Sep 10

Written by: Larry Huppin, DPM
9/10/2009 1:32 PM

A 53 year old woman presented to the office this week with a primary complaint of pain under the first met head right. Her history was significant for an ankle fusion 2 years ago.

Exam was significant for pain on the tibial sesamoid and the fact that she as fused in 5 degrees of plantarflexion. In stance, her heel would not touch the ground unless her knee was in recurvatum. When I placed her knee in a mildly flexed (normal stance) position, I measured the heel off the ground by 9mm.

She wants to be active. She also would like to wear cute shoes occasionally.

Treatment Goal: Reduce pressure on the sesamoids by transferring force to the medial arch and by getting the heel to bear weight

Orthotic prescription:

• Material: Semi-rigid polypropylene. You could use either vacuum formed or direct milled
• Heel cup depth: Standard or shallow. Heel cup depth is not an important consideration as she is not excessively pronated
• Width: Wide. By making the device wide we will better transfer force off of the met heads onto the medial arch
• Cast fill: Minimum. Minimum fill will conform better to the arch and more effectively transfer force off the met heads
• Post: 0/0 post. Either EVA or Poly. We need to post so that we can attach a heel lift to the orthosis
• Additions: 9mm heel lift right. This will act to essentially “bring the ground up to meet the foot”, so that she doesn’t have to bear all the weight on her forefoot or put her knee into recurvatum.
• Cover and Forefoot Extension: A cover is optional. You may want to add a reverse Morton’s extension to transfer more pressure off of the 1st met head onto the lesser met heads. If so, you will need a cover.

This device will work great in her lace-up shoes. She does, however, also want to wear some cute shoes. So she also received a pair of dress orthotics. Here is that prescription:

• Material: Graphite
• Heel cup: shallow (for shoe fit)
• Width: Standard
• Fill: Minimum
• Cover: Vinyl cover to sulcus

This orthosis will act to transfer force off of the met heads and onto the arch, but does not address the equines. To compensate for that a heel lift will need to be added to her shoe. A good pedorthist should be able to handle that easily.

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