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Orthotics Q&A

Tailoring Orthotic Modifications For Hallux Valgus, Flexible Hammertoe Deformities And Morton’s Neuroma

Recognizing the challenges and biomechanical issues involved with hallux valgus, flexible hammertoe deformities and Morton’s neuromas, these panelists share insights on the role of orthotic management for these conditions.

Q:

How can orthotics be helpful for patients with hallux valgus?

A:

Although orthotics will not reduce the bunion deformity, Jane Andersen, DPM, finds orthoses to be helpful in controlling joint pain, especially for people with developing hallux abductovalgus. As she notes, sometimes the orthotics seem to slow the progression of the deformity by correcting the faulty biomechanics. However, Dr. Andersen points out that orthotics may not be as beneficial for people who only have bump pain and no joint pain.

Karen Langone, DPM, feels orthotics have a valuable role both in the treatment and prevention of hallux valgus. As the bunion deformity arises from pathomechanics in the lower extremity, she says addressing these mechanics is an essential part of a successful treatment program. Orthotics will reduce or eliminate pain, stabilize the deformity and minimize progression, according to Dr. Langone. In those patients who are not surgical candidates, she emphasizes that orthotic management will provide comfort and allow continued ambulation.

“Certainly, though, there are times when a surgical approach is the best treatment for hallux valgus but orthotics are necessary following surgery to prevent recurrence,” notes Dr. Langone.  

If the goal of orthoses use is resolution and correction of the bunion, Jarrod Shapiro, DPM, notes that orthoses alone will not be helpful, emphasizing that correction of bunions requires surgery. He cites a randomized controlled study by Torkki and colleagues noting that surgery for hallux valgus decreased pain intensity more effectively than orthoses at six- and 12-month follow-up periods.1 Dr. Shapiro also notes Torkki and coworkers found that both surgery and orthoses were superior to watchful waiting for those with bunions. The authors concluded that orthoses were beneficial for symptomatic relief from hallux valgus.

For painful hallux valgus, Dr. Shapiro recommends surgery in the appropriate clinical setting. For those patients who either cannot have surgery or choose not to, his orthosis prescription centers on improving the hallux limitus component of the deformity (through minimal cast fill and/or a first metatarsal or ray cutout) and additions to decrease pronation when present (including modifications such as a varus heel post, deep heel cup, medial heel skive, etc.).

Q:

Can orthotics benefit patients with flexible hammertoe deformities?

A:

If the hammered digit itself is painful, Dr. Shapiro says surgery is more commonly successful than therapy with orthotics. In his practice, Dr. Shapiro sees a greater number of painful lesser metatarsophalangeal joints (MPJs) than intrinsically painful hammertoes with a primary diagnosis of predislocation syndrome/plantar plate disease. In cases like those, Dr. Shapiro says orthotic therapy often has a role with a focus on plantar pressure redistribution to just proximal to the metatarsal heads with modifications such as metatarsal bars.

As hammertoes are often caused by flexor stabilization in an unstable foot, Dr. Andersen says using a custom orthotic can help stabilize the foot, decreasing the pronation and the need for the toes to flex and stabilize in the gait cycle. If one adds a metatarsal pad, she says the pad can offweight any associated metatarsal stress syndrome and help a flexible digit function in a straighter position.

Dr. Anderson adds that rigid deformities are less likely to benefit from biomechanical control. Dr. Shapiro acknowledges a lack of evidence in the literature that orthoses will correct the etiology of hammertoes (flexor substitution or stabilization). Since extensor substitution is a swing phase phenomenon, he feels orthoses are unlikely to address this cause.

Dr. Langone and Dr. Andersen each say orthoses do have a role in hammertoe treatment. As Dr. Langone says, stabilization of the pathomechanics is part of a successful treatment plan for hammertoe.

Q:

What orthotic modifications are effective for patients with Morton’s neuroma?

A:

When using foot orthoses, Dr. Shapiro will approach Morton’s neuroma in a manner similar to patients with lesser MPJ complaints via offloading of the affected area. His orthosis modifications include a metatarsal bar pad, minimal cast fill, deep heel cup and medial heel skive in pronated feet. Dr. Shapiro will also use first and fifth metatarsal head cutouts to rebalance the forefoot in pes cavus deformities. Some variability exists in the prescriptions based on the biomechanical examination, notes Dr. Shapiro.

Likewise, Dr. Andersen has found success with using a metatarsal pad for Morton’s neuroma. Often, she will make the device thin enough so it will not take up extra room in the patient’s shoe.

The most important orthotic measures for Morton’s neuroma are the evaluation of the patient and capturing the correct impression of the foot, emphasizes Dr. Langone.

“All excellent orthotics begin with excellent impressions of the foot. This cannot be overstated,” maintains Dr. Langone.  

Dr. Langone will capture the foot image with the patient prone and in order to avoid excessive lordosis, she will place a small towel or pillow under the patient’s pelvis.  

When casting patients with Morton’s neuroma, she suggests one should achieve alignment of the entire lower extremity, hip to toe, and the patient’s spine must also be as neutral as possible. Additionally, she says one should ensure and capture plantarflexion of the first metatarsal in the impression. In general, Dr. Langone also includes a small soft metatarsal pad in her devices for those with Morton’s neuroma but also does so in patients with hallux valgus/limitus/ridigus.

For patients with Morton’s neuroma as well as hammertoe and hallux valgus, Dr. Langone will emphasize to her patients the benefit of targeted exercises to strengthen the intrinsic muscles and the use of digital stretching devices, similar to YogaToes, which she says have been “very successful” with patients. Dr. Andersen also recommends strengthening the instrinsic musculature in patients with hammertoes or who are developing hammertoe deformities.

Dr. Andersen is in private practice in Chapel Hill, N.C. She is a Past President of the American Association for Women Podiatrists and the current President of the North Carolina Foot and Ankle Society.  She is board-certified in surgery by the American Board of Foot and Ankle Surgery.

Dr. Langone is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine, and the treasurer of the American Association for Women Podiatrists. She is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Langone is in private practice in Southampton, NY.

Dr. Shapiro is an Associate Professor with the College of Podiatric Medicine at the Western University of Health Sciences in Pomona, Calif. He is the Director of the Chino Valley Medical Center PMSR/RRA Podiatric Residency in Pomona, Calif.

Reference
1.     Torkki M, Malmivaara A, Seitsalo S, et al. Surgery versus orthosis versus watchful waiting for hallux valgus. J Am Med Assoc. 2001; 285(19):2474-2480.

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