Where Orthotic Solutions Come Into Play For Women’s Shoes

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Author(s): 
Guest Clinical Editor: Alona Kashanian, DPM

Q:

What is your treatment of choice for a 16-year-old female tournament level tennis player with lateral ankle instability?

A:

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.

Q:

What is your treatment protocol for the 45-year-old female CEO in heels or dress shoes with recurrent Morton’s neuroma?

A:

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.

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