Treating turf toe and sesamoiditis that does not go away without the need for surgery

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Treating turf toe and sesamoiditis that does not go away

In this article, we will focus on turf toe and sesamoiditis. Sesamoiditis is the inflammation you may have been told you have at the base of your big toe. If you have inflammation in your toe and sesamoiditis has not been discussed with you, it may be prudent to discuss this with your doctor. We will also talk about treatments for turf toe and sesamoiditis that circle around the traditional recommendations of rest and anti-inflammatory medications, and some less traditional but more proactive alternative surgical choices such as regenerative medicine injections, to help the athlete to a more rapid recovery.

Sometimes, surgery for turf toe may be necessary as there is a complete rupture/tear of the plantar plate, the very strong ligament at the base of the big toe. However non-surgical treatments, especially those that repair ligament damage can be very effective in partial plantar tears.

My toe pain is nagging

You have pain in the big toe of your foot. You have learned to manage it as best you can with large doses of ibuprofen and routine application of ice, yet your toe continues to be a big problem for you. Now, in your self-managed treatment, you have added long periods of rest, not running, and reduced activities to allow your toe the time it needs “to heal.” But is it really healing? Why is it not healing? Your problem has become increasingly chronic and challenging.

In looking for relief, you find yourself customizing or re-designing your footwear to alleviate pressure on your foot. This, of course, is not healing, this is symptom suppression, the problem still exists. Eventually, the only running you will do is the few steps it takes to see if the toe pain went away.

Cortisone and steroids

As your problem has progressed, you finally go to the doctor and from there you are sent off to a podiatrist. At the podiatrist, you are told that you have “turf toe,” or “sesamoiditis.” Sesamoiditis is is an inflammation of the tendons caused by the tiny sesamoid bones of the foot. The sesamoid bones, free-floating bones in the big toe region, are regulators of the tendon and muscle strength system in the toe. When there is an injury to the foot, these bones can float around the big toe area in an unnatural movement that will rub, irritate and injure the flexor hallucis longus tendon. The flexor hallucis longus tendon transmits force between the flexor hallucis longus muscle and the big toe. It is the force that makes you jump higher, run faster, and dig in to brace for impact with a 200 pound running back.  When the flexor hallucis longus tendon and muscle are not working right, you become inflamed, you have pain, and you lose the toes’ center of force of power.

For many people, an injection of a corticosteroid will do the trick and they will get relief. For others, cortisone may provide temporary relief but the problems of the big toe will return and in most cases be much worse. In our clinics, we see the people who cortisone did not provide a long-term solution and in fact, made the problem worse.

Other conservative care options in acute injury

A paper from the Department of Orthopaedic Surgery, the University of Alabama at Birmingham published in February 2020 (1) outlines the conservative treatment path most patients and their doctors take for acute turf toe injuries.

“The majority of patients will respond to conservative treatment of their turf foe injury. Conservative management typically starts with RICE therapy, oral anti-inflammatory medications, and a walking boot/shoe. A short leg cast with a toe spica (splint) extension can be beneficial in the early acute phase by immobilizing the joint. . . If symptoms permit, patients should begin a gentle range of motion exercises at 3–5 days from the (acute) injury and gradually increase activity as tolerated. Most cases of turf toe can successfully be treated through conservative management; however, some patients fail these measures, requiring operative intervention to restore stability. . . “

Researchers caution against conventional treatments for Sesamoiditis and toe inflammation

Some of the people that we see in our clinics come in wearing big walking boots. This is an indication of a worsening problem. While it is clear to us why they need to wear it we like to ask why they are wearing the boot. This gives us the patient’s perspective of the treatments they have had thus far, so we ask:

The toe pain has clearly become a body-wide issue.

The walking boot or “moon boot,” like other conservative care methods can help many people with their toe problems, the people we see in our clinics were not helped.

In the Journal of Prolotherapy, (2) Caring Medical researchers published studies on the patients that we have seen in our clinics who suffered from toe and foot pain. Here are the treatments these patients had received:

“(The) patients with unresolved foot and toe pain (of this study) . . . included the subgroup of patients who were told by their MD(s) that no other treatment options were available for their pain. (The patient’s foot and toe pain has become unresponsive to treatment, surgery was given as the last remaining option.)

(Their) conventional therapies for unresolved foot pain include:

Our research team concluded: “The results of such therapies often leave the patients with residual pain.”

Conversion from conservative management to surgical management ranges from 33% to 100% in the published studies.

Doctors at the Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland also had findings in treatments not helping patients with sesamoiditis. (3)

These researchers have found, what others have, a lot of contradictory studies. One report says 100% of athletes can return to their sport with conservative care, while another says 100% of those in conservative care eventually move onto surgical intervention. Clearly, there can only be 100% of anything and these numbers offer contradictions.

Turf toe and sesamoiditis – the connection is inflammation and progression of injury

In this video, Ross Hauser MD discusses a brief ultrasound examination that can show how your big toe pain is coming from toe joint instability. This is a “Progression of Injury.” In the video, this is demonstrated by gently pulling on the toe to check for toe ligament damage and laxity or looseness.

“Turf toe injuries and sesamoid injuries are challenging because of the variety of causes that exist as sources of pain.”

