Assessing Orthotic Quality
So often we are asked to evaluate patients who
Orthotic Treatment for Bunions
Jane Andersen, DPM, Gene Mirkin, DPM, Bruce Williams, DPM, and
James Clough, DPM, FACFAS, Neil Horsley, DPM, FACFAS
Jane Andersen, DPM, tells her patients orthotics will not take away the bunion deformity but they may control the pain and the progression of the deformity.
“I have certainly seen positive results with orthotic therapy for painful bunions in the past, provided that the pain is deep joint pain and not just bump pain,” says Dr. Andersen.
Orthotics never prevent tight shoes from pressing against prominent bunions, notes Gene Mirkin, DPM. In fact, both he and Bruce Williams, DPM, say the added space these devices occupy may make the shoe tighter, which increases pain. Accordingly, for tight dress shoes and heels, Dr. Mirkin says there is no chance of a patient benefiting from an orthotic.
“Bunions are one of the toughest things to effectively treat with orthotics,” concurs Dr. Williams. Since most bunion deformities need extra space inside a shoe, Dr. Williams says patients may gain some biomechanical advantage and lose out to the foot being cramped in the shoe and aggravating the bunion that way. He says one can have some success with some patients utilizing a properly sized first ray cutout with PPT or Poron backfill in conjunction with a digital skive under the hallux.
When a patient does have a prominent bunion, one prone to irritation from rubbing, Dr. Mirkin acknowledges that an orthotic can help in the right shoe. When pronatory forces exist, he says correctly posted orthotics can decrease the rubbing of the bunion against the shoe and provide relief. For athletes, in whom running and jumping aggravate bunions, Dr. Mirkin says orthotics can be useful to avoid a surgical approach and relieve symptoms.
James Clough, DPM, FACFAS, notes most people have some limited motion of the first metatarsophalangeal joint (MPJ), which causes compression of the joint when the toe attempts to move. As he explains, patients may wind up partially mitigating this compression force by pushing the first metatarsal medially, which may cause a bunion in some people. Dr. Clough estimates that about 50 percent of his patients with a bunion respond positively with functional control of the foot, noting that orthotics help as one restores motion to the joint during gait. Therefore, Dr. Clough notes his main goal with the orthotic is improving motion of the first MPJ so he reduces the compression forces associated with a failure of the joint to move. Maximally plantarflexing the first metatarsal with minimal fill in the medial arch is necessary, according to Dr. Clough.
When it comes to orthoses for bunion deformities, Doug Richie Jr., DPM, FACFAS, says he has only had success with this in active athletes. A certain percentage of patients with bunion deformities have pain due to abnormal mechanics of the first MPJ but he says this is not “bump pain.” The increased dorsiflexion-inversion of the first ray with rearfoot pronation causes a reciprocal valgus torque on the hallux across the first MPJ, creating a painful ligamentous strain and joint compression across this joint, according to Dr. Richie. He notes that foot orthoses may have the ability to decrease overload of the first ray and perhaps increase stiffness of the first ray. Additionally, limiting dorsiflexion of the first ray and facilitating the dynamic forces that plantarflex the first ray can decrease the pain associated with hallux valgus, according to Dr. Richie. He notes this treatment requires the use of suitable footwear such as athletic shoes. Dr. Richie says this orthotic therapy is most effective during more vigorous sporting activities. He uses standard functional foot orthotic therapy intervention for the treatment of hallux valgus. Dr. Richie also notes the importance of having appropriate footwear to fit a full-length orthosis with a deep heel cup and normal width. He posts the rearfoot with 4 degrees of inversion and 4 degrees of motion. His patients wear a neutral suspension cast to capture forefoot to rearfoot deformities and notes the fabrication lab must intrinsically balance the deformity with minimal arch fill at the medial arch and transverse metatarsal arch. “I make sure the lab does not make the orthosis too wide as I want the first metatarsal to have freedom to plantarflex during terminal stance,” says Dr. Richie.
Similarly, Bruce Williams, DPM, acknowledges that the difficult part is explaining to patients that orthoses can help with function of the first ray but may take up more room in the shoe. Therefore, he says orthoses may cancel some or all of the improvement in function that patients could gain in relieving their bunion pain. Dr. Williams asks patients to upsize their shoes one-half or one full size for their orthoses. He uses a digital wedge or a Cluffy type wedge at the hallux or for all the digits to engage and plantarflex the first metatarsal head. Dr. Williams also uses a first ray cutout with a kinetic wedge modification to allow the first ray to plantarflex. Using a lateral wedge to dorsiflex the lateral column will often help to drive the forefoot toward the first MPJ as well, points out Dr. Williams.
In contrast, Dr. Clough believes a first ray cutout or reverse Morton’s extension is contraindicated. He says they would destabilize the foot by reducing the support of the medial arm of the tripod of the foot. As Dr. Clough notes, the ground reactive force will push the first metatarsal upward. Additionally, he says an orthotic cutout or accommodations always limit rather than improve weightbearing under a structure so first ray cutouts or reverse Morton’s extensions tend to encourage pronation late in stance as the medial leg of the supportive tripod is weaker. If weightbearing improves at this time, Dr. Clough believes this is due to late stance pronation when the foot should be resupinating at this time. He uses the P4 Wedge (Cluffy Institute) in all of these cases and has found it to be very effective at reducing symptoms and enhancing first MPJ motion. In a subgroup of people with bunions, Dr. Clough has noted a reduction in the intermetatarsal angle as the patient achieves maximal dorsiflexion of the joint.
Neil Horsley, DPM, FACFAS, will employ the P4 Wedge for sagittal plane deformities at the first MPJ. If the chief complaint of the bunion patient is a pain level greater than 8/10 and there is a change in daily activities, Dr. Horsley considers surgical options. If the bunion patient’s pain is less than 7/10 and there has been no change in the activities of daily living, Dr. Horsley considers the patient a candidate for orthoses if the history includes use of over-the-counter inserts and “better” shoes.
For such patients, he applies a proper low Dye strapping with appropriate accommodative apertures or padding. On the next office visit, if patients report a difference in pain using the strapping, he schedules a complete biomechanical evaluation for orthoses. In conjunction with a complete lower extremity biomechanical examination, visual gait analysis, computerized force plate analysis and neutral cast impression, Dr. Horsley orders custom devices based upon the patient’s biomechanical findings. He also considers posting for forefoot or rearfoot deformities, and makes necessary adjustments for any limb length discrepancy. Depending upon the etiology of the bunion deformity, his additions to the orthoses may include a first metatarsal head or first ray cutout, or a metatarsal raise while making every attempt to keep the device low profile for the best shoe fit.
Whatever your patient needs for their orthotic therapy, we can make it.
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