The symptom of sesamoiditis is pain directly beneath the base of the big toe that gradually starts as a dull ache and intensifies over time until it becomes an intense throbbing.

The sesamoid bones are the two tiny bones located within the hallucis longus tendon, the flexor tendon attached to the big toes. These bones rotate forward and backward about two grooves in the first metatarsal head, acting as levers to increase the tension of the flexor tendon.

Because of their location and function, the sesamoids are subject to intense pressure during walking or running.

All direct pressure upon this site is painful. Normal walking becomes so painful that gait is altered so that the heel and/or the outer margin of the foot bears the body’s weight. Over time, this can lead to a cascade of compensatory maladapted gait behaviors.

What causes sesamoiditis?

Sesamoiditis occurs when the feet exhibit maladaptive neuromuscular function. The sesamoids become situated so that they are subject to greater impact forces or the surrounding tendon is subject to excessive tension.

There are three primary causes that, individually or collectively, contribute to sesamoiditis-related maladaptive neuromuscular function:

  1. Inadequate firing of the flexor hallucis longus muscle
  2. Improper timing for firing of the flexor hallucis longus muscle
  3. Wearing restrictive footwear that inhibits the required raising of the great toe and corresponding raising of the arch system

Each can result in less-than-optimal sesamoid positioning – side to side, front to back, or both — contributing the excessive sesamoiditis related loading and tension forces.

Over time, stresses created by the excessive pressures result in local tissue damage and inflammation around the sesamoid bones.

At rest, the sesamoid bones are usually positioned slightly behind the first metatarsal head. Ideally, during walking or running, the following takes place:

  • The sesamoids move forward, gliding in the groove around the first metatarsal head as the great toe rises
  • The great toe rises higher with increased activity levels, causing the sesamoids to rotate to a position in front of the first metatarsal head
  • The great toe rises before the foot contacts the ground in anticipation of the expected forces

In this forward position, the sesamoids are subjected to significantly lower impact and tension forces.


For proper function, our feet require the Right Stimulus and the Right Movement.

Right Stimulus consists of the subtle varied stimulus that the soles of our feet receive when we walk, particularly when we walk barefoot on natural terrain. With each step, there are subtly different sensations.

These subtle differences in stimulus keep our brain on high alert so that our body’s protective reflexes function properly with optimal muscle function.

When our brain is uncertain about what will happen, it triggers protective reflex muscle activations that support our arches before our feet contact the ground to ensure that our feet and legs can safely manage the forces generated by the activity intensity of our bodies.

As activity-related stimulus intensifies, a progressively higher arch is created. That is why, when they are functioning properly, our arches and toes rise and fall dynamically, in response to the varying activity stimulus intensities. This uninhibited dynamic movement is Right Movement.

Right Stimulus and Right Movement prevent the imbalanced muscle function that contributes to sesamoiditis.

Right Stimulus

Conventional footwear impairs optimal foot function in two ways:

First, most conventional footwear dampens Right Stimulus.

This is particularly true for shoes or insoles that support or cushion our feet. They spread the forces evenly across the soles of our feet, creating sensory input that’s muted and repetitive, step after step. Within a short period of time, the brain tunes out the stimulus and stops responding to it.

As a result, our brain doesn’t sufficiently activate the muscles that stabilize our arches and properly align our feet, legs, hips, and lower back before our feet contact the ground. This “tuned-out” brain response is natural and happens all the time. For example, the same thing happens when we walk into a room and first smell coffee that we no longer notice after only a few minutes.

Second, most conventional footwear, especially footwear that’s tightly laced, has snug toe boxes or stiff midsoles or outsoles, restricts the Right Movement dynamic raising of the arches and toes that is critical in the creation of a strong stable arch system and healthy linear propulsion with the toe off forces spread across the forefoot.

Impaired Right Stimulus and Right Movement increase the strain, impact forces, and damaging stresses on the sesamoid bones and flexor hallucis longus tendon.

Conventional treatment methods for sesamoiditis include:

  • Taping
  • Supportive/protective orthotics
  • Cushioning
  • Local tissue therapy
  • Injections
  • Surgery
Soft Cushy Insole

While these methods may temporarily alleviate symptoms, they do not address the poor neuromuscular function that is the cause of the problem. In fact, the more we artificially support or cushion our feet, the weaker and the more dependent we become on these types of products.

These “old school” support and cushioning treatment methods are not recommended in any other area of musculoskeletal medicine as a viable long-term treatment option. In fact, modern treatment methods for poor neuromuscular function focus on increasing mobility, muscle strength, and proper alignment via Proper Technique exercise, which requires both Right Stimulus and Right Movement. Science has shown that simply challenging the body to “do its job” is the best way to restore and enhance function.

This principle is the foundation for virtually all of today’s sports training/rehabilitation programs.

Recommendations to address the poor neuromuscular function that causes sesamoiditis and prevent it from reoccurring:

  • Walk barefoot on natural terrain as much as possible. This provides the optimal Right Stimulus and allows for the Right Movement required for healthy neuromuscular function.
  • To obtain Right Stimulus in your conventional footwear, use BioPods® Stimsoles® and, for best results, use BioPods Stimsoles in loosely laced, soft, flexible footwear that allows your arches and toes to rise easily.
  • Consult with your healthcare practitioner to ask about employing soft tissue mobilization therapies to address the fibrotic scar tissue that may have formed, prior to using BioPods products.