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GENERAL CONSIDERATIONS

Office management of foot and ankle problemsrequires an understanding of the interaction of thefoot and ankle and the shoe or device applied. The bio-mechanics of normal foot function and the effect ofthe disease entity being treated should be analyzed.The anatomy of the normal shoe, the function of eachcomponent, and the effect of modifying each of thesecomponents must be understood.2-4, 13,14 The practi-tioner should have a thorough knowledge of the avail-able orthoses and appliances and the effects of thesedevices on the foot and ankle.5,9

Most of the acquired forefoot deformities seen in theadult population are a consequence of poor-fittingfootwear. These include hallux valgus deformity,hammer toes, hard corns, interdigital neuromas, andplantar keratoses. Educating the patient about theeffects of improper shoes is the starting point of con-servative management. This education is often metwith resistance because ill-fitting shoes continue to bea hallmark of high fashion. It is often necessary toremind patients that there is no other part of the bodythey would consider putting in a container whoseshape is so drastically different from that body part fordaily dress. Comparing an outline of the patient’s footto his or her current footwear assists in conveying this

133

APPLIANCESTREATMENTArthritisTendon DysfunctionHeel PainLESSER METATARSALSCalluses and CornsNeuromasBunionettesFIRST METATARSOPHALANGEAL JOINTHallus ValgusHallux Rigidus

GENERAL CONSIDERATIONSSHOE ANATOMYTypes of UppersTypes of LastsTypes of SolesTypes of HeelsORTHOSESCustom OrthosesOver-the-Counter InsertsBRACESUniversity of California Biomechanics

Laboratory InsertsMarzano BracesAnkle–Foot Orthoses

Conservative Treatment of the FootKeith L. Wapner

C H A P T E R

4

134 PART I General Considerations

point (Fig. 4–1). Unless the patient is willing to acceptthat a change in footwear is indicated, both conserva-tive and operative intervention may be futile.

Proper fitting of the shoe should accommodate thevariations in the person’s foot.11 A set of consumerguidelines has been developed by the National ShoeRetailers Association, the Pedorthic Footwear Associa-tion, and the American Orthopedic Foot and AnkleSociety (Table 4–1). Foot width can expand up to twosizes and length by one-half size on weight bearing.For proper sizing of the shoe, the foot must be meas-

ured under weight bearing and late in the day becausethe foot expands in volume as much as 4% by the endof the day. Shoes should be fitted with the normallyworn socks. There should be a full finger breadth at thetip of the shoe at the end of the longest toe with thetoes fully extended.

The popularity of walking and jogging shoes hasmade proper-fitting shoes more socially acceptable.The breakdown of sexual stereotypes has allowed theredefinition of acceptable styles of footwear in manyworkplace environments. Acceptance of proper fit overtrends in style often adequately relieves a patient’ssymptoms.

Deformity of the foot and ankle caused by progres-sive disease entities often requires modification ofshoes or application of orthoses. The choice of theproper modification is based on a thorough under-standing of the effects of the disease on the normalfunction of the foot. Disease can compromise motorfunction, joint function, skin integrity, sensation, andproprioception. Once the effects have been assessed,the proper modifications should be prescribed to tryto restore normal function or protect the affected limbfrom further breakdown.

SHOE ANATOMY

Shoes can be broken down into various components.The upper is the part of the shoe that is seen from thetop. The outsole and heel form the bottom of the shoe,which contacts the ground. The insole contacts theplantar aspect of the foot inside the shoe (Fig. 4–2).

The shank extends from the heel breast (the front ofthe heel) to the ball of the shoe. The ball is the areaunder the metatarsal heads. The forepart extends fromthe ball to the tip, or end of the shoe. The toe boxdescribes the height of the shoe at this level. The vamp,part of the upper, extends from the tip back over theball and instep to the quarters, which join in the backof the shoe at the back seam. The Balmoral, or Bal last,shoe has the quarters meeting at the front of the throatof the shoe, with the vamp extending as the tonguebeneath them. The Blucher last has the quarters looseat the inner edge and is made to be laced over thevamp and tongue.

