Sesamoid Disorders

Home / Sesamoid Disorders

Expert Patient Guide · London

Sesamoid Disorders: Sesamoiditis & Sesamoid Fractures

A comprehensive patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH) Stanmore and UCL — London, UK.

At a Glance: Sesamoiditis vs Sesamoid Fractures

Key factSesamoiditisSesamoid Fractures
What It IsThe sesamoid bones and the tissue around them become sore and irritated from too much pressure. The bone is not broken.A crack in a sesamoid bone. It can happen from a single injury or, more often, build up slowly from repeated strain (a stress fracture).
Share of Sesamoid ProblemsAbout 3 in 10 sesamoid problems.Stress fractures about 4 in 10, and fractures from a single injury about 1 in 10.
Typical CauseRepeated pressure on the ball of the foot — running, sprinting, dancing, high heels or a high-arched foot.Single injury: a fall, or the big toe being forced backwards. Stress fracture: suddenly doing a lot more training or impact.
How the Pain StartsSlowly. Worse with activity, better with rest.Suddenly after an injury, or slowly getting worse with a stress fracture.
Main TestsX-rays are usually normal. An MRI scan can show swelling in the bone and nearby tissue.X-rays, including a special view of the sesamoids. An MRI scan can pick up early stress fractures. A standing CT scan (WBCT) shows whether the bone is healing.
First TreatmentPads and insoles to take pressure off, changes to footwear, physiotherapy and shockwave therapy.A walking boot or stiff-soled shoe for several weeks, while you limit the weight you put on the foot.
If It Does Not SettleAn operation to shave down the bone, or to remove one sesamoid (sesamoidectomy).If the bone has not healed: a bone graft or a small screw to help it heal, or removal of the bone (sesamoidectomy).
BothAbout 9 in 100 foot and ankle injuries involve the sesamoids. More than 9 in 10 people return to sport after having a sesamoid removed, usually after about 3 months.
SpecialistMr Matthew Welck — Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore & UCL, London. matthewwelck.com

01

What Are Sesamoid Disorders?

The sesamoids are two small bones, each about the size of a pea. They sit under the ball of the foot, just below the big toe joint. They sit inside a tendon that helps bend the big toe down. The one on the inner side of the foot is called the medial sesamoid, and the one on the outer side is the lateral sesamoid. They work like a pulley to help you push off, protect a tendon that runs between them, and take pressure — about half your body weight when you walk, and up to three times your body weight when you run or jump.

Sesamoid disorders is the general name for painful problems with these bones. The two most common — and the focus of this guide — are sesamoiditis and sesamoid fractures. A Consultant Foot & Ankle Surgeon — such as Mr Matthew Welck in London — can find out which one you have. This matters because the treatment is different.

What Is Sesamoiditis?

Sesamoiditis is when the sesamoids and the tissues around them become sore and irritated from too much pressure. This includes the tendon, a small fluid-filled cushion (bursa) beneath them, and the smooth joint surface (cartilage) above them. There is no break in the bone. Doctors often diagnose it after checking that there is no fracture or other cause.

What Is a Sesamoid Fracture?

A sesamoid fracture is a crack in one of the sesamoids. It can happen suddenly from a single injury (an acute fracture), or build up slowly from repeated strain (a stress fracture). The sesamoids have a poor blood supply, so fractures can be slow to heal. Some do not heal at all (this is called non-union). Some people naturally have a sesamoid in two parts (a bipartite sesamoid). This can look like a fracture on an X-ray, but it is normal.

02

How Common Are They?

About 9 in every 100 foot and ankle injuries involve the sesamoids, as do just over 1 in every 100 running injuries. The inner (medial) sesamoid is bigger and takes more pressure, so it is affected more often than the outer (lateral) one.

How Common Is Sesamoiditis?

Sesamoiditis causes about 3 in 10 sesamoid problems in published studies — and up to half, depending on how it is defined. It most often affects young, active adults, especially runners, sprinters and dancers. It has become more common as more people take up long-distance running.

How Common Are Sesamoid Fractures?

Fractures are the biggest group. Stress fractures cause about 4 in 10 sesamoid problems, and fractures from a single injury about 1 in 10. Stress fractures are common in people who run, jump or play sports such as football and rugby. Fractures from a single injury usually happen after a fall, or when the big toe is forced backwards.

