Our expert panelists discuss the role of orthotics, orthotic modifications and other conservative solutions for pregnant women, female athletes and CEOs in dress shoes.
What is your treatment protocol for the active pregnant woman with medial calcaneal neuritis and associated plantar fasciitis?
Alona Kashanian, DPM, notes the multifaceted etiology of medial calcaneal neuritis with associated plantar fasciitis. She points out that patients with pes cavus and pes planovalgus foot types are predisposed to acquiring this condition. She advises DPMs to carefully consider the treatment protocol for the active pregnant woman with plantar fasciitis because of the hormonal restrictions, namely the increase in progesterone and estrogen that results in increased ligamentous laxity, causing a widening and stretching of the upper extremity, abdominal area and lower extremity.
“The pregnant woman’s increase in weight as well as increase in ligamentous laxity is often the etiology of plantar fasciitis,” says Dr. Kashanian.
Accordingly, one will need to adjust conservative modalities, advises Dr. Kashanian. She says homeopathic anti-inflammatory modalities such as Traumeel (Heel, Inc.) and Arnica might be effective alternatives for the pregnant woman. In addition, Dr. Kashanian says ice can decrease inflammation locally at the medial calcaneal nerve and the insertion of the plantar fascia.
Jenny Sanders, DPM, notes that pregnancy can increase swelling of the foot, ankle and leg, and can also cause an unsteady gait and increased foot width.1 She says the timing of symptom onset in mid- to late pregnancy may suggest that biomechanical factors play a larger role than hormonal influences.2 Treatment protocols address edema and biomechanical changes associated with pregnancy and Dr. Sanders emphasizes educating the patient on the importance of frequently elevating the lower extremities and providing compression.
As Dr. Sanders notes, one can take the patient’s foot measurements and make shoe recommendations in regard to torsional stability and overall support. In women for whom pregnancy increases rearfoot pronation, she advises dispensing either a non-custom or custom orthotic.
Active pregnant women should use icing and massage, and avoid walking barefoot, according to Jane Andersen, DPM. She advises using physical therapy as needed.
Both Drs. Andersen and Kashanian emphasize stretching for pregnant women. Dr. Kashanian notes one can dispense posterior night splints to the active pregnant woman but these must have decreased tension. In addition, she says a bio-evaluation and gait analysis will demonstrate an increase in lordosis of the back and pelvic area. Accordingly, Dr. Kashanian advises prescribing a shoe that will allow for moderate shock absorption as well as moderate rearfoot control.
In regard to orthoses, Dr. Andersen advises using a custom orthotic with a polypropylene shell and soft topcover, and a rearfoot post with 4/4 motion. The custom functional foot orthoses should include a deep heel cup as well as an EVA rearfoot post, which Dr. Kashanian notes will aid in shock absorption during gait. She also says a bilayer topcover is another way to increase shock absorption.
“Shoe recommendations and OTC insoles as well as custom insoles are the cornerstone for any sports medicine treatment,” she notes.
What is your treatment pyramid for the 40-year-old female marathon runner with recurrent sesamoid pain bilaterally?
Initially, Dr. Andersen recommends biomechanical assessment and control as well as a custom orthotic with a cutout for the first metatarsal head and a reverse Morton’s extension. Until one can fabricate the orthotic, she suggests applying aperture padding to the underside of the insole of the shoe.
A quick review of the etiology of sesamoiditis can reveal a multitude of foot types, according to Dr. Kashanian. As she notes, the pes cavus athlete with a plantarflexed first metatarsal head and the pes planovalgus patient with a hypermobile first metatarsal predispose the female marathon runner to injury and irritation of the sesamoids.
For recurrent cases of sesamoid pain, Dr. Sanders will order magnetic resonance imaging (MRI) to rule out a sesamoid fracture. If the patient does have a fracture, she will immobilize the limb in a controlled ankle motion (CAM) walker for six to eight weeks and order bone stimulation. Likewise, in more severe cases, Dr. Andersen advises possible immobilization with a post-op shoe or CAM walker and cutout for the sesamoid.
In cases of sesamoiditis without fracture or following fracture, Dr. Sanders’ goal is to improve first metatarsophalangeal range of motion and reduce weightbearing along the sesamoids. She notes one can accomplish this through the use of a non-custom orthotic or custom orthotic with a first ray cutout or sesamoid notch and a reverse Morton’s extension.3
“Like most athletes, the female marathon runner will not adhere to conservative treatment modalities as easily as her inactive counterpart. One must present alternative exercise options to the female marathon runner,” says Dr. Kashanian. “The podiatric physician must attempt treatment modalities that will keep the female marathon runner active as well as attempt a recovery period.”
