Developing big toe pain either during or after running is a common foe to many runners, with the potential to throw your training off track and leave you feeling frustrated and sore. Big toe injuries are prevalent among runners because when your foot strikes the ground during running, your feet absorb forces up to three times your body weight - and this force can increase to between four and seven times at the forefoot, according to research by Saucony.
Your forefoot and toes are then pivotal in the push-off phase of running, which propels the body forward and naturally places this area under significant stress. Your big toes also help with stabilising your foot and maintaining your balance as you run and walk.
Sesamoiditis Causes Toe Pain During Running
There’s one cause of big toe pain in runners that isn’t often discussed but is a very common occurrence seen by our physiotherapists at our clinic: sesamoiditis.
Sesamoiditis is an overuse injury that creates pain, swelling, and discomfort directly beneath your big toe. Interestingly, sesamoiditis actually specifically affects two pea-sized bones immediately beneath the big toe joint called the sesamoids. They’re embedded within a tendon below your toe called the flexor hallucis brevis, and offer important leverage and support as your toes move. When the sesamoids (and this tendon) are inflamed from the repeated stress or pressure on them, you experience the painful symptoms of sesamoiditis.
Causes and Symptoms
While sesamoiditis is caused by overloading the forefoot, big toe and sesamoids, there can be many contributing factors:
- Being a forefoot runner
- Having naturally larger sesamoid bones
- Suddenly increasing your training load or intensity (this places greater strain on the forefoot)
- Regularly wearing high heels
- Having other forefoot injuries or trauma
- Wearing shoes that inadequately support your feet during exercise
- Having conditions such as osteoarthritis or osteoporosis may increase your risk
- High-impact activities including running, dancing, or sports involving repetitive push-off movements
Your typical symptoms include pain and swelling around the big toe, particularly when you’re walking, pushing off the ground, or bending the big toe upwards. The pain may start gradually and worsen over time or appear suddenly after intense activity. Many runners experience their symptoms starting midway through a run.
Treating Sesamoiditis
Our physiotherapists tailor sesamoiditis treatment to each person, their symptoms, and the severity of the condition. Initially, our goal will be settling down the painful symptoms. This typically involves temporarily pausing or reducing the intensity of any activities causing pain (such as running or dancing) and using things like ice, oral anti-inflammatory medications, and carefully applied padding or strapping to help relieve pressure on the sesamoid bones.
Once your immediate symptoms have calmed, our focus shifts towards healing the damaged bones and tissues and addressing any underlying factors contributing to the injury. This helps reduce the risk of your pain recurring. A combination of full-length custom orthotics and supportive footwear is often recommended. The orthotics help deflect pressure away from the painful sesamoid area, redistributing weight across other areas of the foot to reduce irritation and promote healing. Your orthotics can also be designed to help with flat feet and other biomechanical factors that may have contributed to the problem developing in the first place. Our physios may also recommend hands-on therapy (manual therapy) and exercises to perform at home and advise you on when and how to safely return to running or your regular physical activities.
In persistent or severe cases of sesamoiditis, such as when they occur together with stress fractures, we may recommend temporarily wearing a moon boot to completely offload the affected area and allow proper healing. Surgery is typically considered a last resort, and involves removing the damaged sesamoid bone or repairing it with bone grafting in more complicated scenarios.
Bursitis
Beyond sesamoiditis, several other conditions can also lead to big toe pain in runners, one of which is bursitis. Bursitis is a painful condition where small fluid-filled sacs, called bursae, that normally act like cushions between bones and soft tissues, become inflamed. This usually happens because of repetitive stress from running, pressure from tight shoes, or unusual foot movements - the same things that cause sesamoiditis.
When you have bursitis, you'll feel swelling and tenderness around the base of your big toe, which can become red and warm. Pain often intensifies during activities like running or when direct pressure is applied.
Capsulitis
Capsulitis describes the inflammation of the joint capsule between two bones - like the one in your big toe. It develops when the tissues surrounding your big toe joint become irritated and swollen, making it painful and difficult to move your toe normally. It’s common in runners because of the repetitive toe-bending movement during running, as well as wearing shoes that don't fit well, or running on hard surfaces regularly. If your feet roll inwards too much (pronation), you're more likely to develop capsulitis.
Symptoms of capsulitis include pain, swelling, stiffness, and difficulty moving the toe, which is especially noticeable during push-off in running.
Plantar Plate Tear
A plantar plate tear involves injury to a small but important ligament located beneath the ball of your foot, directly under the joints of your toes, called the plantar plate. This ligament helps to stabilise your toes and keeps them properly aligned when you walk or run. A tear often occurs gradually due to repeated stress, like running frequently on hard surfaces, or wearing shoes that don't offer sufficient support to the front part of your foot. It can also happen suddenly if you stub your toe or land awkwardly.
If you have a plantar plate tear, you'll usually experience sharp pain under the base of your toe, a sense of instability (almost as if your toe isn't securely attached) and noticeable swelling. Pain typically worsens when you bend your toe upwards or during activities like running or jumping.
Are Your Shoes Adding To The Problem?
One thing to consider is that the design of your shoes, their age and condition, and the surface you’re running on all often contribute to the stress that leads to forefoot pain and big toe pain. Shoes that lack proper cushioning or support, or those with a narrow toe box, can exacerbate pressure on the forefoot and toes. Running techniques that emphasise forefoot striking can also place additional pressure on the toes. So don’t forget to check your shoes and their condition - and bring them to your appointment so your physio can have a look, too.
When To Seek Physio Treatment For Toe Pain
If you’re experiencing toe or foot pain, we recommend booking in with a physiotherapist experienced in treating sesamoiditis, capsulitis, bursitis, plantar plate tears and forefoot pain in general.
Here at PhysioCentral, our physiotherapists are experienced in sports medicine and treating foot injuries and can develop a personalised treatment plan to relieve your symptoms and make you feel more comfortable.
Book your appointment by calling us at +852 2801 4801 or book online here.