03

What Causes Sesamoid Problems?

Causes of Sesamoiditis

  • Too much repeated pressure: running, sprinting, jumping and dancing on the ball of the foot
  • Foot shape: a high arch, or a big toe bone that points further down than usual, putting extra pressure on the sesamoids
  • Footwear: thin-soled shoes, high heels, or a football boot stud sitting directly under the sesamoid
  • Sesamoid shape: the two sesamoids being different sizes or sitting slightly out of line
  • Other conditions: arthritis in the big toe joint, gout, or inflammatory arthritis (such as rheumatoid arthritis)

Causes of Sesamoid Fractures

  • A single injury: a fall from height, a direct blow, or the big toe being forced backwards (as in turf toe)
  • Stress fracture: suddenly training a lot more, running on hard surfaces, or repeated impact without enough rest
  • Poor blood supply: the sesamoids only get a small blood supply. This slows healing and raises the risk of the bone not healing, or of the bone dying from lack of blood (avascular necrosis)

04

What Are the Symptoms?

Symptoms of Sesamoiditis

  • Aching pain that comes on slowly under the ball of the foot, beneath the big toe joint
  • Pain that gets worse with activity and pushing off, and better with rest
  • Pain when bending the big toe upwards
  • Soreness when pressing on the bone, sometimes with mild swelling

Symptoms of a Sesamoid Fracture

  • Fracture from an injury: sudden, sharp pain after a specific injury, with swelling and sometimes bruising
  • Stress fracture: pain that builds up over weeks and makes running or walking harder
  • Soreness in one small spot, right over the broken bone
  • Difficulty pushing off, and walking on the outside of the foot to avoid the big toe

05

What Investigations Might You Need?

Everyone has X-rays taken while standing, including a special view that looks along the underside of the big toe joint. Whether you need other scans depends on what is suspected.

Investigating Sesamoiditis

  • X-rays are usually normal — this helps rule out a fracture or arthritis
  • An MRI scan shows swelling in the bone and nearby tissues, and helps tell sesamoiditis apart from bone that has lost its blood supply (avascular necrosis)
  • A weight-bearing CT (WBCT) scan, taken while you stand, can show arthritis under the sesamoids and how they sit when you put weight on your foot

Investigating a Sesamoid Fracture

  • X-rays of both feet — a fracture has sharp, uneven edges. A sesamoid that is naturally in two parts (bipartite) has smooth, rounded edges and is often found in both feet
  • MRI scan — the best test for picking up an early stress fracture, which may not show on X-ray for the first few weeks
  • Weight-bearing CT (WBCT) — a low-dose 3D scan taken while you stand. It shows the fracture clearly and whether it is healing. WBCT is a routine part of Mr Welck’s practice
  • Bone scan — sometimes used, but it can be misleading: about 1 in 4 people with no symptoms show changes in this area

06

Non-Surgical Treatment Options

Non-surgical treatment is the first step for almost all sesamoid problems, and most patients improve without an operation.

Non-Surgical Treatment for Sesamoiditis

  • Resting from high-impact activity, and keeping fit with cycling or swimming instead
  • Taking pressure off: a dancer’s pad or custom insole with a cut-out under the sesamoid
  • Stiff-soled or rocker-bottom shoes, lower heels, and removing a boot stud under the sesamoid
  • Taping to limit upward movement of the big toe
  • Physiotherapy to strengthen the small muscles of the foot and improve the way you run
  • Anti-inflammatory painkillers for a short time; occasionally, a steroid injection guided by a scan
  • Shockwave therapy (ESWT) for pain that does not settle — a 2024 study in athletes showed good early results when combined with physiotherapy. Platelet-rich plasma (PRP) injections may help some people

Non-Surgical Treatment for Sesamoid Fractures

  • A walking boot or stiff-soled shoe, usually for several weeks, while you limit the weight you put on the foot
  • Insoles to take pressure off once you are out of the boot, then a slow, step-by-step return to running and sport
  • Repeat scans if the pain does not settle, to check the bone is healing
  • Shockwave therapy may be considered for slow-healing stress fractures

Healing can be slow: in one review, only around two-thirds of athletes with sesamoid stress fractures returned to sport without surgery.

For both conditions, surgery is usually only considered if symptoms continue after at least 3 to 6 months of proper non-surgical treatment.

