Keys To Prescribing Orthotics For Sports, Neuromas And High Heels

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Author(s): 
Guest Clinical Editor: Joseph D’Amico, DPM

   Dr. Valmassy suggests considering vacuum casting techniques to better capture the unique characteristics of a specific high heeled shank. Other than that, he says utilizing a thin material, either polypropylene or graphite, is essential to this type of device. He says one should cut the device narrowly. In these cases, Dr. Valmassy typically asks for a very shallow heel cup, realizing that he is sacrificing some control. However, he warns that any heel cup depth beyond 2 to 4 mm will compromise the use of the orthotic device in most fashionable shoes. He typically asks for a Holethotic, which has a hole in the heel area to maximize contact of the patient’s foot with the inner sole of the shoe. As Dr. Valmassy explains, a Cobra or serpentine type of orthotic also tends to reduce the overall bulk of the orthotic device itself and leads to a better fit in most instances.

   If there is a sagittal plane deficiency, forefoot deformities or symptomatology, Dr. D’Amico employs a device with a calcaneal inclination enhancement of 2 to 4 mm to prevent forefoot calcaneal migration and enhance sagittal plane control. With heel heights over 3 to 4 inches, he says an ultra-thin graphite composite shell with a heel cut-out, intrinsic rearfoot and appropriate forefoot posts is often effective.

   Since women in a high heel shoe walk on an inclined plane, Justin Wernick, DPM, says the mechanical objective is to use a modification that levels the heel. That way, he says one can reduce that plantarflexory force on the forefoot. Dr. Wernick also notes that using a sagittal plane post on the heel of the orthoses is very helpful and suggests angling the post so the anterior edge is thicker than the posterior edge. There is no varus or valgus angle in his design.

   Dr. Wernick also notes that casting the foot in the type of shoe to be worn will give a much more reliable impression of the foot as it functions in that shoe. The arch height will increase as the heel height increases so he says fabricating the shell with this built-in arch height helps the foot resist sliding forward. Additionally, Dr. Wernick notes that leveling the heel and filling the arch of the foot will reduce the load on the metatarsal heads.

   For high heels, Dr. Valmassy feels the most important consideration is realizing that the correction of the orthotic device decreases significantly as the shoe becomes more stylized and the heel becomes higher.

   “Certainly, there are a few considerations to make that will allow some degree of comfort and stability that clearly goes well beyond any type of over-the-counter support,” notes Dr. Valmassy.

   Heel height and type are among the factors that dictate the prescription of foot orthoses for women’s fashion footwear, according to Dr. D’Amico. He employs intrinsic rearfoot posting in most fashion footwear not so much because of its reduced effectiveness in higher heel heights but because it stabilizes the rearfoot in the shoe itself. Dr. D’Amico cites the Slimthotic (Langer), a subortholene shell with a cutout central heel region and extrinsic rearfoot post, as an example.

Q:

What orthotic modifications do you find effective in the conservative management of Morton’s neuroma?

A:

Dr. D’Amico has found metatarsal pads, neuroma plugs and digital crests to be helpful modifications for Morton’s neuroma. In his experience, the metatarsal pad works well to rest on the longitudinal arch and spread the central metatarsal.

   Dr. Beekman has found that using a metatarsal pad and a 1/8-inch Korex extension under the fifth metatarsal head is effective. He notes an additional adjunct is manipulation of the fourth metatarsocuboid joint.

   Dr. Wernick finds most patients with neuroma have a ligamentous lax foot type in which there is a large range of motion in the joints of the foot, especially in the transverse plane of the midtarsal joint. He notes this results in a relative abduction of the forefoot relative to the rearfoot. In this situation, Dr. Wernick says there is more movement of the medial column of the foot than in the lateral column, resulting in shearing of the nerve, particularly between the third and fourth metatarsals.

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