Background
Methods
Design
Participants
Data collection
Data analysis
Results
Participant characteristics
ID | Sex | Focus group | Years in practice | Country of training | Qualification | Countries practiced in | Current region of practice | Private or public |
---|---|---|---|---|---|---|---|---|
P01 | Female | #1 | 44 | United Kingdom | Postgraduate | Australia, New Zealand, United Kingdom | South Island | Private |
P02 | Female | #1 | 15 | New Zealand | Postgraduate | Australia, New Zealand, United Kingdom | North Island | Private |
P03 | Male | #1 | 13 | New Zealand | Postgraduate | New Zealand | North Island | Private |
P04 | Male | #1 | 20 | New Zealand | Undergraduate | New Zealand | North Island | Private |
P05 | Male | #2 | 14 | New Zealand | Postgraduate | New Zealand | North Island | Private |
P06 | Male | #2 | 08 | New Zealand | Postgraduate | New Zealand | North Island | Private |
P07 | Female | #2 | 14 | New Zealand | Postgraduate | New Zealand | North Island | Private |
P08 | Female | #2 | 10 | New Zealand | Postgraduate | New Zealand | North Island | Private |
P09 | Male | #3 | 35 | New Zealand | Undergraduate | New Zealand | North Island | Private |
P10 | Female | #3 | 09 | New Zealand | Postgraduate | Australia, New Zealand | North Island | Private |
P11 | Male | #3 | 25 | New Zealand | Undergraduate | New Zealand | South Island | Private |
P12 | Male | #3 | 18 | New Zealand | Postgraduate | Australia, New Zealand | South Island | Private |
Assessment of sesamoiditis
Theme 1. Obtaining a patient history
“I probably try to get a lot of information from my subjective assessment which is then gonna guide to the approximate region that the person is talking about, try to work out what kind of tissues are involved” (P03).
“I get them to, if they can, replay or show me the mechanism” (P05).
“Early season rugby [or] football training where the ground is still hard, there seems to be a little bit of an influx where you might get quite a few people in with pain in that sesamoid area” (P02).
Theme 2. Recreating patient symptoms
“I normally just push on the sesamoid bone and go, oh, yeah” (P06).
“ … get in there and give it a good wobble” (P08).
“I like the calf raises, seeing how much they can tolerate, whether they can only do double leg or whether they can do single leg.” (P06).
Theme 3. Determining contributing biomechanical factors
“Sometimes, in my opinion, that lateral sesamoid tends to be slightly more deviated so I like to give it a bit of a push from lateral and medial to see if that exacerbates any pain” (P10).
“If they have a particular foot type where the way that they walk is really overloading that particular area … working around that and thinking more of the long term and thinking more preventatively as well so it doesn’t become a recurring issue for them” (P02).
“I start at the pathology site of concern and then work my way in reverse trying to look for patterns that could explain why this is occurring” (P04).
“ … depending on what activity they do, say, they’re doing sport or something, I probably go and get them having a bit of a run, just to see what aggravated it” (P07).
“Weight distribution point of view, with a in shoe pressure or pressure plate is actually a good assessment tool in terms of understanding loading patterns through that joint.” (P12).
“I quite like looking at the insole of the shoe too, pulling that out and having a look and see if there’s any obvious wear pattern can sometimes be a give-away” (P04).
“Sometimes people buy a boot that’s too small or too big and that really affects [how] that metatarsophalangeal joint extends and flexes” (P05).
Theme 4. Ruling out differential diagnoses
“I think we forget sometimes that we actually probably know the foot anatomy better than anyone else” (P08).
“I don’t tend to use much; I think mostly it’s a clinical thing. If I’m suspecting a fracture or bipartite sesamoid or something like that, potentially an x-ray” (P03).
“I would like to be able to at some stage, refer for MRI or CT, because I think we know enough to do it but … it’d be great to see in greater detail what’s happening in a specific joint” (P05).
