Can Orthoses Have An Impact For Bunions, Hammertoes And Morton’s Neuromas?

Author(s): 
Guest Clinical Editor: James Clough, DPM, FACFAS

These expert panelists examine the role of orthoses in the management of common clinical presentations such as bunions, hammertoes and Morton’s neuromas.

Q:

Do you think orthotics can be helpful in the treatment of bunion deformities?

A:

James Clough, DPM, FACFAS, notes most people have some limited motion of the first metatarsophalangeal joint (MPJ), which causes compression of the joint when the toe attempts to move. As he explains, patients may wind up partially mitigating this compression force by pushing the first metatarsal medially, which may cause a bunion in some people. Dr. Clough estimates that about 50 percent of his patients with a bunion respond positively with functional control of the foot, noting that orthotics help as one restores motion to the joint during gait.

   Therefore, Dr. Clough notes his main goal with the orthotic is improving motion of the first MPJ so he reduces the compression forces associated with a failure of the joint to move. Maximally plantarflexing the first metatarsal with minimal fill in the medial arch is necessary, according to Dr. Clough.

   When it comes to orthoses for bunion deformities, Doug Richie Jr., DPM, FACFAS, says he has only had success with this in active athletes. A certain percentage of patients with bunion deformities have pain due to abnormal mechanics of the first MPJ but he says this is not “bump pain.” The increased dorsiflexion-inversion of the first ray with rearfoot pronation causes a reciprocal valgus torque on the hallux across the first MPJ, creating a painful ligamentous strain and joint compression across this joint, according to Dr. Richie. He notes that foot orthoses may have the ability to decrease overload of the first ray and perhaps increase stiffness of the first ray.

   Additionally, limiting dorsiflexion of the first ray and facilitating the dynamic forces that plantarflex the first ray can decrease the pain associated with hallux valgus, according to Dr. Richie. He notes this treatment requires the use of suitable footwear such as athletic shoes. Dr. Richie says this orthotic therapy is most effective during more vigorous sporting activities.

   He uses standard functional foot orthotic therapy intervention for the treatment of hallux valgus. Dr. Richie also notes the importance of having appropriate footwear to fit a full-length orthosis with a deep heel cup and normal width. He posts the rearfoot with 4 degrees of inversion and 4 degrees of motion. His patients wear a neutral suspension cast to capture forefoot to rearfoot deformities and notes the fabrication lab must intrinsically balance the deformity with minimal arch fill at the medial arch and transverse metatarsal arch.

   “I make sure the lab does not make the orthosis too wide as I want the first metatarsal to have freedom to plantarflex during terminal stance,” says Dr. Richie.

   Similarly, Bruce Williams, DPM, acknowledges that the difficult part is explaining to patients that orthoses can help with function of the first ray but may take up more room in the shoe. Therefore, he says orthoses may cancel some or all of the improvement in function that patients could gain in relieving their bunion pain. Dr. Williams asks patients to upsize their shoes one-half or one full size for their orthoses. He uses a digital wedge or a Cluffy type wedge at the hallux or for all the digits to engage and plantarflex the first metatarsal head.

   Dr. Williams also uses a first ray cutout with a kinetic wedge modification to allow the first ray to plantarflex. Using a lateral wedge to dorsiflex the lateral column will often help to drive the forefoot toward the first MPJ as well, points out Dr. Williams.

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