Shoes for Sesamoiditis: Pain Under the Big Toe

Sesamoiditis is inflammation or overload of the two small sesamoid bones under the head of the first metatarsal, in the ball of the foot at the base of the big toe. It hurts at push-off, in heels and in thin soles. The diagnosis is made by a doctor, who also decides whether a brace, an insole or other treatment is needed. Shoes for sesamoiditis take pressure off this spot, and how they are made decides how far you can walk without pain.

This article is for general information. The workshop does not diagnose or replace a doctor: diagnosis, treatment and any correction are decided by a medical specialist. Bespoke shoes are made to follow a doctor’s recommendations.

Where the sesamoid bones are

Under the head of the first metatarsal lie two pea-sized bones, one medial and one lateral. They sit inside the tendon of the short flexor of the big toe and work like a pulley: they help the toe push off and take the body’s weight at the end of each step.

The stance phase of every step ends on these bones, and the load on them at that moment is high. If the load grows, the sesamoids and the tissues around them become inflamed, and sesamoiditis develops.

The pain is felt precisely under the base of the big toe, on the ball of the foot. It gets worse when the toe bends upwards, when rising onto the toes, when walking in heels and on hard surfaces.

Who is at risk

Sesamoiditis is more common in runners, tennis players and people who walk a lot in thin-soled shoes or heels. A cavus foot with a plantarflexed first metatarsal and prominent metatarsal heads predispose to it.

It also appears in people who suddenly increase walking: a new job, long walks or hikes. The bone and tissues do not have time to adapt.

Sometimes pain in this area comes from a stress fracture of a sesamoid bone or from a bipartite sesamoid, a congenital variant. Imaging helps tell them apart, and that is the doctor’s task.

How sesamoiditis differs from a bunion and a neuroma

A bunion in hallux valgus is a bump at the side of the big toe joint. It hurts from the upper pressing from the side, while sesamoiditis hurts on the sole, underneath.

Morton’s neuroma is a thickened nerve between the third and fourth toes. It causes burning and numbness between the toes, closer to the middle of the forefoot.

Metatarsalgia, pain under the heads of the second to fourth metatarsals, feels similar but sits closer to the middle of the forefoot, under the middle toes. Sesamoiditis and metatarsalgia sometimes occur together.

The exact location of the pain matters for the shoe: the offloading is built under a specific spot, and a half-centimetre error in its position is already felt.

What is known about conservative treatment

A 2025 systematic review pooled data on 59 patients from 11 publications treated without surgery. Braces and insoles, injections, physiotherapy and biological methods were used.

Pain on a visual analogue scale decreased in 66% of cases. In some patients the pain returned after improvement, and in one case series 45.4% of participants returned to sport without pain.

The authors write that insoles and injections appear useful, but recurrences and incomplete recovery are common and there are no standard protocols yet. The treatment plan is drawn up by the doctor; shoes complement it.

Offloading in the insole

The main technique is to take pressure off the first metatarsal head and move it to neighbouring areas. For this the insole gets a recess or cut-out under the sesamoids, and the area around is raised so weight moves onto the arch and the neighbouring metatarsal heads.

Such an insole is usually prescribed by an orthopaedist or podiatrist. A consensus of podiatrists in New Zealand and Australia includes footwear and insole assessment in the recommended examination for sesamoiditis: the podiatrist looks at what the person walks in first and only then chooses the insole.

Bring the insole to the measuring appointment. The last is built with its volume from the start, so the recess under the bones lands exactly in place and the pair does not shift it while walking.

Offloading in the last

If no insole has been prescribed, or it is hard to fit into the style, part of the offloading goes directly into the last. A small recess is made in the bottom of the last under the first metatarsal head, and the arch is supported along its whole length.

The last is built from measurements and a footprint taken under load. The footprint shows clearly where pressure is highest, and that is where the offloading goes.

Sergey Grechushkin makes the lasts himself from measurements of each foot. The fit and the position of the offloading are checked on a demo pair, a trial shoe, before the main pair is made.

Sole and rocker

A thin flexible sole is painful with sesamoiditis: the toe bends upwards at every step and the bones under it are compressed. So the sole is made firmer, with a shank under the arch.

A rocker, a raised toe, reduces bending of the big toe. But in a study of 29 healthy women a rigid rocker reduced pressure in the central and lateral forefoot, while in the medial forefoot, where the sesamoids lie, no difference was found. Pressure under the big toe with a rigid rocker even increased.

The practical conclusion is that a rocker alone is not enough. It is combined with local offloading in the insole or the last, and the stiffness is chosen so as not to overload the toe itself.

