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:

• “Why are you wearing the walking boot?” The answer will come back:
• “Because I cannot fully support my body weight on my foot. It is either the boot or the crutches and the crutches hurt my underarms.”

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:

• medical treatment with analgesics,
• non-steroidal anti-inflammatory drugs,
• anti-depressant medications,
• steroid shots,
• trigger point injections,
• muscle-strengthening exercises,
• physiotherapy or physical therapy,
• weight loss,
• rest,
• massage therapy,
• manipulation,
• orthotics,
• surgical treatments including fusions,
• multidisciplinary group rehabilitation,
• education and counseling.

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)

• Sesamoiditis is commonly seen in sports that involve repeated, forced dorsiflexion (backward bending) of the great toe. These sports include dancing, gymnastics, and sprinting. The medial (tibial) sesamoid is most frequently injured due to its positioning directly beneath the head of the first metatarsal (the ball of the big toe)
• Current management protocols advocate conservative management as the first-line treatment for all such injuries.
  • This comprises rest/immobilization, with a period of 4 to 8 weeks limited-weight bearing in a below-knee cast, or moon boot.
    • Immobilization, or stress deprivation, is a term to describe casting, splinting, or other means of limiting movement to an injured area of the body. Immobilization is part of the RICE therapy which involves rest, ice, compression, and elevation. Please see our Caring Medical article: Immobilization syndrome and tendon damage.
  • Following this, weight-bearing should be progressed, using a forefoot offloading shoe or modified orthotic.
  • Return rates to sport following successful conservative management include 100%, with return times ranging from 3 weeks to 1 year.
  • There is however a high rate of delayed union, nonunion, and recurrence with this treatment, so if the patient remains symptomatic after 3 to 6 months of conservative treatment, surgical intervention should be considered.
  • Conversion from conservative management to surgical management ranges from 33% to 100% in the published studies.
  • Reported return rates following surgery range from 90% to 100% with return times ranging from 2.5 to 6 months.

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

• Grade 1 “turf toe” injury usually allows a return to athletic competition as tolerated, with little or no loss of playing time. After the acute phase of the injury, the great toe will benefit from taping in a slightly plantar-flexed position to limit motion and provide compression. (as your doctor or trainer). The athlete should use a stiff-soled shoe with a turf toe plate insert or a custom orthotic with Morton’s extension to limit hallux motion. (This is a shoe insert that limits the big toe’s range of motion). If the primary injury is more medial (towards the center of the foot) and there is a concern of a traumatic hallux valgus, a toe separator between the hallux and second toes can provide further support.
  • Comment: These treatments can help a lot of athletes, however, let’s read between the lines. There is a problem with big toe instability here: The ligaments and the tendon attachments of the big toe can be weak enough to cause “traumatic hallux valgus,” the big toe is bent badly. Doctors here then focus on what is happening to the medial collateral ligament. This is where we too focus on the medial collateral ligament and strengthening it and regenerating natural elastic strength.  While some doctors achieve this surgically, we achieve this non-surgically with Prolotherapy injections.
• Grade 2 “turf toe” injury. Returning to the recommendations from the UK specialists at the Royal National Orthopaedic Hospital: For Grade 2 injuries, symptomatic treatment is warranted (doctors need to provide relief from the symptoms) and may include a walking boot and protected weight-bearing. If the capsule (the toe joint) has a substantial injury as seen on MRI but no instability on provocative testing, then casting for four to six weeks may be prudent.  The patient should be carefully followed in these early stages of recovery because deformity can progress with athletic activity. Low-impact exercise, such as bicycling, elliptical training, and hydrotherapy, can be attempted with toe protection. Cortisone or anesthetic agents are not advised. There is some evidence to support biological therapies (such as platelet-rich plasma (PRP) and autologous conditioned plasma (ACP) injections). Once the toe can tolerate the low-impact exercise, the athlete can progress to higher impact activities, followed by explosive or push-off activities. Footwear should be adjusted to include the use of a turf toe plate.
  • Comment: Where do we begin here? Substantial injury revealed on MRI is in many cases the toe moving out of place. Instability is not an issue as of yet because the ligaments are stretching in an attempt to hold things together. However, the bone may start forming bone spurs or overgrowths to help the ligaments or be there for when the ligaments fail.
  • The recommendation is against cortisone and a guarded recommendation is offered for Platelet Rich Plasma therapy. An injections treatment we have found great success with when combined with Prolotherapy treatments that help restore tensile strength in the toe’s connective tissue. We will discuss this treatment below.
• Grade 3 “turf toe” injury. Returning to the recommendations from the UK specialists at the Royal National Orthopaedic Hospital: Grade 3 injury may require eight weeks or longer of recovery and immobilization. It may take up to six months for the complete resolution of symptoms.
  • Comment: It is at this point, even though their doctor may recommend against it, that the parents of a young athlete will explore the surgical option. Six months of recovery without surgery may seem too long. However, surgical recovery may take equally as long.

