Back Pain Doctor
Sesamoiditis & Sesamoid Fracture
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Sesamoiditis is pain in the ball of the foot at the base of the big toe, caused by irritation of the tendons around the two small sesamoid bones that sit under the big toe joint. It is a form of tendinitis and is common in dancers, runners and other activities that repeatedly load the forefoot. The same bones can also fracture, either suddenly, when the big toe is forced sharply backward, or gradually as a stress fracture.
Assessment focuses on localising the tenderness to the sesamoids, checking big-toe movement, and using a weight-bearing forefoot X-ray when a fracture is suspected. A naturally two-part sesamoid can mimic a fracture, so imaging is interpreted with care; a bone scan or MRI is reserved for cases that remain unclear or do not settle with first-line care.
First-line care is usually conservative: resting from the aggravating activity, ice and simple analgesia, supportive footwear, and cushioning pads or orthotics to offload the sesamoids, often coordinated with a podiatrist or physiotherapist. A fracture may need a stiff-soled shoe or short walking brace and can take several months to settle. Most sesamoid problems resolve without surgery, which is reserved for persistent symptoms or a displaced or non-healing fracture.
If the pain started with the big toe being forced upwards in sport, the injury may be a sprain of the whole joint complex: see turf toe.
Common symptoms
- Pain under the big toe, on the ball of the foot
- Gradual onset with overuse, or sudden pain after the toe is bent backward
- Difficulty and pain bending or straightening the big toe
- Swelling or bruising over the ball of the foot (not always present)
Commonly seen in
Evidence for twelve treatment options in sesamoiditis & sesamoid fracture
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).
Pairing reviewed 2026-09-02.
Where it fits
This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. No study in this condition
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with sesamoid, sesamoiditis or hallux, 4 records, none about the sesamoids; and a randomised-trial and systematic-review pass). No study has injected or needled a muscle trigger point for sesamoid pain. The nearest trials are in bunions, a different condition: dry needling of the abductor hallucis added to toe exercises reduced resting pain over four weeks in 31 people (Dede, J Am Podiatr Med Assoc 2026), while in 30 women dry needling against sham changed the toe angle but not pain or foot function (Kharazmi, J Bodyw Mov Ther 2020). Nothing was injected in either.
Pairing reviewed 2026-11-07.
Where it fits
Offloading with padding or an orthosis and modified activity are the treatment. A trigger point injection is rarely relevant, because the pain comes from the small bones under the big toe joint rather than from a muscle.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Case series, injection not isolated
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Searched 3 November 2026 (PubMed: sesamoiditis or sesamoid pain with injection, corticosteroid, steroid or anaesthetic, 23 records, most of them horse studies; and a randomised-trial and systematic-review pass, which found no trial). No controlled study exists. A 2025 systematic review pooled 11 case reports and series (59 patients) of non-surgical treatment, including corticosteroid injection, orthotics and physiotherapy: pain scores improved in 66% of cases, the authors judged steroid injection and orthotics to appear beneficial, and pain returning after initial improvement was common (Biz, Medicina (Kaunas) 2025). In 27 athletes with medial sesamoid pain followed prospectively, a combined program of pain relief, activity restriction, insoles, local steroid injection and a walking boot helped 48%; the injection's share of that result cannot be separated (Choi, Clin Orthop Surg 2024). An ultrasound-guided injection of local anaesthetic and steroid relieved pain from an extra sesamoid at the end joint of the big toe in one case report (Shin, Korean J Pain 2013). A narrative review suggests a fluoroscopically guided injection may avoid surgery once fracture and bone death have been excluded (Sims, World J Orthop 2014).
Pairing reviewed 2026-11-03.
Where it fits
Offloading with padding or an orthosis, and modified activity, come first. Where pain persists and imaging has excluded a fracture or bone death, a guided injection may be discussed alongside offloading, with the chance of the pain returning explained. See the note on cortisone.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible: no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Case reports only
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Searched 20 October 2026: shockwave, shock wave, ESWT, rESWT or radial shock with sesamoid, sesamoiditis or sesamoids (10 records), and with hallux or first metatarsophalangeal and sesamoid, plantar plate or turf toe (3), with randomised-trial and systematic-review passes that found nothing in people (the only review was veterinary); horse and sheep studies were set aside. No trial exists. One case report used radial shockwave, eight sessions, in a 52-year-old man with loss of blood supply to a sesamoid that had not settled with conservative care; he returned to tennis with little or no pain (Thompson, BMJ Case Rep 2017). A second report describes shockwave in the recovery of a volleyball player with stress injuries of both sesamoids, device not stated in its record (Doyle, PM R 2026). A narrative review discusses shockwave for sesamoid problems without new data (Nakajima, J Clin Med 2025).
Pairing reviewed 2026-10-20.
Where it fits
Plausible for a sesamoid problem that has not settled with offloading, padding and footwear changes, and can be discussed on that basis, but patients are told the evidence is two single case reports.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. One case report; device not stated
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Searched 20 October 2026 (the searches named in the radial row: 10 and 3 records, no trial and no review in people). No study names a focused device at the sesamoids. The case of sesamoid osteonecrosis used radial shockwave (Thompson, BMJ Case Rep 2017), and the case of a volleyball player with sesamoid stress injuries does not name the device in its record (Doyle, PM R 2026).
