If you have pain in the bottom of the big toe joint, it may be due to injury, a bunion, or arthritis - or, it could be due to a condition called sesamoiditis. Sesamoiditis is the inflammation of one or both of the small bones that are located at the base of the big toe.  They are "floating bones," much like your knee caps, that are pea shaped and are located within a tendon that crosses the big toe joint. When these two little bones are inflamed, you may feel aching in the big toe joint, or pain when the big toe flexes.  The two little bones, called the tibial and fibular sesamoids, act as a pulley within the tendon of the flexor hallucis longus at the bottom of the big toe joint.   Certain activities that involve pushing off the ball of the foot aggravate the area, such as ballet dancing, football, or croutching in baseball.  Other risk factors include running and jumping from high heights, wearing high heeled and pointy toed shoes, or biomechanical deformities of the foot including the way the 1st metatarsal (long bone of the foot) is shaped and the way the foot and arch are shaped.  

In order to diagnose sesamoiditis, a thorough exam is needed by your physician.  An X-ray of the affected foot will be taken, and often and Xray of the unaffected foot as well in order to compare the sesamoid bones in each foot.  Often times the sesamoid bone will present in 2  (or more) well defined pieces, known as a "bipartate" sesamoid,  which is a normal finding.  Comparing to the other side will rule out a facture or any other abnormality of the sesamoid bones.  In general, a diagnosis can be made by palpating one of the two sesamoid bones and eliciting pain or discomfort.  You may also feel pain when the big toe is flexed and the tendon it sits in, the flexor hallucis longus, is stretched.  

Treatment for this condition is successful the sooner it is detected.  In mild cases, it is treated with padding to deweight the area, and alterations in shoe gear to decrease the pressure at the ball of the foot and decrease the movement of the big toe joint that aggravated the bones in the first place.  Other treatment modalities include physical therapy, oral anti inflammatories, and even possibly steroid injections to decrease the inflammation in the area.  In more advanced cases, full immobilization in a walking boot may be prescribed.  In these cases, your doctor may order advanced modalities to confirm the diagnosis and to rule out any other conditions. In very rare cases, surgery may be required if the bone has degenerated enough.  

Pain in the area of the sesamoids may in fact not be sesamoiditis, but it may be a different condition.  Often the pain you feel may be similar, but examination by a physician may reveal an actual fracture of one of the sesamoid bones.  If there is a fracture, just like any other fractured bone, it is treated with immobilization, icing, and antiinflammatories.  On the other hand, it may not be a bony injury at all but in fact a soft tissue injury of the ligaments around the big toe joint referred to as "turf toe." If the soft tissue around the joint is injured, it is often accompanied by swelling and pain on range of motion, and many times you may have heard a "pop" when the injury occurred.  In order to diagnose turf toe, an Xray may be negative for a fracture, but the soft tissue may be injured and can be confirmed with an MRI.  However the treatment is the same; your doctor will recommend immobilization and compression, and treating with ice and anti inflammatories.    

As part of your recovery, your doctor will recommend orthotics in order to correct the biomechanical abnormality that caused the conditionin the first place, or to help protect and accomodate the area so that you can go back to your favorite sports and activities without the fear of re-injury. Remember, the sooner you get it checked, the sooner treatment can start and the sooner you can get back to doing the activities you love.  Make an appointment with one of our doctors today.