoot walking. Cross-training options like cycling, swimming, or rowing can maintain fitness while the sesamoids settle. Importantly, activity modification is not “stop everything”. It is a plan to stay under your pain threshold, then gradually reload the area.
Manual Therapy
Manual therapy in physiotherapy for sesamoiditis is usually aimed at improving contributing restrictions rather than pressing directly on the sore sesamoids. Your physio may mobilise the big toe joint if stiffness is forcing abnormal loading, and treat calf and ankle restrictions that push weight forward onto the forefoot. Soft tissue techniques may be used to calm surrounding muscle tension and help restore more normal movement patterns. Manual therapy should always support your loading plan, not replace it.
Postural Retraining
For sesamoiditis, “posture” often means how your whole leg stacks over your foot during walking, running, and sport. A physiotherapist may retrain your gait so push-off is smoother and less “toe-jammed”, reduce excessive big toe extension moments, and improve control through the midfoot. For runners, small technique changes such as cadence adjustments, reduced overstriding, or better hip control can reduce peak forefoot pressures. The goal is not a perfect-looking gait, but a gait that reduces sesamoid compression while you rebuild capacity.
Bracing & Taping
Taping and padding can be very effective for short-term symptom control in sesamoiditis physiotherapy, because they reduce direct pressure and limit painful big toe extension. A physiotherapist may use a “dancer’s pad” style offload (a cut-out under the sesamoids) or taping to support the big toe and reduce compression under the joint. Some people benefit from a stiff-soled shoe, a carbon fibre insert, or a rocker sole to reduce bending through the big toe during walking. These strategies can help you stay active and walk more normally while the irritation settles, but they should be paired with strengthening and load management so you are not dependent on them long-term.
Heat & Ice
Ice can help settle symptoms after activity flares by reducing pain and calming the area. Heat is less commonly helpful directly on the sesamoids, but some people prefer warmth for comfort around stiff joints and tight calf muscles. Your physiotherapist will guide this based on how your foot responds.
Education
Education is central to physiotherapy for sesamoiditis. You will learn how the sesamoids get overloaded, what “too much too soon” looks like for your training, and how footwear and surface choices affect symptoms. Your physio should help you plan training progression, choose appropriate shoes, and recognise early warning signs. Education also includes realistic timelines: sesamoid pain can be stubborn because every step loads the area, but good sesamoiditis rehab with consistent offloading and progressive loading is usually very effective.
Other
A physiotherapist may collaborate with a podiatrist or sports doctor when orthotic modification, a boot, or medical pain relief is needed to create a window for rehab. If the diagnosis is uncertain or progress stalls, your physio may recommend imaging to rule out stress fracture, osteochondral injury, or other causes of persistent big toe pain.
Other Treatments
Other treatments may be used alongside physiotherapy for sesamoiditis, depending on severity and response. This can include short-term immobilisation in a walking boot for significant pain or when a stress reaction is suspected, as well as orthotic devices or shoe modifications to reduce pressure under the big toe joint. Some clinicians may consider injection therapies in selected chronic cases, but these decisions should be made carefully with an accurate diagnosis, as pain relief without load management can lead to worsening overload.
Surgery
Surgery is not the first-line treatment for sesamoiditis. It is generally considered when symptoms persist despite a well-structured conservative program. Surgical options depend on the underlying diagnosis and may include sesamoidectomy (removing one sesamoid) or procedures that address associated problems such as fracture non-union or joint surface damage.
If surgery is required, physiotherapy remains essential. Post-operative physiotherapy focuses on wound and swelling management, restoring big toe motion, rebuilding calf and foot strength, retraining gait, and gradually reintroducing running and sport-specific loading.
Prognosis & Return to Activity
Prognosis depends on how long symptoms have been present, how well the area can be offloaded day-to-day, and whether there is an underlying stress fracture or joint surface injury. In many cases, symptoms improve steadily when forefoot load is reduced early and physiotherapy rehab is progressed appropriately.
Return to activity is usually staged. Your physiotherapist will typically aim for:
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Comfortable walking without limping and without next-day flare-ups.
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Strength and control targets for calf, foot intrinsics, and hip stability.
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Gradual return to impact (skipping, hopping, then running), starting flat and controlled before hills, speed, and sport.
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Sport-specific skills, including cutting and jumping, once push-off is consistently tolerated.
A common reason sesamoiditis becomes persistent is returning to running or jumping too quickly once pain is “better”. A physiotherapist will help you treat improved symptoms as a starting point for rebuilding capacity, not a signal to immediately resume full training.
Complications
- Reduced push-off strength due to ongoing pain inhibition.
- Altered gait leading to secondary issues (lateral foot pain, ankle irritation, calf overload).
- Progression to stress fracture or joint surface irritation if overload continues unchecked.
Preventing Recurrence
- Avoid sudden increases in running speed work, hills, jumping, or dance hours; build forefoot load gradually so the sesamoids can adapt.
- Choose footwear that reduces big toe joint bend and forefoot pressure during flare-prone phases (stiffer sole, appropriate cushioning, adequate toe box), especially if you have a history of sesamoiditis.
- Maintain calf, quad, hamstring, glute, and foot intrinsic strength so push-off force is shared across the whole foot rather than concentrated under the big toe joint.
- For court sports and dance, include technique and landing drills to reduce repeated high-pressure forefoot loading during jumps, turns, and accelerations.
When to See a Physio
- Pain under the big toe joint that persists longer than 1 to 2 weeks despite rest and footwear changes.
- Pain that causes limping, altered walking, or inability to rise onto your toes.
- Symptoms that repeatedly flare when you try to return to running, jumping, or sport.
- Significant tenderness directly under the sesamoids or pain with big toe extension.
- Pain after a clear traumatic event (for example, landing awkwardly or a forced big toe bend back), especially if bruising or swelling is present.
- Ongoing pain that is not improving with self-management, where imaging or a clearer diagnosis may be needed.