#007 Sesamoiditis of the ball of the big toe

(You never realise how important your big toe is until you injure it...)

Jan 24, 2023

Start writing today. Use the button below to create your Substack and connect your publication with BT’s Pilates Blog

Video: exercises stretches and massage for big toe sesamoiditis

What is sesamoiditis?

Sesamoiditis is when you have pain under the ball of your big toe that is obvious during toe-off: the more forceful the toe-off and the higher the lift of the ankle, the worse the pain. "You never realise how important your big toe is until you injure it".

Picture: sesamoids are bones that lie under the ball of the big toe. They are embedded in the tendons of the Flexor Hallucis Brevis muscles. These are the muscles that point your big toe downwards. Sesamoids sustain damage when their tendon is heavily loaded while turning a sharp corner.
(picture source: Daniel Bohl, MD)

Two sesamoiditis case studies:

“I injured my big toe of my right foot by running in tight circles on a hard gym floor about 12 years ago. It's in the ball of foot area. It is often sore in the morning. I usually will not run in the morning because it takes so long to warm up. (30 to 45 minutes before I am able to jog without pain)”. (12)

“I’m a competitive dancer, aged 18 years. For a few months, I’ve had pain under the ball of my left big toe. I’ve tried resting, Panadol, orthotics and physiotherapy, but the pain comes back when I dance”. (13)

Sesamoiditis is slow in onset.

Sesamoiditis takes, on average, 5 months from the first twinge until you decide to visit your physician(1). It is also slow to heal: it takes on average 3 and 1/2 months from the first physio visit to exercising without pain(1). (Hint: it’s easy to fix if you start treatment early, so don’t leave it too long).

Picture: sesamoiditis shows up as pain upon toe-off (the harder you push into the toe and the higher the ankle, the worse the pain under the ball of the big toe):

Other signs of big toe sesamoiditis include:

Pain upon pressing on the underside of the ball of big toe (no surprise there!).
Toe flexion (toe points down) action is weak.
Toe dorsiflexion (toe points up) range of motion is limited and painful.

Prevalence: very common in dancers who do high-heel lifts

I could not find any prevalence studies but I did discover that sesamoiditis is very common in dancers, and particularly common in young ballet dancers(1,7).

Sesamoid-injured young athletes, broken down into their sports categories:-

Dancer: 40%
Runners: 13%
Soccer players: 13%
Football players: 10%

Prevalence: more common with high-heeled shoes

Sesamoiditis also occurs when wearing high-heeled shoes (6, 11)

Prevalence: Hallux valgus and sesamoiditis go together

Hallux valgus in old age causes sesamoid subluxation. Because of the subluxation, sesamoiditis is common with Hallux valgus. With severe surgical cases, the surgeon must plan to repair the sesamoid subluxation as well as the valgus.

Sesamoiditis is a slow injury.

It is slow to worsen and slow to heal:-

Average time from first twinge to first clinic visit: 5 months
Average time from first clinic visit to resolution: 3 and ½ months

Causes of big toe sesamoiditis

There are two categories of causes for sesamoiditis: (1), excessive ankle and/or foot arch lift when the big toe is pressed hard into the ground (an overload in combination with sharp cornering); (2) Hallux Valgus (which pulls the sesamoids out of alignment). Hallux valgus is a topic that will be covered in a separate article. The Hallux valgus contribution to sesamoiditis will be covered here.

1. High ankle and/or foot arch at toe off causes sesamoiditis

Tendons are good at transmitting a load in a straight line but are not good at transmitting a load while turning a sharp corner (see picture 1 below). Loaded, sharp cornering is what happens when we press heavily into our big toes while the ankle is high. At toe-off, the following factors contribute to the high load and sharp cornering that may trigger sesamoiditis:

High foot arch
Stiff ankle
Tight calf muscles
High-heeled shoes
Dancing

Picture: A dancer’s heel lift puts a heavy load on the sesamoid tendons while also forcing them to go sharply around the bend of the big toe.

Picture: The sesamoid bones are located under the ball of the big toe and within the tendons of the Flexor Hallucis Brevis (FHB) muscle.

2. Hallux valgus “bunion toe” causes sesamoiditis

When the big toe moves out of alignment it pulls (luxates) the sesamoids towards the mid-line of the foot (see picture below). With mild Hallux valgus this takes the load off the fibular sesamoid and puts extra load on the tibial sesamoid (again, see picture below). Since just one sesamoid is loaded and it is also being pulled out of its groove in the bone, it will suffer damage even at moderate loads. This is why we consider that even a mild Hallux valgus may contribute to sesamoiditis. This means that Hallux Valgus should be corrected (if possible) in a sesamoiditis treatment program.

Picture: The lateral movement of the sesamoids in Hallux valgus makes sesamoiditis more likely.

Aim of corrective exercises

The aim of corrective exercises is to reduce or avoid the combination of high load and sharp cornering of the sesamoid tendons. We can do this by:-

Removing the causes of Hallux valgus (by splaying the toes and going barefoot as much as possible).
Removing the need to push the big toe hard into the ground at toe-off, or while dancing with the heels lifted high.

Rules of thumb to guide your sesamoid repair workout

Include as much barefoot time as possible, every day for the rest of our life. This will slow the onset of Hallux valgus.
Spread the toes while exercising, and whenever you think about it. This will align the sesamoids correctly and reduce the risk of the sesamoids being pulled out of their grooves. (It will also strengthen the weaker toe muscles and improve control and fluidity during walking and running).
Make flexible the calf, ankle joint, and foot. Increased overall flexibility means you can use your foot with less heel lift and so, less bend at the ball of the big toe.
Load the big toe flexor tendons while the big toe is in a straight line with the rest of the foot. Straight-line loading of the sesamoid tendons will heal them.
Use toe agility and awareness exercises to teach you to avoid the bad habit of pressing the big toe hard into the ground at toe-off.

Suggested exercise list

(Take some notes, make a plan, and do these daily, the video at the top of the page will help)

Stretch:
* Toe pulls (joint distraction)
* Calf shin and sole of foot stretches

Strengthen:
* Eccentric strength:- While standing with splayed toes press into the ball of the toe while lifting the heel; de-load to lower. (Important: don’t take the ankle too high)!
* Pure strength:- Isometric contraction with the joint at mid-range of movement. Toes splayed, single leg heel lift with heel just 1 mm off the ground.

Mobilize:
* Rocking back on all fours, heels wide
* While standing, splay the toes and lift and lower the heel (modest load and range of motion, so that there is minimal pain or discomfort)

Alignment/strength/control:-
* While seated in a chair, splay the toes and “push the chair legs wide”.
* With the foot resting on the ground or free of the ground, do 4 plus 1’s with the toes splayed

Massage:-
* Massage the muscles of the shin, calf, and sole foot. This normalises function and brings about a state of comfortable awareness and control of the foot and toes.