There are two small bones that sit beneath the big toe joint
which are called sesamoids. The sesamoid is sit within one of the
tendons beneath the big toe joint and help to protect the tendons
during walking and to stabilise the inside of the foot as we push
of into the next step. They are the foot's equivalent to the knee
cap (Patellar). The top surface of the sesamoids is covered in
cartilage as they form part of the big toe joint.
If there is too much pressure on the sesamoids or a direct
injury then the area can become inflamed (sesamoiditis). In some
instances, the cartilage on the sesamoid can be damaged and result
in arthritis. It is also possible to fracture the sesamoids. If the
blood supply to the bone is interrupted then this can cause an area
of the bone to die and is termed avsacular necrosis. Sometimes the
bone can fragment or alternatively, as it heals, it becomes harder
(sclerotic). In either instances, this can cause pain.
What causes sesamoiditis?
Generally, a direct injury or overuse during sport causes
sesamoiditis. However, patients with a low arch or high-arched foot
or a prominent joint can be predisposed to sesamoid damage/injury.
In correctly fitting shoes or shoes with a higher heel can all
increase stress to the sesamoid area. Some patients have enlarged
sesamoids which can predispose to sesamoiditis.
Will it get worse?
It is likely that sesamoiditis will get worse if the area is not
protected and rested. It is not uncommon for people to ignore this
problem initially only to find that it stops on walking normally,
forcing them to seek treatment.
What are the common symptoms?
- Pain beneath the big toe joint
- There may be some redness and swelling beneath the big toe
- There may be pain and/or stiffness on moving the toe joint
- Difficulty in shoes
- Difficulty in walking
- There may be an associated deformity, especially a prominent
How is it recognised?
Clinical examination and a detailed history allow diagnosis.
X-rays are helpful in evaluating the sesamoids although more
detailed scans (e.g. bone scan, C.T. or MRI) are often
What can I do to reduce the pain?
There are several things that you can do to try and relieve your
- Wear good fitting shoes with plenty of cushioning (e.g.
- Avoid high heels
- Wear a protective pad beneath the joint
- Rest is often required
- Anti-inflammatories can be helpful although should not be taken
long-term without a professional opinion
- Hot or cold packs may be helpful
- See a podiatrist
What will a podiatrist do?
If simple measures do not reduce your symptoms, there are other
- Advise appropriate shoes
- Advise exercises
- Consider prescribing orthotics
- Request appropriate investigations
- Administer a cortisone injection when appropriate
- Consider a period of immobilisation
- Advise on surgery
Will this cure the problem?
In many instances, the conservative measures are sufficient to
resolve discomfort and allow her return to activity. However,
because of the nature of the problem, this can take a few
What will happen if I leave this alone?
Although your symptoms may settle, it is likely they will get
What happens if the symptoms do not settle?
In a small number of cases, surgery is required to resolve
How does the operation solve the problem?
If the sesamoid has become fractured and the fracture does not
heel properly, removal of the sesamoids may be necessary. However,
this can affect function of the big toe joint and these to be
If the sesamoids are enlarged then they can be reduced (sesamoid
planing) and this may be sufficient to relieve discomfort but avoid
the need to remove the sesamoid completely.
I have heard it is very painful.
The nature of surgery means that there will be pain and
swelling, usually worse the night after surgery. However, with
modern anaesthetic techniques and pain killers, this can be well
controlled. The level of pain experienced varies greatly from
patient to patient with some experiencing no significant
Will I have to have a general anaesthetic (be asleep)?
Not if you did not want one. Many of these procedures are
performed perfectly safely under local anaesthetic (you are awake).
Some patients worry that they may feel pain during the operation
but it would not be possible to perform the operation if this were
Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home
support, many patients are able to have this type of operation
performed as day surgery and go home.
Will I have to have a plaster cast?
No. A plaster cast is not required for this type of surgery.
Are there a lot of complications?
There are risks and complications with all operations and these
should be discussed in detail with your specialist. However, with
most foot surgery it is important to remember that you may be left
with some pain and stiffness. This is why it is not advisable to
have surgery if the deformity is not painful and does not limit
your walking. A thorough examination of your foot and general
health is important so that these complications can be
Although every effort is made to reduce complications, these can
occur. In addition to the general complications that can occur with
foot surgery, there are some specific risks with sesamoid
- Fracture of the remaining portion of sesamoid
- Weakness and / or deformity of the big toe
- You may get discomfort in other parts of your foot during the
recovery period. This
When will I be able to walk again and wear shoes?
In the majority of cases, you will able to walk with the aid of
crutches within 2-4 days but you will remain somewhat limited for
the first 2 weeks. However, if the surgical incision is on the sole
of the foot, you will not be able to walk on this area for 3 weeks.
This is to minimise the problems with scarring as this could result
in discomfort and hard skin formation for the rest of your
Some patients are able to return to wider shoes within two weeks
and most are generally back into shoes by 4-6 weeks.
Swelling generally starts to reduce at 6-8 weeks and the foot
will be beginning to feel more normal at 3 months although the
healing process continues for 1year.
When will I be able to drive again?
When you feel able to perform an emergency stop. This is
generally between 4-8 weeks post operatively but you should always
check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active
and you can elevate your foot, you may be able to return after 1-2
weeks. Generally, patients return to work between 4-8 weeks
depending on the type of job, activity levels and response to
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you
should be able to return to impact type activity at around 2-3
months. This will depend on the type of operation you need and how
you respond to surgery.