What is that pain under my big toe? (Sesamoiditis)
WHAT IS THAT PAIN UNDER MY BIG TOE?
Our big toe (or first metatarsal) is very important because it plays a huge role when we are standing still to help with balance and also helps to propel us forward when walking or running. So having pain underneath the big toe can be very frustrating.
A cause of pain under your big toe could be coming from two small bones we call sesamoid bones. The sesamoid bones in your foot lie within the plantar plate of your first metatarsal within the flexor hallicus brevis tendon.
THE ROLE OF SEASMOID BONES
The role of the sesamoid bones is to:
- Absorb and disperse weight underneath your big toe
- Enhance gliding at the first toe joint
- Protect the flexor hallicus longus tendon (1)
- Transmit 50% of body weight when standing
- Transmit 300% body weight during push off (2)
So if you spend a lot of time on your feet or enjoy a lot of walking or running, your sesamoid bones are very important to you! This also means that they are susceptible to overuse injuries such as a sesamoid stress fracture or sesamoiditis. The two conditions present similarly, the difference being that sesamoid stress fracture can be seen on X Ray/Bone scan/CT where as sesmoiditis has the same pain/signs and symptoms without any radiographic changes.
Sesamoid related inuries are responsible for 9% of foot injuries and 1.2% of running injuries (1).
WHO IS SUSCEPTIBLE?
- Dancers (particularly ballet)
- People who walk on hard floors often
- People who spend a lot of time in shoes that place a lot of pressure on the big toe eg high heels
SIGNS & SYMPTOMS
- Pain/tenderness/swelling under the big toe
- Running or jumping limited by pain
- Pain with “toe off” phase in running
Sesamoiditis or sesamoid stress fracture conservative treatment is delivered by a physiotherapist and generally includes:
- A period of rest
- De-loading the area by mobilizing in a boot or using crutches
- Potential taping to de-load the area
- Soft tissue techniques to release tight muscles around the area
- Mobilization of surrounding joints in the foot
- Custom made orthotics or change in shoes
- Stretches for the calf and hamstring advanced stretch physiotherapy
- Strengthening of the foot, calf strengthening (see video 5 of book resources) and potentially hip stabilising exercises POGO Physio
- Gait retraining and possible POGO orthotic intervention
- Running assessment (such as via one of our RUN 101 Workshops)
- Failure of conservative management may require review by a foot/ankle surgeon who may need to remove the sesamoid bones
If you are experiencing pain under your big toe and it is stopping you from participating and enjoying your sports or activities, seeing a trained physiotherapist would be very beneficial for you.
Emily Georgopoulus (APAM)
PAIN-FREE | PERFORM | PROLONG
(1) Oloff L, Schulhofer, D. Sesmoid comples disorders. Clin Podiatr Med Surg 1996; 13(3):497-513
(2) Richardson E. Hallucal sesmoid pain: causes and surgical managements. J Am Acad Orthop Surg 1999;7:270-178
(3) Boike A, Schnirring-Judge M, McMillin S. Sesmoid disorders of the first metatarsophalangeal jointy. Clin Podiatr Med Surg 2011;28(2):269-285