Heels and sesamoiditis

A heel shifts weight onto the forefoot, and the first metatarsal head takes it first. Even five or six centimetres during a flare-up feel like walking on a stone.

During a flare-up heels are put aside. Once the pain settles and the doctor agrees, you return to a low stable heel, up to three centimetres, on a last with offloading under the sesamoids.

High heels and stilettos stay for short outings. If an event needs such a pair, its last is built separately, with offloading, and it is worn for a short time.

Lining and cushioning

A soft layer under the forefoot softens impact but does not redistribute pressure on its own: a thick soft insole under the sesamoids simply compresses.

A firm base, a recess under the bones and a thin resilient top layer work better together. Weight moves to the neighbouring areas, while contact with the sole stays soft.

The soft leather lining in the front part has no seams under the ball of the foot. With sesamoiditis a seam in this spot is felt within an hour of walking.

Which styles work

Derbies and lace-up boots: the laces hold the foot so it does not slide forward onto the painful spot.

Chelsea boots and ankle boots on a low heel with a firm counter.

Loafers are possible if the last holds the heel precisely. Without a fastening the foot slides forward and the offloading moves away from the sesamoids.

For summer, sandals with a heel strap and an offloading insole. Flat flip-flops with a thin sole are painful with sesamoiditis. Indoor shoes should also have a firm sole: barefoot on tiles or laminate the ball of the foot gets the same load as outdoors.

Sesamoiditis and a cavus foot

In a high-arched cavus foot the first metatarsal is often plantarflexed, and its head presses into the floor harder than usual. The sesamoids under it take most of the load.

The last for such a foot is built with a high instep and support along the whole arch. The support takes some weight off the forefoot, and the offloading under the sesamoids works more fully.

If you have a cavus foot and pain under the big toe, show both problems to your doctor: the insole is chosen for them together.

Sesamoiditis with a bunion

In hallux valgus the sesamoids shift outwards together with the tendon. Load under the first metatarsal head is distributed unevenly, and the ball of the foot may hurt.

Such a pair solves two tasks: room at the side for the bump and offloading underneath for the sesamoids. Both are built into the last, and the vamp is cut so no seam runs over the bunion.

Women’s shoes and sesamoiditis

In women, sesamoiditis is often linked with heels and a narrow toe: weight moves forward, and the toe box squeezes the toes and presses the ball of the foot into the insole.

Shoes and ankle boots for such feet are built on a last with offloading under the big toe and a rounded toe. The heel is wide, stable and low so weight is shared between the heel and the arch.

Pumps are possible once the pain settles, on a low heel and with a thin insole with a recess. The style is chosen so the insole is not visible from outside and the pair stays elegant.

One pair or several

With sesamoiditis it helps to rotate shoes: pressure falls slightly differently in different pairs, and the tissues under the big toe get a rest.

On one last you can make an everyday pair, a dressier one and a winter one. The offloading is built the same way in all three, so the foot does not have to adapt again.

If one of the pairs starts pressing under the ball of the foot, show it to the shoemaker before the pain comes back: it is usually wear of the insole or sole.

Sport and walking

For runners and tennis players, the decision to return to training is made by the doctor and coach. Sports shoes are chosen separately, sometimes with a sports insole with offloading.

The workshop makes bespoke trainers for the city and walking. They carry the same offloading as the everyday pair, so the foot gets used to one fit.

Long walks with sesamoiditis are increased gradually, watching the pain the next day. If the ball of the foot aches in the morning, the increase is postponed and you go back to the previous distance for a few days.

When to see a doctor

Pain under the base of the big toe lasting more than two weeks, swelling, bruising, pain at rest or at night, or being unable to step on the ball of the foot are reasons to see an orthopaedic or trauma specialist.

Similar symptoms may hide a sesamoid fracture, arthritis of the big toe joint or gout. They are told apart by examination and imaging. Shoes are made once the diagnosis is clear.

How the work is done

Both feet are measured, a footprint is taken under load, the painful spot is marked and old shoes are examined. The insole of a worn pair usually shows a compressed area under the big toe.

Then the lasts, about six weeks, and the trial shoe, on which the position of the offloading is checked. A pair starts from 100,000 ₽, and a pair on a finished last takes from four weeks.

Repeat pairs are made on the same last without new measuring. If the insole has been replaced, bring it and the last is checked against its new thickness. The workshop is on Shelaputinsky Lane 6/3 near Taganskaya metro in Moscow, 10:00–20:00 by appointment only.

Wear and care

For the first week, wear the new pair on your usual routes and watch how it feels under the big toe. If the pain moves, the offloading is corrected.

Check the insole with the recess every two or three months: the material compacts over time and the recess gets shallower. The sole and heel tip are replaced before wear reaches the base.