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

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

   In contrast, Dr. Clough believes a first ray cutout or reverse Morton’s extension is contraindicated. He says they would destabilize the foot by reducing the support of the medial arm of the tripod of the foot. As Dr. Clough notes, the ground reactive force will push the first metatarsal upward. Additionally, he says an orthotic cutout or accommodations always limit rather than improve weightbearing under a structure so first ray cutouts or reverse Morton’s extensions tend to encourage pronation late in stance as the medial leg of the supportive tripod is weaker. If weightbearing improves at this time, Dr. Clough believes this is due to late stance pronation when the foot should be resupinating at this time.

   He uses the P4 Wedge (Cluffy Institute) in all of these cases and has found it to be very effective at reducing symptoms and enhancing first MPJ motion. In a subgroup of people with bunions, Dr. Clough has noted a reduction in the intermetatarsal angle as the patient achieves maximal dorsiflexion of the joint. Neil Horsley, DPM, FACFAS, will employ the P4 Wedge for sagittal plane deformities at the first MPJ.

   If the chief complaint of the bunion patient is a pain level greater than 8/10 and there is a change in daily activities, Dr. Horsley considers surgical options. If the bunion patient’s pain is less than 7/10 and there has been no change in the activities of daily living, Dr. Horsley considers the patient a candidate for orthoses if the history includes use of over-the-counter inserts and “better” shoes.

   For such patients, he applies a proper low Dye strapping with appropriate accommodative apertures or padding. On the next office visit, if patients report a difference in pain using the strapping, he schedules a complete biomechanical evaluation for orthoses.

   In conjunction with a complete lower extremity biomechanical examination, visual gait analysis, computerized force plate analysis and neutral cast impression, Dr. Horsley orders custom devices based upon the patient’s biomechanical findings. He also considers posting for forefoot or rearfoot deformities, and makes necessary adjustments for any limb length discrepancy. Depending upon the etiology of the bunion deformity, his additions to the orthoses may include a first metatarsal head or first ray cutout, or a metatarsal raise while making every attempt to keep the device low profile for the best shoe fit.

Q:

Are orthotics helpful for flexible hammertoe deformities?

A:

When Dr. Horsley decides to use an orthosis for flexible hammertoe deformities, he tests the flexibility of the digits by loading the forefoot. If the digits become rectus during loading of the forefoot and do not remain plantarflexed through the maneuver, he will include a metatarsal pad on the orthoses in order to achieve rectus digits during stance.

   If the digits are flexible and continue to plantarflex during the maneuver, Dr. Horsley incorporates a toe crest into the extension of the orthotic device.

   Dr. Clough believes orthotics can help with flexible hammertoe deformities. He says this condition is all about first ray insufficiency. If the first metatarsal does not bear enough weight, Dr. Clough notes that pressure transfers to the lesser metatarsals, causing swelling of the MPJs.

   The small intrinsic muscles, primarily the dorsal and plantar interossei and the lumbricals, are dysfunctional as they pull on a swollen joint, according to Dr. Clough. In addition, he says if the windlass mechanism is not working, the plantar fascial slips inserting into the toes are not functional and wind up destabilizing the toe. A hammertoe is the result. When one can reverse these factors, Dr. Clough commonly sees the flexible hammertoes relax as normal stability improves and eventually the hammertoes straighten to a degree that they are often asymptomatic. He advises that corrections to the orthotic involve casting with the first, fourth and fifth metatarsals plantarflexed, and cites the use of the P4 Wedge.

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