Pertinent Roundtable Insights On Indications For Orthotic Management

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Guest Clinical Editor: Ronald Valmassy, DPM

A: Preoperatively, Dr. Kirby says orthoses can slow the progression of the deformity and decrease pain to the first MPJ. Dr. Blake says orthoses may be crucial in helping some patients avoid bunion surgery. He emphasizes the importance of obtaining a stable pre-op orthotic as there are many pitfalls with fit and shoegear.
For example, Dr. Blake says one may discover preoperatively that the patient has nerve hypersensitivity secondary to Morton’s neuroma and cannot wear the orthotic. He points out that this finding could change the post-op choices if one notes these pre-op problems and completely addresses them.
In Dr. Burns’ experience, HAV is influenced, if not caused, by abnormal function. However, he acknowledges there is mixed literature on the subject. Therefore, if Dr. Burns repairs a bunion deformity without surgically addressing the cause of the midfoot instability, he emphasizes the importance of continuing orthotic control to reduce the deforming force from acting again on the first MPJ.
In practice, he discusses this with the patient before starting treatment and establishes orthotic control. If the midstance instability is well controlled, Dr. Burns encourages the patient to continue orthotic control after surgery. If there are remaining symptoms or significant deformity, Dr. Burns then offers surgical repair.
In regard to the common HAV repair with distal metatarsal osteotomy, Dr. Burns says the orthotic device will still fit well after surgery. Usually, he says the only adjustment necessary is shortening the device a bit to permit the slight first ray shortening that accompanies such procedures.
Dr. Burns describes the common scenario of a patient who presents with first MPJ pain that resolves with functional orthotic control. He notes that these patients may return years later with pain in the second MPJ with digital contracture and perhaps some increase in HAV deformity. As Dr. Burns maintains, this is often the precipitating event that spurs him to recommend HAV repair and continued orthotic control.
Postoperatively, Dr. Kirby says orthoses protect the first MPJ from abnormal mechanical forces and moments that may have caused the bunion deformity. He says post-op orthotics can also prevent other problems from occurring.
Dr. Blake emphasizes that post-op orthoses are “utterly mandatory” after bunion surgery. After surgery, he notes the first MPJ is very weak and good orthotic devices are normally mandated for a minimum of two years postoperatively.

Dr. Blake is the Past President of the American Academy of Podiatric Sports Medicine. He practices in San Francisco.
Dr. Burns is the CEO of Burns Lab. He is a Fellow of the American Academy of Podiatric Sports Medicine.
Dr. Kirby is an Adjunct Associate Professor in the Department of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is the Director of Clinical Biomechanics at Precision Intricast Inc.
Dr. Valmassy is a Past Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco.

For further reading, see “Exploring Orthotic Indications For Various Conditions” in the June 2006 issue of Podiatry Today or “How To Overcome Obstacles With Custom Orthoses” in the June 2007 issue. Also check out the archives at www.podiatrytoday.com.

 

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