Most younger athletes we see do not come in with a diagnosis of sesamoiditis, they come in with an easier grasp and understand the diagnosis of “turf toe.” In a 2009 study, doctors writing in the journal Foot and Ankle Clinics, (4) offered this as an explanation of Turf toe and sesamoiditis and what kind of treatments may be pursued:

“Turf toe injuries and sesamoid injuries are challenging because of the variety of causes that exist as sources of pain. Through a systematic approach to evaluation, injuries to the hallux metatarsophalangeal joint (big toe) can be diagnosed properly. Correct diagnosis leads to accurate and efficient treatment. If conservative measures fail, operative interventions are available to relieve pain and restore function. With careful surgical technique and appropriate postoperative management, athletes can return to play and efficiently reach their pre-injury level of participation.”

In other words, the journey of the patients we described above. When all the conservative treatments do not work, then surgery can help. For many, it can make things worse. We will see below recovery from this surgery can vary from 2 months to 6 months. Surgery for this condition, we will also see, is rarely offered. Perhaps the long recovery time is the major reason.

In a 2018 clinical update review (5), specialists at the Foot & Ankle Unit, Royal National Orthopaedic Hospital, in the United Kingdom published these suggestions for treatment based on the grade of injury

Study: Half of the athletes will not return to sports

To understand these treatments we need to understand the problem of a loose, unstable toe joint and understand that turf toe and sesamoiditis are NOT problems limited to a ligament sprain of the metatarsophalangeal joint but is a problem that extends to the whole foot.

Brazilian foot specialists published a 2018 study in the journal Foot and Ankle Surgery (6) where they presented evidence and suggestions to doctors that expanded the understanding of big toe instability or “turf toe,” to be understood as “a wide variety of traumatic lesions of the first metatarsophalangeal joint).” As these researchers point out, soft-tissue injury or lesions are typically difficult to diagnose. Treating turf or sesamoiditis can be challenging if doctors focus solely on the metatarsophalangeal joint and not the whole foot complex. This is something we have seen in our patients of more than 26 years in helping people with toe pain.

Here is the summary of their research:

The injuries while grades I, II, III could be classified beyond that. Starting with injury from load and stress on the first metatarsophalangeal joint

That would be HALF the patients.

Injection treatments to treat the toe and foot complex

In our experience with athletes, there is almost always a  great sense of urgency to “do something . . . anything,” to get these athletes back on the field or back to training, ASAP.” Our preferred methods are regenerative medicine injections that rebuild, restore, regenerate damaged connective tissue, and the tissue’s elastic strength. Explosive power generated from the toe and foot comes from this strength and resilience of the ligaments and tendons.

In the video below you will hear Danielle R. Steilen-Matias, MMS, PA-C describe this patient’s treatment for turf toe.

In this video, Ross Hauser, MD explains and demonstrates the treatment for Prolotherapy for toe pain, instability, and bunions.

The treatment begins at 1:12.

In this video, a medical professional is being trained on the Prolotherapy technique by Dr. Hauser. Dr. Hauser is the one making the pointing gestures to guide the injections.

Patients reported a significant reduction in pain and stiffness

In Caring Medical Research, published in the Foot & Ankle Online Journal (7) twelve patients complaining of various big toe pain issues were treated with Prolotherapy. In the days following the procedure, patients were allowed and advised to return to normal non-strenuous activities. Patients were advised to avoid such medications as ibuprofen, which block the inflammatory process. However, we did approve of the use of acetaminophen-based analgesia. Patients returned for treatment every four weeks, depending on their schedule, completing from 3 – 6 treatments.

It is important to stress to the athlete that a customized treatment program allows them to continue supervised training even immediately after treatment. The basis of the Prolotherapy treatment is that the joint remains in motion and is not bound or splinted.

During and after treatment:

Of the twelve patients at the onset of treatment:

When to introduce Platelet Rich Plasma therapy to the treatment plan

Some of you may have been recommended to Platelet Rich Plasma (PRP) injection for your toe pain. This, in many cases, is a single injection into the base of the big toe. In some patients, we may also suggest PRP injection, but not as a single injection, but in a “peppering” manner such as shown above in the Prolotherapy treatments to make sure we get to and treat the tendon attachments at the bone. In addition we typically never offer PRP alone, we use it in conjunction with Prolotherapy.

If this article has helped you understand turf toe and sesamoiditis you can get help and information from our specialists

1 Pinter ZW, Farnell CG, Huntley S, Patel HA, Peng J, McMurtrie J, Ray JL, Naranje S, Shah AB. Outcomes of Chronic Turf Toe Repair in Non-athlete Population: A Retrospective Study. Indian journal of orthopaedics. 2020 Feb;54(1):43-8. [Google Scholar]
Hauser RA, Hauser MA, Cukla JK. A retrospective observational study on Hackett-Hemwall Dextrose Prolotherapy for unresolved foot and toe pain at an outpatient charity clinic in rural Illinois. J Prolotherapy. 2011;3:543-51. [Google Scholar]
3 Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017 Mar 18;8(3):242-255. [Google Scholar]
4 McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot and ankle clinics. 2009 Jun 1;14(2):135-50. [Google Scholar]
5 Najefi AA, Jeyaseelan L, Welck M. Turf toe: a clinical update. EFORT open reviews. 2018 Sep;3(9):501-6. [Google Scholar]
6 Nery C, Fonseca LF, Gonçalves JP, Mansur N, Lemos A, Maringolo L. First MTP joint instability—Expanding the concept of “Turf-toe” injuries. Foot and Ankle Surgery. 2018 Nov 22. [Google Scholar]
7 Hauser R, Feister W. Dextrose prolotherapy with human growth hormone to treat chronic first metatarsophalangeal joint pain. The Foot and Ankle Online Journal. 5(9):1.doi: 10.3827/faoj.2012.0509.0001 [Google Scholar]

This article was updated July 5, 2021

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