07

Surgical Options for Sesamoid Disorders

The right operation depends on your diagnosis, which sesamoid is affected, how active you are and the shape of your foot, so it is tailored to you. Where possible, the aim is to keep the sesamoid.

Surgery for Sesamoiditis

Sesamoid Shaving

If a sesamoid sticks out and causes pressure pain, the underside can be shaved down. The tendon and ligaments attached to it are left in place.

Sesamoidectomy (Removal of One Sesamoid)

If pain continues despite other treatments, the painful sesamoid is removed and the tendon around it is carefully repaired.

Surgery for Sesamoid Fractures

Bone Grafting or Screw Fixation

If a fracture has not healed (non-union), a small piece of bone (a graft) can be added, or the break fixed with a small screw, so the sesamoid can be kept. There is not much research yet, but results in suitable patients are good.

Partial Excision or Sesamoidectomy

If a small piece of broken bone is painful, it can be removed on its own. If the fracture will not heal or the bone has lost its blood supply, the whole sesamoid is removed. Newer treatments, such as drilling into bone that has lost its blood supply (core decompression) and custom 3D-printed sesamoid implants, are still experimental.

Recovery After Sesamoidectomy

The cut can be made on the inner side, the underside or the top of the foot. The surgeon chooses the route that best protects the small nerves and avoids a painful scar on the sole. Afterwards you walk in a stiff-soled shoe or boot, usually for around 2 weeks, before gradually returning to normal footwear. Surgeons avoid removing both sesamoids, as this can cause a cock-up deformity (where the big toe is pulled upwards).

What Does the Evidence Show?

  • A review of 10 studies (196 feet), mostly people treated for stress fractures, found pain scores improved from 6.5 to 1.2 out of 10, with 94% returning to sport and 90% getting back to their previous level, after about 12 weeks on average
  • A 2026 review of 193 athletes found 92% returned to sport after about 12 weeks, and 84% got back to the level they played at before their injury
  • After removal of the outer (lateral) sesamoid, a study that followed patients for around 5 years found 88% would have the surgery again, with no change in the position of the big toe or push-off strength
  • A study of 70 operations in athletes at two hospitals found they returned to activity after about 11 weeks, and fewer than 6 in 100 had a complication

Risks to Be Aware Of

The chance of a complication varies between studies, from under 6% in one large study to over 20% when studies are combined. Many are minor, such as temporary numbness. Possible problems include nerve irritation, ongoing pain, stiffness, new pain under another part of the ball of the foot, weaker push-off and, rarely, drifting of the big toe (towards a bunion if the inner sesamoid is removed, or the other way if the outer one is removed). On average, studies have not shown a big change in the position of the big toe, and few people need further surgery.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — one of the UK’s leading specialist orthopaedic hospitals — and Honorary Associate Clinical Professor at UCL.

He has an exclusive specialist practice dedicated to disorders of the foot and ankle, including sports injuries, forefoot surgery, complex reconstruction, repeat (revision) surgery and total ankle replacement. He has written over 50 published research papers, including research on the big toe joint, has completed two specialist training fellowships, including international experience, and is an expert in weight-bearing CT and 3D-printed surgical guides made for each patient.

Patients are seen across North and Central London with rapid access to MRI, WBCT and specialist physiotherapy. Every option — from insoles and shockwave therapy to surgery — is discussed openly, and together you agree a plan that suits you. Visit matthewwelck.com to learn more.

09

Frequently Asked Questions

Sesamoiditis FAQs

What is the difference between sesamoiditis and a sesamoid fracture?

Sesamoiditis is when the sesamoid bones and the tissues around them become sore and irritated, usually from too much repeated pressure. The bone is not broken. A sesamoid fracture is a crack in the bone, either from a sudden injury or, more often, a stress fracture that builds up from repeated strain. They can feel similar, so scans such as MRI or weight-bearing CT are often needed to tell them apart.

How long does sesamoiditis take to settle?

Most cases get better over several weeks to a few months with pads or insoles to take pressure off, supportive shoes and a break from high-impact activity. Recovery can be slower in athletes who keep putting pressure on the ball of the foot, so it helps to see a specialist early and have a clear plan.

Do injections or shockwave therapy help sesamoiditis?