Pairing reviewed 2026-10-20.
Where it fits
Plausible where a sesamoid problem is slow to settle, and can be discussed on that basis alongside offloading, but patients are told there is no study of a focused device at the sesamoids.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. A few case reports only
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Searched for PRP at the sesamoid bones of the big toe. Five records, one of them a trial in racehorses, and no trial in people. The human reports are three teenage athletes with long-standing sesamoid injuries who were cleared for running and jumping six to nine weeks after a single injection, their own doctors noting that other parts of their care probably contributed (Le, Phys Sportsmed 2022), and one dancer with loss of blood supply to a sesamoid whose pain improved for some months and was back where it started at two years (Callahan, J Dance Med Sci 2025). None of the reports is of sesamoiditis as such.
Pairing reviewed 2026-10-10.
Where it fits
Not something to choose ahead of offloading the sesamoids with padding, footwear or an orthotic and a graded return to impact. PRP can be discussed only on the understanding that it rests on a handful of individual cases.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. No study in this condition
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
No study of prolotherapy for sesamoiditis. PubMed searches on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with sesamoid, sesamoiditis, plantar plate, first metatarsophalangeal, hallux or metatarsalgia) returned three records: one used dextrose only to dilute a local anaesthetic for bunion surgery, one was a fungal nail study in which dextrose was the culture medium, and the third is a single case of a professional dancer whose second-toe plantar plate tear settled over a 16-week program of taping, padding, physiotherapy and a series of prolotherapy injections, so the injection's part cannot be separated (Ojofeitimi, J Orthop Sports Phys Ther 2016). Passes restricted to randomised trials and to systematic reviews found nothing in this condition.
Pairing reviewed 2026-10-16.
Where it fits
Can be discussed where sesamoid pain persists despite offloading, footwear changes and a graded return to load, with the absence of studies stated. It sits alongside that program, not in place of it.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not offered for this
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
A tested absence. Searched 12 November 2026 (PubMed: hyaluronic acid, hyaluronate, hyaluronan or viscosupplementation with sesamoiditis or sesamoid, 11 records; trial and review pass, 1; second wording, 2). None studied hyaluronic acid for sesamoid pain in people. The records are laboratory and veterinary work on the horse's navicular bone, and the one review is a Cochrane review of arthritis of the big toe joint, a different diagnosis (Munteanu, Cochrane Database Syst Rev 2024).
Pairing reviewed 2026-11-12.
Where it fits
Not offered for this. The sesamoids sit in a tendon under the big toe joint, and the treatment is offloading and footwear. If arthritis of the big toe joint is also present, that is assessed on its own terms.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Nerve targets only
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No study injects dilute dextrose under the skin for a painful sesamoid. The perineural work at the forefoot targets nerves: across 59 ultrasound-guided perineural injections in 46 people, the hallux branch of the medial plantar nerve was the commonest target and lasting relief was reached in 23 of 38 followed up, with the injectate a local anaesthetic given for nerve pathology rather than bone pain (Walter, Skeletal Radiol 2017). The only dextrose report anywhere near this joint is a professional dancer with second metatarsophalangeal instability and a plantar plate tear, treated with taping, padding, physiotherapy and a series of intra-articular prolotherapy injections over 16 weeks (Ojofeitimi, J Orthop Sports Phys Ther 2016) - a different structure and a different procedure. Two of the five records the sesamoid search returned were equine nerve-block studies.
Pairing reviewed 2026-09-28.
Where it fits
Considered only where pain under the ball of the foot comes with tender, hypersensitive skin rather than focal bone tenderness over the sesamoid. Offloading and load management are what settle a sesamoid.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Nerve beside the joint only
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Searched 6 November 2026 (PubMed: sesamoid, sesamoiditis, hallux, first metatarsophalangeal, plantar digital nerve or Joplin with hydrodissection, hydrorelease, perineural, 5% dextrose or nerve entrapment, animal studies excluded, 27 records; every abstract read). No study has tested hydrodissection for a painful sesamoid; the only sesamoiditis record was a review in horses. The nearest human work is at the small nerve running along the inner side of the big-toe joint (Joplin's nerve), which can be irritated after bunion surgery or by repeated pressure. In a retrospective review, 15 ultrasound-guided injections around that nerve were followed by average pain falling from 6.4 to 0.25 out of 10 over a mean of 26 months, with no comparison group and the injectate not stated (Burke, Acad Radiol 2019). A second review of 59 foot and ankle nerve injections, 17 of them at the same nerve, reported lasting relief in 23 of the 38 followed up, without separate results for that nerve (Walter, Skeletal Radiol 2017). Neither describes hydrodissection, and neither treated the sesamoid.
Pairing reviewed 2026-11-06.
Where it fits
Not a treatment for the sesamoid, which settles with offloading and load management. Considered only where the pain is burning or electric along the inner edge of the big toe, pointing to the nerve there rather than the bone.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other foot, ankle & lower leg conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
What is the difference between sesamoiditis and a sesamoid fracture?
How is it treated?
When should I get it checked?
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