Management of sesamoiditis
Theme 1. Consideration of patient factors
“Something obviously will work for someone and it doesn’t work for someone else so, … creativity is key here … is it gonna fit into the shoe? Is it really realistic workwise? How long are they gonna be weight bearing on it from day-to-day? Is it durable? All of these variables you have to take into consideration when you are creating a management plan” (P10).
“I’ll start really simple, like … just modifying the insole/sock liner if it’s on the lower budget end. If we’ve got a little bit more money to work with then we’ll do a prefab or a custom orthotic” (P06).
Theme 2. Patient education
“I’m gonna spend that time educating them about what I think it is and how I think we’re gonna manage it and also what I think my goal posts are gonna be” (P09).
“I’m not a pharmacist so I don’t wanna get in trouble, but I certainly do recommend a course, just to take the edge off” (P10).
“I am really brutal about women’s footwear, and I basically refuse to treat anything which is gonna make my treatment compromised so I do sit down with people and have a pretty hard talk about how we’re gonna make it work” (P09).
Theme 3. Cushioning of the sesamoids to allow more comfortable weightbearing of the 1MTPJ
“I’d say rocker sole, really thick cushion shoes and then gel forefoot cushion shoes” (P06).
“I think it kind of goes without saying … it’s obviously avoiding high heel shoes. Probably a really important point to make in your management” (P08).
“I’ll use a softer based orthotic. We usually use a cushion foot bionic and pretty much some kind of first MTP pad, often double layered and, again, well bevelled” (P09).
Theme 4. Pressure redistribution and offloading of the sesamoids
“ … in a moon boot for a week … that generally works pretty well to help settle things down” (P02).
“Patient turns up and there’s no way you’re gonna get a prefab or something into a [dress] shoe, so just a simple offloading principle as soon as you can, if there’s no other option. Certainly it’s only a very temporary method because most of that padding will break down” (P11).
“2 to 5 s [reverse Morton’s] just seem to work. I know they shouldn’t but for some reason they seem to work quite well” (P05).
“I’d never think to do a reverse Morton’s because I’d be too concerned with plantar flexing that first ray, that you would get more pain” (P08).
“Definitely does depend on the foot that we’re seeing. The majority of the time, I’d do a firm density EVA that’s relatively thick.” (P10).
“Another thing I often do … with football boots I typically take that cleat out under that first metatarsal phalangeal joint as well” (P08).
Theme 5. Immobilising the 1MTPJ and sesamoids
“I do a bit of strapping tape as well to reduce the motion of the first MTPJ and if that feels really good then I’ll implement that into an orthotic with a Morton’s extension” (P10).
“If we restrict one joint and typically what you do with the Morton’s extension is we don’t open up a can of worms for other injuries or pathologies” (P08).
“I’ve got [rugby] players that are actually still playing in them all season even though [the ground has] got really soft and they’ve just been using it cos it gives them some stiffness through scrummaging and changing their load” (P05).
“I don’t find there’s enough room for an orthoses either prefab or custom and a carbon plate unless you’ve got something like a work boot scenario” (P12).
Theme 6: Facilitating efficient sagittal plane motion during gait
“I’m trying to enhance sagittal plane movement to try and move them through that area more quickly or change loading through the forefoot to redistribute load more evenly away from that area.” (P03).
“That great little rocker through there makes a massive difference to unloading that joint because minimal extension takes place in the toe when they’re walking” (P11).
“ … using something like a PMP to try and spread load across that part of the foot so that I can allow them to carry continuously through or efficiently through the sagittal plane without excessively placing load on the first MPJ” (P03).
Theme 7. Referring to other health professionals to find different ways to treat or manage patient symptoms
“I feel like sesamoiditis, you get a fairly quick indication of whether your treatment plans’ working but maybe four to six weeks if it wasn’t working, I’d go and refer on” (P07).
“If we haven’t got the skills to do it ourselves, then there’s really only the surgeon and, as I say, I haven’t found surgery to be successful for sesamoiditis but maybe I haven’t seen enough” (P01).