Running with sesamoiditis: How I resolved a 10 year injury by ditching my traditional running shoes.

I was asked to discuss this topic from a reader and ironically this is the injury that plagued me for 10 years before I finally learned how to run. Sesamoiditis is a condition where the two small bones of the great toe joint become inflamed. This can be the result of what is termed a bipartite sesamoid bone(referring to two bones that have not united into one during develop) or one that has become fractured. A debate exists amongst the literature as to whether a fracture truly occurs to this bone, and if so can it reunite or heal. Symptoms present with sesamoiditis include pain and swelling to the bottom or plantar aspect of the great toe joint. A sharp piercing feeling is sometimes described and one usually will limp or walk with pressure on the outside (lateral) aspect of the foot to avoid pain. The condition can go on for months and sometimes does not respond to rest or padding. It is very common amongst volley players or sports that entail forceful jumping or exploding off of the ball of the foot.

So here’s my story. I was just starting residency and had ran most of my life at that point. I had done 3 marathons and numerous other types of races and really just ran as a means of relaxation. In the year 2000, I developed pain in my right great toe in the region of my sesamoid bones (for those not understanding what they are, i’ll explain shortly). Initially I attributed it to playing ice hockey and my skates were tight and it placed increased pressure to the great toe joint. The problem was, it never resolved. After living with it for about 4 years, it finally cultivated in the winter of 2003 when I was on a run in the wintery snow of Erie, PA and the pain became so severe I could barely run. I had x-rays taken of my foot and found in addition to the bipartite tibial sesamoid knew I had, I now had a fractured fibular sesamoid to go along with it! I wore a boot for 3 weeks, and had to stop running. It never worked. It calmed it down and eventually I was able to run again, but the pain in this region persisted. I had worn holes out to the great to region in the fabric on the insides of my Birkenstock Clogs that I would operate and work in. Was I putting too much pressure here? I just figured I was limping from the pain and the region was wearing. I continued to run. I would have good months, and bad months. Eventually I went on to run several more half marathons, another full marathon, and other road races. My foot still hurt. I would try multiple custom orthotics, OTC semi-custom orthotics, and even various running shoes, but just couldn’t resolve it. I focused on “heel-striking” because that was what at that time I was “told” was the proper way to run. Imagine my frustration. A podiatrist, foot and ankle surgeon, who couldn’t fix his own foot. I had contemplated have the sesamoid removed but I felt that would be too destructive of a procedure because it is encompassed in the flexor hallucis brevis tendon and would create a ton of scarring and fibrosis. Not to mention that I was still able to run at times with no pain.

Notice the sesamoid on the left (lateral) is in 3 pieces and the sesamoid on the right (tibial) is in 2 pieces. (Dr. Nick’s Sesamoid Bones of right foot)

Notice how the sesamoid bones are intratendonous (within the tendon of the flexor hallucis brevis)

Enter 2009, the year when the questions starting pouring in about barefoot running. I was working an event for the Akron Marathon, when the owner of a local running shoe store (Vertical Runner) walked by wearing a pair of FiveFingers. I needed to put them on. I was getting bombarded with questions about them, and what better way then to have them on my feet to draw more attention to the matter. I wore them for the second half of the day with a suit and tie and fielded questions from the manny runners that walked by my booth. By the end of the evening, I had discovered that I was learning to stand differently because these shoes were killing my great toe! How could they possibly be good to run it? But that was just it. They forced me to stand differently. Had I been standing wrong in my other shoes? Absolutely, but I didn’t know it. I was wearing a pair of dress shoes that day, so of course my feet were going to hurt. But what did the shoe have to do withme standing wrong? I didn’t figure this out for at least another year.

I decided to focus a little more on barefoot running then just wearing a pair of FiveFingers. I started pulling the literature to understand this a little better. Surprisingly there wasn’t much out there on barefoot running. In fact most of it was anecdotal by an underground of runners who most would probably laugh at and never think much of it. But there was something about it. They weren’t getting injured and were running this way for years. That’s when I started pulling more and more literature on traditional cushioned running shoes. Surprisingly, there was not a shred of evidence to support prescribing these for running, foot pain, or any foot ailment that I had been treating and recommending them for. While all of this was happening, I had began transitioning to running in my FiveFingers. I will leave that story for another blog post!

After 8 weeksof transitioning, my sesamoiditis was all but gone! I just presumed it was coincidental as I had good months in the past, but never this long. How could this be? The treatment for sesamoiditis is to cushion the 1st MPJ, use a cut out offloading orthotic, or not run at all and rest it. I was, for all intensive purposes, running barefoot and mine resolved! Fast forward 5 months and I now completed a half marathon in a pair of FiveFingers and my sesamoiditis was 100% painfree.

Was it the shoes? Nope. I learned how to run. After another year or more of reading, learning (world wide collaboration of runners and physicians including Mark Cuccuzzella, Dan Lieberman, and Irene Davis) and now lecturing on this fascinating topic, I had finally got it. It has nothing to do with the shoes. It’s how you run. Yes I had strengthened my feet beyond what they had ever been my whole life, but the form I had now grown accustomed to was what was helping me.

So what does this have to do with fixing my sesamoiditis specifically? I took the pressure off of that area. This happened through a multitude of ways, but one that I think is most crucial is eliminating what most podiatrists and biomechanists used to describe as the “propulsion phase” of the gait cycle. By adapting a midfoot/forefoot strike pattern, with shorter strides,and landing with your foot below your body, the force that gets generated to the MPJ is reduced. You no longer pro-pulse with the great toe joint, but instead you drive forward with your thigh and the foot gets picked off the ground. There is a slight push off occurring with the foot, but its through the entire foot, not just the MPJ. So basically instead of pushing off with only your great toe, the entire foot takes the load minimizing the stress to great toe joint. This reduction in stress and force can allow the flexor hallucis longus and brevis tendons in the great toe joint to heal if they were inflamed which we typically refer to as sesamoiditis. This makes the condition more consistent with a tendonitis then a true boney pathology which can explain why many don’t respond to just simply resting the foot.