Utilizing Semi-Custom Orthotics For Neuromas

Nicholas A Campitelli DPM FACFAS

Too often, physicians prescribe custom fabricated orthoses to treat a forefoot issue when they can address the problem through the use of a semi-custom orthotic.

Do we need to cast, mold and scan the foot, et cetera, to produce a custom rearfoot shell, which we can attach to the forefoot device? Do we need to control the rearfoot to help the forefoot pathology? The debatable answer is that it depends on the pathology.

Regarding neuromas, when ordering an orthotic, one can simply check the box to insert a neuroma pad on the forefoot between the involved metatarsals. The goals of the pad are to splay the metatarsals and reduce the irritation to the nerve. One can greatly minimize the expense of the custom orthotic by implementing a semi-custom insert.

Podiatrists can create these semi-custom inserts or they can utilize a pedorthist. In my practice, I send patients to a specialty shoe store, Lucky Shoes (www.luckyshoes.com ), which uses a prefabricated shell and modifies the forefoot with the appropriate material to offload or make adjustments.

The use of pedobarography determines the placement of the insert. This can be as simple as using carbon paper to identify the pressure areas for locating the metatarsals. Any modifications are simple and podiatrists can add, remove or adjust the orthotic for perfect placement. There is no need to construct an expensive shell as this is a temporary device to help address a forefoot problem.

When trying to construct semi-custom devices with outside laboratories, practitioners need to send the device back for minor adjustments. These adjustments may take days to weeks although they should only take minutes. The pedorthists at Lucky Shoes will make adjustments as many times as necessary on the spot for the patient. I have had great success with this company and continue to use it in my practice.

Comments

Pedorthics is a dying field that needs to be supported by podiatrists so that they do not die out altogether. The idea that a lab will make adjustments for a foot that they never see (not even with a photo from an iPhone) nor do they want to see because they do not want to interact directly with patients is very sad.

Take Dr. Campitelli's advice and find a local pedorthist who can make adjustments that the patient can try right away. It will be a win-win for everyone.

The problem I've had is that many of these "stores" that have pedorthists in them are not willing to send the patient back for further care once they fabricate the insole.

I've also had many of these types of stores employ less than proficient staff who have boldly told my patients that I don't know what I'm talking about with respect to insoles and feet for that matter. Their employees also make diagnoses to sell products that my patients don't really need. Many will also not accept returns but will give "store credit" if the patient isn't satisfied.

Sorry, but these "stores" have lost me. Why would I send my patients to a place that would do that? Further more, if "cost" is a sticking point, how could you justify having them go to these stores and sometimes spend $200 or more for a non custom device? We have the technology in our office to manage these patients, their pathologies, and their needs with respect to these devices.

That's very unfortunate. We developed a great relationship with our store (Lucky's) and it's very mutual. My patients return to me and I see referrals from them as well. I just don't have the time nor the expertise to make the devices and adjustments that they do. Additionally, they help to fit the devices into proper shoes and spend time with the patient which is a plus. The goal isn't to dump patients on them, it is to incorporate them into the process of helping the patient. Our office goal is to place our emphasis on diagnosis of pathologies and making sure the patient gets the best option for their pathology. Could I make an insert? Yes but they will do it more efficiently and better while allowing me to focus my time on seeing other patients. Sometimes carrying too many roles in the office takes away from being a true physician.

Biomechanics is a huge part of our practice.

We are the foot and ankle experts. I can't imagine having someone else do this for us. Especially with the horrid experiences I've had with many of these chain stores.

I thank Dr. Campitelli for his opinion, but as a podiatrist of 37 years, I can say for certain, rearfoot mechanics do affect the forefoot. Excessive pronation, beginning with rearfoot instability, can and does cause neuritis of digital nerves. Correcting rearfoot biomechanics is the first place we start. It is not just incidental to other problems of the foot. If you do not want to treat these patients' pathomechanics, plenty of your colleagues do.

Dr. Steinberg, thank you for the comments.

Unfortunately, controlling pronation is not the cure all for most foot problems. In fact, addressing neuromas by controlling rearfoot motion is really not even discussed much in the literature. The most recent publication of neuromas in Clinics in Podiatric Medicine and Surgery advocates the use of a metatarsal pad (placing metatarsal pads just proximal to the metatarsal heads can help alleviate pressure and assist in spreading the metatarsal heads) to help resolve Morton's neuroma.1

The article mentions the use of a "orthotic device" alone to treat neuromas but it was only successful 41 percent of the time. In fact, I reviewed numerous articles to verify conservative treatment of neuromas and the consensus on conservative care of neuromas is the use of metatarsal pads in regard to orthotics not controlling rearfoot pathology.

You can certainly debate the issue from a clinical standpoint as well as an evidence-based medicine standpoint, but rarely does someone present with a valgus rearfoot and pes planus deformity and complain of neuroma pain. In my opinion, there is no link to an increased incidence in neuroma-like symptoms in those suffering from severe pes planus or valgus rearfoot issues.

Sometimes slipping an orthotic into a shoe isn't the answer. Our feet were designed to pronate for a reason and we need to stop focusing on controlling a normal motion.

Reference

1. Adams WR 2nd. Morton's neuroma. Clin Podiatr Med Surg. 2010;27(4):535-45.

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