Where Orthotic Solutions Come Into Play For Women’s Shoes

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

   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.

References
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 .

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