Where Orthotic Solutions Come Into Play For Women’s Shoes
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.