A steroid injection, carefully guided by a scan, can settle sesamoiditis in some people, but it is only used occasionally. Focused shockwave therapy and platelet-rich plasma (PRP) are being used more often for long-lasting sesamoid problems in athletes. Early results are encouraging, but good-quality research is still limited.

Sesamoid Fracture FAQs

Can a sesamoid fracture heal without surgery?

Many do. You wear a stiff-soled shoe or walking boot for a while to protect the foot, then slowly return to activity. However, the sesamoids have a limited blood supply and some fractures heal slowly or not at all (non-union). In one review, only around two-thirds of athletes with sesamoid stress fractures returned to sport without surgery.

Is a bipartite sesamoid the same as a fracture?

No. A bipartite sesamoid is a normal bone that formed in two parts. It is often found in both feet and has smooth, rounded edges. A fracture has sharp edges that fit together. A bipartite sesamoid can still become painful if the tough tissue joining the two parts is injured.

Surgery & Appointment FAQs

Will removing a sesamoid bone affect how I walk or run?

Most people manage well after having one sesamoid removed, and on average studies have not shown a big change in the position of the big toe. There is a small risk of the big toe drifting, weaker push-off or new pain under another part of the ball of the foot. Surgeons avoid removing both sesamoids, as this can cause a “cock-up” deformity of the big toe.

How soon can I return to sport after sesamoidectomy?

In published studies, more than 9 in 10 athletes returned to sport, on average at around 11 to 12 weeks after surgery. Most got back to their previous level, although about 1 in 6 did not get back to the level they played at before their injury.

Where can I see Mr Matthew Welck for sesamoid problems in London?

Mr Welck consults across North and Central London. NHS patients are seen at the Royal National Orthopaedic Hospital (RNOH) Stanmore. Private appointments can be booked on 07547 395 270 or by emailing secretary@matthewwelck.com.

10

Book a Consultation

If you have pain under the ball of your foot or big toe that is not settling, seeing a specialist can make a real difference to your recovery and return to sport.

Book a private or NHS consultation with Mr Matthew Welck, Consultant Foot & Ankle Surgeon. Getting expert advice early gives you more treatment options and the best chance of avoiding surgery.

References

  1. Shimozono Y, Hurley ET, Brown AJ, Kennedy JG. Sesamoidectomy for hallux sesamoid disorders: a systematic review. J Foot Ankle Surg. 2018;57(6):1186–1190. doi:10.1053/j.jfas.2018.03.044
  2. Atiya S, Quah C, Pillai A. Sesamoiditis of the metatarsophalangeal joint. OA Orthopaedics. 2013;1(2):19.
  3. Ford SE, Adair CR, Cohen BE, et al. Efficacy, outcomes, and alignment following isolated fibular sesamoidectomy via a plantar approach. Foot Ankle Int. 2019;40(12):1375–1381. doi:10.1177/1071100719868734
  4. Saxena A, Fournier M, Patel P, Maffulli N. Sesamoidectomy in athletes: outcomes from 2 centers. J Foot Ankle Surg. 2022;61(1):139–142. doi:10.1053/j.jfas.2021.07.008
  5. Engasser WM, Coetzee JC, Seybold JD, et al. Early functional outcomes and complications of tibial and/or peroneal sesamoidectomy utilizing a burr through a medial approach. Foot Ankle Int. 2024;45(10):1070–1075. doi:10.1177/10711007241264239
  6. Bouzid NM, Johri M, Simpson C, et al. Return to athletic activity following sesamoidectomy: a systematic review of time frames and clinical outcomes. Orthop J Sports Med. 2026;14(8). doi:10.1177/23259671261477555
  7. Schon JM, Gureck AE, Rhim HC, Malik GR, Tenforde AS. Treatment of chronic hallux sesamoid injuries with focused extracorporeal shockwave and physical therapy in an athletic population: a retrospective case series. Dtsch Z Sportmed. 2024;75(4):142–148.
  8. Nakajima K. Avoiding hallux sesamoidectomy: a narrative review. J Clin Med. 2025;14(21):7687. doi:10.3390/jcm14217687
  9. Scala VA, Kikuchi CK. Sesamoid avascular necrosis and stress fracture treated with core decompression and biologic augmentation. Hawaii J Health Soc Welf. 2022;81(3 Suppl 1):16–18.

This guide is for general information and does not replace a personal consultation.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 2 October 2026

CALL ME
+
Call me!
/ GMC No. 6074385