Where Orthotic Solutions Come Into Play For Women’s Shoes

Guest Clinical Editor: Alona Kashanian, DPM

   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.

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