The sesamoid may be a small area, but when sore, you feel it in every movement. Running, walking, pushing off, going up onto your tiptoes, or standing for long periods of time

Sesamoiditis is irritation of the small sesamoid bones and surrounding soft tissue underneath the big toe joint. It usually develops when this area is repeatedly loaded beyond what it can comfortably handle.

But not all pain under the big toe joint is the same. Sesamoid stress fractures, acute fractures, bipartite sesamoids, and avascular necrosis can feel similar, so getting the right diagnosis matters.

At Functional Soles Podiatry, we assess what is driving your pain, reduce pressure through the irritated area, and help you return to walking, running, sport, and daily activity with a clearer plan.

What is sesamoiditis?

The sesamoids are two small bones that sit underneath your big toe joint.

They are embedded within the tendons that help your big toe push off the ground. Every time you walk, run, jump, climb stairs, or rise onto your toes, load passes through this area.

When the sesamoids and the soft tissue around them become irritated from repeated load, this is commonly called sesamoiditis.

You can think of it as a load tolerance problem. The area is not coping well with the amount of pressure, push-off, or forefoot loading being placed on it.

The goal of treatment is not simply to rest forever. The goal is to reduce irritation, find what your foot can currently tolerate, and gradually rebuild capacity so the area can handle load again.

What does sesamoiditis feel like?

Sesamoiditis usually causes pain directly under the big toe joint.

You may notice:

• Pain under the big toe joint
• Pain in the ball of the foot beneath the big toe
• Discomfort when pushing off to walk or run
• Difficulty rising onto your toes
• Tenderness when pressing under the big toe joint
• Swelling or irritation around the area
• A feeling that you are avoiding pressure through the front of your foot
• A push-off that just doesn’t feel right

For runners, sesamoid pain may show up during faster running, hills, toe-off, intervals, or after increasing training load. For others, it may become noticeable with long periods of standing, walking barefoot, wearing flexible shoes, or spending more time on hard surfaces.

What causes sesamoiditis?

Sesamoiditis is usually a load-related overuse condition.

That means the sesamoid area has been asked to tolerate more stress than it is currently ready for.

Common contributors include:

• A sudden increase in walking, running, gym work, or sport
• More time spent loading the forefoot
• Hill running, sprinting, jumping, or plyometrics
• Hard or unforgiving surfaces
• Flexible shoes that allow more pressure to go through the big toe joint
• Barefoot training or more barefoot walking than usual
• Reduced strength in the calf, foot, or big toe
• Limited big toe mobility or calf tightness
• A foot shape or movement pattern that places more pressure under the big toe joint

If the load going through the area is greater than the tissue’s current ability to handle it, then an injury may occur. 

What else can cause pain under the big toe joint?

Pain under the big toe joint is often sesamoiditis, but not always.

Because the sesamoids sit in a small, concentrated area, several different conditions can create very similar symptoms. This is why persistent sesamoid pain is worth assessing properly.

Sesamoid stress fracture

A sesamoid stress fracture can develop when repeated load through the sesamoid bone exceeds what the bone can recover from. This pain is often more persistent than simple irritation. It may not settle as quickly with short rest, and it may flare again as soon as load increases.

Bipartite sesamoid

Some people naturally have a sesamoid bone that formed in two parts rather than one. This is called a bipartite sesamoid. It is a normal anatomical variation and often causes no pain at all.
However, it may become painful under load. It can also look similar to a fracture on imaging, which is why clinical assessment and the right interpretation matter.

Acute sesamoid fracture

An acute sesamoid fracture is less common, but it can happen after a direct impact or sudden forceful movement through the big toe joint. Pain is usually immediate and significant. There may be bruising, swelling, or difficulty putting weight through the front of the foot.

Avascular necrosis

Avascular necrosis occurs when the blood supply to the sesamoid is disrupted, affecting the bone’s ability to recover. This is less common, but it is worth considering when symptoms are slow to improve, do not behave like typical sesamoiditis, or continue despite appropriate management.

getting the right diagnosis matters

Pain under the big toe joint can feel very similar, but they are not managed in exactly the same way.

Sesamoiditis usually responds well to load management, footwear changes, targeted offloading, and a structured rehab plan.
A sesamoid stress fracture may need more careful protection and imaging to guide load decisions.
Avascular necrosis may require specialist input.