Those exercises include stationary biking or “spinning” and elliptical “pre-core” machines, which she says are two suitable substitutes for running. Dr. Kashanian says these exercises enable the marathon runner to maintain her endurance level while avoiding the toe loading process of running. Dr. Andersen concurs that patients with severe sesamoid pain should substitute cycling or aqua jogging for running.
Patients might take nonsteroidal anti-inflammatory drugs (NSAIDs), either oral or topical, but they should avoid oral NSAIDs around race day, according to Dr. Andersen.
Topical anti-inflammatory modalities, including ice and topical analgesics, “are a wonderful option,” agrees Dr. Kashanian. The analgesics include Biofreeze (Hygenic Corp.), CryoDerm (Cryoderm) and prescription Voltaren Gel (Novartis), which she notes will all decrease local inflammation when patients take them twice a day. Furthermore, Dr. Kashanian says oral anti-inflammatory options include prescription meloxicam (Mobic, Boehringer Ingelheim) and celecoxib (Celebrex, Pfizer), noting that the once-a-day oral regimen will result in better patient adherence.
As for daily shoe therapy, Dr. Kashanian notes this should include a shoe with a stiff last with little or no bend at the forefoot area. Similarly, Dr. Sanders recommends a shoe with an inflexible forefoot. Dr. Andersen says one should also assess shoe gear to ensure the patient is utilizing the correct amount of biomechanical control.
Dr. Kashanian advises that orthotic therapy is a crucial treatment modality to correct the runner’s biomechanical abnormalities and the marathon runner requires a lightweight orthotic device with minimal biomechanical control. She suggests considering a thin polypropylene device with minimal arch fill and a reverse Morton’s extension to offload the first metatarsal head. She says the podiatric physician should not over-control or overcorrect the marathon runner with an excessive medial skive, inversion or rigid orthotic plate. Dr. Kashanian does not recommend injection into the first MPJ as it rarely has a long lasting therapeutic effect.
What is your treatment of choice for a 16-year-old female tournament level tennis player with lateral ankle instability?
For Dr. Sanders, the key goals for such tennis players are stabilizing the ankle and preventing future injury, given that the most common risk factor for ankle sprains in sports is a history of a previous sprain.4 Her clinic dispenses an Air-Stirrup Ankle Brace (Aircast) to tennis players suffering a moderate or severe sprain. In cases in which there is ankle instability without serious prior sprain, she instructs patients in self-taping of the ankle and foot.
When it comes to bracing, Dr. Kashanian cautions that not all ankle braces are created equally. She says the ankle brace with a combination of shoelaces and a figure 8 Velcro strap will aid in lateral as well as medial motion.
Court shoes are limited in style and control, and Dr. Kashanian notes most court shoes are designed for lateral and medial rearfoot control. Dr. Sanders also educates patients regarding the three-point test to shoe evaluation (see her DPM Blog at http://tinyurl.com/aawr2jf .)
The 16-year-old female tournament tennis player who suffers from lateral ankle instability requires a careful examination, according to Dr. Kashanian. One can attribute the etiology of lateral ankle instability to a high subtalar joint axis, which she notes causes repetitive stretching of the lateral ankle ligaments. She has found that 50 percent of all lateral ankle instability involves pain along the sinus tarsi.
Dr. Kashanian suggests considering a therapeutic corticosteroid and lidocaine combination injection to the area to decrease pain for such tennis players. She notes the first objective for a podiatric physician is to stop motion at the rearfoot with the aid of a removable cast such as a CAM walker. As Dr. Kashanian emphasizes, the teenage patient must be adherent about the use of a removable cast for four to six weeks to decrease pain and inflammation on the lateral aspect of the rearfoot.
For Dr. Andersen, orthotics would include a polypropylene shell, cut wide, with a full length Spenco topcover, which one should cast with the foot slightly pronated. Her patients use ankle braces until she can fabricate an orthosis.
Dr. Kashanian says the prescription for the custom made orthotic should include a lateral skive to decrease lateral column loading. Furthermore, she notes a lateral extension on the rearfoot post as well as no lateral bevel on the rearfoot post will decrease the stress on the lateral column of the rearfoot.
“Orthotic prescription writing is an integral part of therapy for the young tennis player,” notes Dr. Kashanian.
