Turf Toe or Sesamoiditis? Two Different Problems Under the Same Joint

Pain at the base of the big toe sounds like one problem. It is really two, and they separate on a question most people can answer immediately.

Here is how the two separate, what the grading actually means, and why footwear does more work here than in most foot problems.

The joint, and the two small bones underneath it

The big toe joint is a hinge and sliding joint at the same time. The StatPearls overview of turf toe describes the plantar plate as the strongest stabiliser of the joint, formed by a thickening of the joint capsule underneath.

Sitting within that structure are the two sesamoids, small bones embedded in the tendon that runs under the joint. There is a medial one on the inside and a lateral one on the outside. They act as a pulley, improving the leverage of the muscles that push the big toe down, and they take a share of load every time you push off.

That share is larger than most people expect. A 2025 systematic review of conservative treatment for sesamoiditis reports that the sesamoids transmit between 50 and 300 percent of body weight, depending on the movement and the load applied. The medial sesamoid is affected more often, because it is the larger of the two and carries more of that weight.

Turf toe is a moment. Sesamoiditis is a period of time.

This is the single most useful distinction, and it is usually the first question worth asking.

Turf toe was described in 1976 as a sprain of the plantar capsule and ligament of the great toe joint. The mechanism, as described in a 2023 review of turf toe injuries, is an athlete's foot planted with the heel off the ground while the great toe is forced into hyperextension. Someone lands on the back of your heel during a scrum, you push off hard on a surface with a lot of grip, or you catch the toe awkwardly. There is a moment, and pain and swelling follow it quickly.

Sesamoiditis has no such moment. The 2025 review describes it as acute or chronic inflammation of the sesamoid bones and surrounding soft tissues, with mechanisms including repetitive stress from running and jumping alongside acute dorsiflexion of the joint. It builds across weeks. Someone increased their running volume, started a dance season, or changed to a less cushioned shoe, and the ache underneath the joint gradually became a problem.

The location differs too. Turf toe tends to be tender across the underside of the joint and painful to bend upward. Sesamoid pain tends to sit directly underneath, on one of the two bones, and is often reproduced by pressing on that specific spot.

Sport patterns overlap heavily. Both show up in football, soccer, basketball, tennis, dance, volleyball, and wrestling. Sesamoiditis specifically accounts for around 4.2 percent of injuries in athletes and about 18.3 percent of injuries involving the first toe joint.

What the turf toe grades mean

Turf toe is graded, and the grade drives everything that follows.

Grade 1 is an acute sprain without bony problems or joint instability. Range of movement is normal and the person can bear weight. Grade 2 is a partial tear of the plantar plate or joint capsule, with painful movement, bruising, swelling, and pain on weight bearing. Grade 3 is a complete tear with loss of continuity of the plantar plate or capsule.

Return-to-play figures from the 2023 review run at roughly 3 to 5 days for grade 1, 2 to 4 weeks for grade 2, and 4 to 6 weeks or more for grade 3 managed without surgery. It is worth being careful with these numbers, because the StatPearls page gives recovery from a grade 3 injury as 6 to 12 months. Those are not contradictory so much as measuring different things: getting back onto the field is not the same as the tissue being fully recovered, and this is one of the injuries where the gap between those two is wide.

Examination includes point tenderness underneath the joint and a vertical Lachman test, which assesses how much the toe bone can be translated vertically relative to the one behind it. MRI without contrast is used to evaluate the soft tissue when the picture needs clarifying.

Surgery is uncommon. Less than 2 percent of turf toe injuries require it, reserved for findings like separation or retraction of the sesamoids, vertical instability, a chondral injury, a loose body, or failed conservative care.

Why footwear does the heavy lifting

For most foot problems, footwear is one factor among several. Here it is close to the main treatment, because the mechanism of both injuries is the joint bending too far under load.

Protective options named in the turf toe review include taping the toe in a spica pattern, a graphite or carbon fibre insole, a stiff-soled shoe, and a Morton's extension, which is a firm extension under the big toe that limits how far it bends. All of them do the same job from different angles: stop the joint reaching the position that hurts it while it heals.

For sesamoiditis, the 2025 review describes custom-fitted orthoses used over long periods, ranging from 2 to 21 months of full-time use in the studies pooled. Other measures included a short leg cast for 20 days and periods of non-weight-bearing after injection. Outcomes are moderate rather than dramatic: in one included study, 45.4 percent returned to their previous level of sport without pain and 36.4 percent resumed sport with mild residual pain, with overall pain improvement in 66 percent of cases.

Those numbers are worth knowing, because they set a realistic expectation. This is a problem that usually improves substantially with patient, consistent load management, not one that resolves in a fortnight.

What rehabilitation looks like

Non-operative rehabilitation for turf toe is described in three phases running up to 10 weeks, with operative rehabilitation running four phases up to 20 weeks. Early work protects the joint while keeping the rest of the foot and leg moving. Middle work restores range and strength. Late work rebuilds the ability to push off, cut, and accelerate, which is where the joint is loaded hardest.

Progression is guided by what the joint tolerates rather than by the calendar alone, the same principle covered in our guide to criteria-based return to sport. Pushing off hard on a joint that is not ready is how a grade 2 becomes a longer problem.

Because the load history matters so much in sesamoiditis, the assessment also looks upstream. Foot mechanics, training volume changes, and footwear all feed into it, in the same way they do for plantar fasciitis and other load-driven foot problems. Risk factors named in the 2025 review include prior foot conditions, trauma, excessive pronation, and inappropriate footwear.

When to get it looked at

Big toe pain that came on in a single identifiable moment, especially with swelling, bruising, or difficulty pushing off, is worth having assessed rather than taping and continuing. So is pain underneath the joint that has been building for more than a few weeks and is not settling with lighter training.

Some situations need prompt medical attention: an obvious deformity, inability to bear weight at all, or a toe that looks out of position. Those are calls to your physician or to Lions Gate Hospital.

If your big toe has been sore since a specific play, or has been quietly getting worse all season, book a 30-minute assessment and we will work out which problem you have and what load it can take. You can see what we treat or reach the clinic here.

This article is general information, not personal medical advice. A regulated practitioner can confirm whether the patterns described apply to you.

Sources

• Turf Toe, StatPearls, NCBI Bookshelf
• Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes (Current Reviews in Musculoskeletal Medicine, 2023)
• Conservative Treatment of Sesamoiditis: A Systematic Literature Review with Individual-Level Pooled Data Analysis (Medicina, 2025)
• College of Health and Care Professionals of BC public registry

This article is for general information only and does not constitute medical advice, diagnosis, or treatment. Individual presentations vary, and assessment findings and treatment plans differ from person to person. If you are experiencing severe symptoms, neurological changes (numbness, weakness, bowel or bladder changes), or a significant trauma, contact your physician or emergency services. Care at Medstar Sport Physio & Health is provided by practitioners registered with their respective British Columbia regulatory colleges.