Getting clarity means you are not just guessing. You are managing the right problem with the right plan.

When should I get sesamoid pain assessed?

Pain under the big toe joint is worth getting assessed if it is not improving or if it keeps returning when you increase activity.

You should consider an assessment if:

• Pain is sharp, focal, or very specific under the big toe joint
• Symptoms started after a direct impact or sudden movement
• There is bruising or noticeable swelling
• You are limping or changing how you walk
• You cannot push off normally
• Walking barefoot is painful
• Running, jumping, or sport keeps flaring it up
• Rest helps briefly, but pain returns as soon as you reload the area
• Symptoms have been hanging around for more than a couple of weeks

The earlier you understand what is going on, the easier it is to make smart decisions around load, footwear, training, and recovery.

How is sesamoiditis treated?

The goal is not to stop you moving.

The goal is to find the amount of load your foot can currently tolerate, while reducing direct pressure under the irritated sesamoid area.

Treatment may include:

• Modifying walking, running, gym, or sport load
• Changing footwear to reduce pressure under the big toe joint
• Using padding or deflection to offload the painful area
• Taping to reduce irritation during walking or activity
• Orthotics where extra load modification is needed
• Gradual strengthening of the calf, foot, and big toe
• A clear return-to-running or return-to-sport plan when appropriate

For some people, a small footwear or padding change makes a big difference.

For others, especially runners or active people, sesamoiditis needs a more structured plan that manages load while rebuilding capacity.

Do orthotics help sesamoiditis?

Orthotics can help sesamoiditis when they reduce pressure under the painful sesamoid area.

They are not a cure by themselves, and they do not replace rehab. Their job is to modify load so the irritated area has a better chance to settle.

At Functional Soles, we use orthotics when they are useful, not for every single injury or pain in the foot.

Sometimes padding, taping, footwear changes, or a shoe modification is enough. Other times, an orthotic can help reduce pressure more consistently, especially if you are on your feet all day, trying to keep running, or repeatedly flaring symptoms.

Can I keep walking or running with sesamoiditis?

It depends on how irritable the area is. In many cases, you do not need complete rest. We just need to adjust the load accordingly.

That might mean reducing distance, speed, hills, barefoot time, jumping, or anything that increases painful push-off through the big toe joint.

For runners, we may need to temporarily adjust:

• Weekly volume
• Speed sessions
• Hill running
• Long runs
• Shoe choice
• Running surface
• Strength training exercises that load the forefoot

The aim is to keep you as active as possible without repeatedly irritating the painful area.

If symptoms suggest a stress fracture or another bone-related issue, we may need a more aggressive offloading approach.

What shoes are best for sesamoiditis?

There is no single perfect shoe for sesamoiditis, but certain features can help reduce pressure under the big toe joint.

Helpful shoe features may include:

• More cushioning under the forefoot
• A slightly stiffer forefoot
• A rocker-style sole
• Adequate width around the forefoot
• A stable base that does not force extra pressure through the big toe
• Less flexibility through the front of the shoe during painful stages

Very flexible, thin, or minimalist shoes may aggravate symptoms for some people, especially early on.
That does not mean you can never wear them again. It just means we may need to reduce irritation first, then gradually work back towards the footwear or activity goals that matter to you.

How Functional Soles Podiatry can help

At Functional Soles Podiatry, we help people with pain under the big toe joint understand what is going on and what to do next.

That means looking at the painful area, how your big toe joint is moving, how pressure is loading through your forefoot, your footwear, your activity levels, and what happens when you walk, run, or push off.

From there, we build a plan around three goals.

1. Settle the irritation

First, we reduce pressure through the painful area. This may involve footwear changes, padding, taping, training modifications, or orthotics if needed.

The aim is to calm symptoms without unnecessarily stopping all movement.

2. Restore capacity

Once the area is less reactive, we gradually rebuild the strength and tolerance of the calf, foot, and big toe.

The goal during this stage is to improve your ability to handle walking, standing and training load again.

3. Reclaim activity

The final stage is getting you back to the activities that matter. For some people, that means walking comfortably at work.

For others, it means running, gym training, field sport, dancing, or returning to barefoot activity.