Dr. Kashanian also touts topical modalities including Biofreeze, Cryoderm and prescription Voltaren as well as oral modalities including OTC naproxen (Aleve, Bayer) and ibuprofen. After reducing the inflammatory process, Dr. Kashanian says the podiatric physician should consider prescribing physical therapy for six to eight weeks. The physical therapy should include increasing proprioception as well as peroneal and posterior tibial tendon muscle strength, and stretching the Achilles tendon. Dr. Sanders and Dr. Andersen agree that physical therapy can also be beneficial in proprioceptive re-education and strengthening rehabilitation.
What is your treatment protocol for the 45-year-old female CEO in heels or dress shoes with recurrent Morton’s neuroma?
Dr. Kashanian acknowledges numerous etiologies of Morton’s neuroma. She says the most common is a splayfoot type with increased pressure in given interspaces. She emphasizes that the professional CEO woman with Morton’s neuroma needs conservative treatment modalities that would not interfere with her busy lifestyle. To that end, Dr. Kashanian says shoe gear modification is an initial course of treatment. Noting that shoe companies have introduced stylish shoes with a wide and square toe box, she says Rockport, Munro, Clarks and New Balance offer the female CEO comfort and style by accommodating the splayfoot type without compromising style.
Dr. Andersen advises CEO patients to limit their heel height to 2 inches or less. She suggests choosing shoes with good biomechanical qualities, a wide forefoot and soft or stretchy uppers.
In regard to orthoses, Dr. Kashanian says there are multiple variations of metatarsal pads, bars, cookies and neuroma pads that one can apply directly to the foot to offload the specific interspace. Due to the restriction of space in a dress shoe, she emphasizes that custom-made orthotic therapy becomes a very challenging treatment. Podiatrists may want to consider fabricating an orthotic device for an athletic shoe for the patient to wear on weekends or casual off days. If a specific pad, bar or cookie is effective in eliminating pain, then she says the podiatric physician can incorporate the specific pad onto an orthotic device.
Dr. Andersen applies a metatarsal pad to the shoe or considers a custom orthotic with a graphite shell (dress device) with a metatarsal pad.
In her practice, Dr. Sanders sees such female CEOs. “Unfortunately, in these cases, I am usually unsuccessful in treating neuroma with metatarsal pads, strapping or dress orthotics,” she says.
Instead, she goes straight for a series of three ultrasound guided corticosteroid injections, spacing them several weeks apart. If there is no improvement with the corticosteroid injections, Dr. Sanders orders MRI, with and without contrast, to confirm the neuroma’s position, size and location.
Once she confirms the location and dimensions of the neuroma, Dr. Sanders will proceed to give up to eight sclerosing injections, spacing them two weeks apart. Dr. Kashanian sees a series of alcohol sclerosing injection as “a last conservative modality” to eliminate the pain cycle.
Dr. Kashanian says one can introduce serial corticosteroid and lidocaine injections to a specific interspace to decrease the inflammatory process during a 12-month period. She notes that an oral anti-inflammatory regimen of once-a-day prescription meloxicam or celecoxib as well as prescription topical Voltaren gel can aid in reducing the inflammatory process. As she notes, many podiatric physicians have started using oral gabapentin (Neurontin, Pfizer), pregabalin (Lyrica, Pfizer) and Metanx (Pamlab) to decrease the neuritic pain associated with Morton’s neuroma. Should conservative treatments fail, Drs. Sanders and Andersen recommend surgical excision.
Dr. Andersen is in private practice in Chapel Hill, N.C. She is the Past President of the American Association for Women Podiatrists, and is a podiatric expert for Caring.com .
Dr. Kashanian is in private practice in Los Angeles. She is a Medical Consultant for ProLab Orthotics in Napa, Ca.
Dr. Sanders is an Adjunct Clinical Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. She is in private practice in San Francisco.
1. Lower extremity changes experienced during pregnancy. Ponnapula P, Boberg JS. J Foot Ankle Surg. 2010; 49(5):452-8.
2. Vullo VJ, Richardson JK, Hurvitz EA. Hip, knee, and foot pain during pregnancy and the postpartum period. J Fam Pract. 1996; 43(1):63-8.
3. Scherer PR. Functional hallux limitus and hallux valgus. In: Scherer PR (ed.), Recent Advances in Orthotic Therapy. Lower Extremity Review, Albany, N.Y., 2011, pp. 57-67.
4. Surve I, Schwellnus MP, Noakes T, et al. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the sport-stirrup orthosis. Am J Sports Med. 1994; 22(5):601-606.
Editor’s note: For related articles, see “A Closer Look At Orthotic Solutions For Women’s Shoes” in the December 2009 issue and “Key Insights On Prescribing Orthoses For Dress Shoes And Sandals” in the August 2004 issue. For other related articles, visit the archives at www.podiatrytoday.com .