Following surgery, orthoses can be crucial in helping restore altered lower extremity biomechanics. These expert panelists discuss when to prescribe post-op orthoses, how patients can benefit, and what orthotic modifications are most effective.
For which lower extremity conditions do you prescribe post-op orthoses? What kind of benefits do these patients see?
All four panelists note orthoses can be beneficial for patients in restoring lower extremity biomechanics postoperatively.
Jane Andersen, DPM, always prescribes orthotics postoperatively for hallux valgus correction as biomechanics often contribute to the deformity. She might consider orthotics in a patient with hallux limitus who has a joint preservation procedure or would consider orthoses for a patient who has difficulty ambulating normally following a fusion procedure. In addition, Dr. Andersen says any rearfoot procedure involving the posterior tibial tendon, such as a Kidner or tendon debridement, would warrant the use of post-op orthoses.
Whenever patients have a procedure that changes their biomechanical function, David Levine, DPM, CPed, agrees that such patients should have postoperative evaluation for orthotic devices.
“The foot is like a jigsaw puzzle. All the pieces fit together a certain way,” says Dr. Levine. “When one of the pieces changes, it can change the look and function of the entire puzzle. Orthotic devices are a great way to accommodate the changes an aid in improving function.”
As Dr. Levine notes, the benefits of post-op orthoses include enhanced comfort and improved function. He adds that the key to optimizing the function of the orthotic devices is to ensure that the orthotic devices not only fit the foot, but also fit the shoe.
Likewise, Karen Langone, DPM, says patients should have custom foot orthoses fabricated if the pathology for which they had surgery has a biomechanical etiology or component. She notes custom foot orthoses also work well for patients who develop new symptomatology related to their new biomechanical functioning.
Most frequently, Dianne Mitchell-Pray, DPM, will prescribe orthotics following bunionectomies, cheilectomies for hallux limitus and plantar fascia releases. As she explains, first metatarsophalangeal joint (MPJ) pathology originates from ground reactive forces pushing up or dorsiflexing the first metatarsal, or originates from pathology such as an everted heel or a pronated foot type, resulting in either buckling or jamming of the first MPJ respectively. Therefore, she notes such patients will benefit from a functional foot orthotic post-operatively because orthoses can control that hindfoot pathology and hopefully prevent recurrence and pain by avoiding a re-overloaded first metatarsal head.
Similarly, in the case of a plantar fascia release, Dr. Mitchell-Pray notes the function of post-op orthoses is to avoid transferring stress to the bony arch and plantar intrinsic musculature, as well as better redistribution of plantar pressure across a larger surface area. In her practice patients seem to benefit from orthoses, especially if at post-op follow-up, the pain has returned despite surgical intervention for these types of pathologies. Dr. Mitchell-Pray can cast those patients and create a molded total contact type device to redirect and redistribute pressures and reduce or diminish pain.
What are the indications for using orthotics postoperatively?
Any situation in which there is a change in the function of a joint should warrant post-op orthoses, according to Dr. Levine. Whether it is the first MPJ following a bunionectomy or more complicated midfoot or hindfoot procedures, he notes orthotic devices “play an integral role in the care of the patient.” As Dr. Levine explains, foot surgery can create asymmetry, similar to a car with a misaligned front end, in which the car pulls to one side and the tires wear unevenly.
“The same is true for our bodies,” says Dr. Levine. “That’s why alignment, starting with shoes and orthotic devices, is so important for overall function.”
For Dr. Mitchell-Pray, indications include any time the patient is having correction for distal pathology that was driven or caused by more proximal mechanical findings. She cites examples including hallux limitus, hallux valgus or first MPJ sesamoiditis caused by an everted heel or pronated hindfoot. As Dr. Mitchell-Pray explains, one would address the first MPJ surgically but not the everted heel. Therefore, she says the functional foot orthotic can control the everted heel or pronated foot shape to allow less pressure to the first metatarsal head and therefore less buckling or jamming of the first MPJ and then hopefully less pain and recurrence of the original deformity.
“I always explain this to my patients who present to the office wanting bunion surgery immediately when I meet them for the very first time,” says Dr. Mitchell-Pray. “I explain that conservative care preoperatively is valuable to start reducing and redistributing plantar pressures and postoperatively this is continued with orthotics.”
Dr. Andersen notes indications for post-op orthotics would be any biomechanical abnormality that might be contributing to the deformity or any biomechanical abnormality that might contribute to future deformities.
Are there any modifications you have found effective for post-op orthotics?
Dr. Langone chooses modifications based on an individual patient’s anatomy and functionality.
Dr. Langone says reverse Morton’s extensions can address first metatarsal positioning and function, while metatarsal pads can aid in the treatment of lesser metatarsal issues and neuromas. She will use heel lifts for limb length discrepancies and equinus, whether functional or structural. Dr. Langone notes arch reinforcement can provide greater shock absorption or better medial column control base on material choice. She uses valgus wedging with a reverse Morton’s extension to address ankle instability. A medial heel skive/Kirby skive can aid in slowing pronation, and extending the rearfoot post medially can also aid in slowing pronation, notes Dr. Langone. She adds that dancer’s pads and balance pads are some of the most common modifications she makes to orthoses.
Dr. Levine says a modification such as a reverse Morton’s extension for a hallux that is not effectively purchasing the ground following a bunionectomy or a first MPJ fusion can help in engaging the hallux during propulsion. For hindfoot procedures, he notes extrinsically posted orthotic devices are an effective modification depending upon how the patient is functioning. Adjusting the posting is an easy way to control the varus or the valgus deformities that might be present, adds Dr. Levine.
As Dr. Andersen says, the modifications for the orthotic devices are dependent on the deformity and the surgery. Oftentimes she will use a reverse Morton’s extension for a bunion correction or a joint preservation procedure with hallux limitus in order to increase the patient’s range of motion. If the patient has a significant posterior tibial tendon issue or pes planus, she sometimes will consider a Mueller TPD Foot Orthotic.
Some of Dr. Mitchell-Pray’s patients will present with pain postoperatively, either at the surgical site or elsewhere. She will try to salvage or modify orthotic devices first before considering a new pair of functional foot orthotics. Dr. Mitchell-Pray’s modifications include adding a simple topcover for padding to dampen the load on the entire plantar foot or adding a padded forefoot extension to reduce stress to the metatarsal heads. Frequently she will add a reverse Morton’s extension to allow additional first metatarsal plantarflexion to reduce ground reactive forces on post-op bunions.
Additionally, if the orthotic isn’t contacting the plantar arch like a glove, Dr. Mitchell-Pray says one can invert the orthotic or add arch fill on top of the device to create improved contact and mimic a total contact orthotic, which she notes is superior in order to best redistribute plantar pressures to a larger surface area and reduce pain.
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. Levine is in private practice at Foot and Ankle Specialists of the Mid-Atlantic in Frederick, Md. He is also the director and owner of Physician’s Footwear, an accredited pedorthic facility, in Frederick, Md., and the owner of Shoefly-Frederick.
Dr. Mitchell-Pray is in private practice at Mercy Medical Group, Inc. in Sacramento, Calif. She is a Fellow of the American Academy of Podiatric Sports Medicine and is Board Certified by the American Board of Podiatric Medicine.