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:

• 24 patients were treated with metatarsophalangeal 1 joint (base of the toe) instability. The researchers call the problems these patients had an “Expanded Turf-toe” diagnosis. Meaning they were looking at the many causes of toe pain.
• All patients were performing sports activities when they were injured:
  • Soccer (33%);
  • martial arts (17%);
  • running (13%);
  • tennis (8%);
  • Olympic gymnastics (8%)
  • and others (basketball, slalom, motorcycling, surfing, and ballet) (21%).
• Injuries were classified as Grade I (2 patients – 8%), Grade II (8 patients – 33%), and Grade III (14 patients – 59%) lesions. All patients with grades I and II were treated conservatively whereas those classified as grade III were treated surgically.

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

• Instability causing hallux varism (toe pointed out) (seen in 42% of patients)
• Pure hyperextension – the toe over bends (seen in 25% of patients),
• Extension with hallux valgism (the toe is curling inward and bunion formation has started – seen in 21% of patients),
• Pure hyperflexion (8%) and hyperflexion with hallux valgism (4%).
• Four patients with GIII injuries (29%) and two with GII injuries (20%) did not resume their previous activities.

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.

• This is a Prolotherapy treatment. The Prolotherapy injection consists of simple dextrose. The dextrose is given in the areas of the ligament attachments. This creates a controlled inflammation at the ligament attachments surrounding the big toe. This stimulates and accelerates healing and strengthens the ligaments to stabilize the toe joint and repair problems of hyperextension and hyperflexion. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.
• The whole toe joint capsule is treated. This means a lot of injections to make sure all the ligaments are treated.
• After the treatment, the patient is told to rest for about 4 days and then they can start resuming their exercise gradually or as tolerated.

• MOVEMENT: When Prolotherapy is given, the patient is encouraged to move the toe. Toe crunches can be recommended. This can be done with toe spacers in place if there is a bunion forming or the toe is not anatomically aligned.

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.

• Prolotherapy injections involve using a simple and safe base solution, dextrose as the primary proliferant (treatment), along with an anesthetic (such as procaine or lidocaine), that is given into and around the entire painful/injured area(s). Many injections are given during each treatment. Most treatments are provided every 4 to 6 weeks to allow time for the growth of new connective tissues.
• We recommend toe crunch exercises in most patients. This is discussed at the time of the treatment.
• If there is a valgus deformity, we may suggest “Yoga Toes,” or other toe separation or toe stretching apparatus.
• If sesamoid bone pain or sesamoiditis was present, we would have continued the treatment to address those concerns.

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:

• Patients reported a significant reduction in toe pain and stiffness.
• To gauge patient progress, patients were asked to rate their toe pain levels on a scale of 0 to 10, with 0 being no pain and 10 being severe crippling pain, and to measure:
  • 1) Toe pain at rest,
  • 2) Toe pain with normal activities, and
  • 3) Toe pain with exercise.
• Concerning 1) pain at rest:
  • prior to Prolotherapy treatment, pain measurement scores averaged 4.42./10. After Prolotherapy treatment, pain measurement scores averaged less than 1/100th. Only one patient reported a VAS pain level of 1, and all others reported zero.
• Concerning 2) pain with normal activities:
  • prior to Prolotherapy treatment, pain measurement scores averaged 6.50.
  • 5 of 12 patients could walk less than fifty feet without pain; 7 of 12 could not walk a half-mile without pain, and 10 of 12 could not walk a full mile.
  • After Prolotherapy, all but one patient reported no restrictions in walking any distance without pain, and a pain measurement average score of 1.17 was noted.
• Concerning 3) pain with exercise:
  • prior to Prolotherapy, five of 12 patients reported being severely compromised (only 0 to 30 minutes possible) in their ability to exercise, and pain measurement score of 7.42.

Of the twelve patients at the onset of treatment:

• two were totally compromised and unable to exercise; three were moderately (only 30 to 60 minutes possible).
• Over half of the patients were severely compromised in their athletic abilities prior to treatment.
• After Prolotherapy, seven of 12 patients reported being able to exercise as much as they wanted without impediments and with satisfaction.

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.

• PRP treatment re-introduces your own concentrated blood platelets into the toe joint area.
• Your blood platelets contain growth and healing factors that when concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.

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

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This article was updated July 5, 2021

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.