The last is the three-dimensional form that theupper of the shoe is made from (Fig. 4–3). Historically,all lasts were made by hand with no distinctionbetween the left and right foot until about 1820. In the1850s the ability to duplicate shoe lasts, mold theleather uppers, and attach them to the soles bymachine allowed the shoemaker to progress frommaking 1 pair of shoes per day to more than 600 perday. Over the next century and a half, the technology

Figure 4–1 Comparing the outline of a foot to a woman’sdress shoe demonstrates the disparity in shape.

TA B L E 4 – 1

10 Points of Proper Shoe Fit

1. Sizes vary among shoe brands and styles. Do notselect shoes by the size marked inside the shoe.Judge the shoe by how it fits on your foot.

2. Select a shoe that conforms as nearly as possible tothe shape of your foot.

3. Have your feet measured regularly. The size of yourfeet changes as you grow older.

4. Have both feet measured. For most persons, one footis larger than the other. Fit to the larger foot.

5. Fit at the end of the day when the feet are largest.6. Stand during the fitting process and check that there

is adequate space (3/8 to 1/2 inch) for your longesttoe at the end of each shoe.

7. Make sure the ball of your foot fits snugly into thewidest part of the shoe.

8. Do not purchase shoes that feel too tight, expectingthem to stretch.

9. Your heel should fit comfortably in the shoe with aminimum amount of slippage.

10. Walk in the shoe to make sure it fits and feels right.

National Shoe Retailers Association, the Pedorthic FootwearAssociation, and the American Orthopedic Foot and AnkleSociety: 10 Points of Proper Shoe Fit. Columbia, Md, NationalShoe Retailers Association, 1995.

CHAPTER 4 Conservative Treatment of the Foot 135

of manufacturing has rapidly progressed, just as thematerials available have.9

Lasting also describes the bottoming method that isemployed to attach the upper to the sole. Many tech-

niques have been used, and one shoe can be lastedwith more than one method, called combination lasting.Slip lasting involves sewing the upper pieces togethermoccasin style and gluing this to the midsole, givinga flexible construction. With board lasting, the upper isglued to a firm board, providing a stiff shoe; thismethod is often employed in athletic shoes to decreasepronation. A combination last can provide stabilityfrom a board-lasted heel and flexibility from a slip-lasted forefoot (Fig. 4–4).

Types of UppersMany different materials are available for constructingthe upper of the shoe. Traditionally, leather has beenemployed because of its durability, moldability, andbreathability. Athletic shoes are made from soft nylon,mesh nylon, and canvas reinforced at the counter, toebox, or vamp with leather, rubber, or plastics for addedstability. This combination allows the shoe to belighter but still stable. The nylon mesh shoe may beuseful in accommodating deformities of the lessertoes.

Leather uppers can be stretched to accommodateforefoot deformities, but the extent of shoe deforma-tion is limited. The toe box should have the height and width to properly fit the foot. If friction againstthe skin is a concern, as in a neuropathic foot, a

Foxing

Heel

Quarter

Welt

Wing tip Out sole

Perforations fordecorations

Vamp

Eyelet row

Lining

Heel

Heel breast

Welt

Vamp

Eyelet row

Tongue

Durable rubberoutersole

Flexion grooves

Lace lock

Variable-widthlacing

Upper

Achilles’ notch

Heel collar

Stabilizing bar

Flared heel

Outersole

Variable-height tread

Contoured midsoleMulti-density midsole

Sockliner

Shock-absorbingmidsole material

Stabilizing straps

Flex point

Toe wrap

Toe box

Durablerubberoutersole

Exposedmidsole

Pivotpoint

Heel counter

Top lines

Bal pattern

Blucher pattern

Figure 4–2 Structural components of the shoe.

Heel lift

Toe spring

Medial curvature

Lateral curvature

Heelseat

Ball ar

ea

Heel girth

Inst

ep g

irth

Wai

st g

irth

Bal

l girt

h

Figure 4–3 Diagram of the last, the form on which the shoeis made. (Adapted from Frey C: Shoe wear and pedorthicdevices. In Lutter LD, Mizel MS, Pfeffer GB [eds]: OrthopedicKnowledge Update: Foot and Ankle. Rosemont, Ill, AmericanAcademy of Orthopaedic Surgeons, 1994.)


heat-moldable foam (Thermold) upper may beemployed.

Several patterns of lace stays are available, and eachhas its own advantage (Fig. 4–5). The Blucher pattern,with no seam across the instep, has the advantage ofallowing easier entry into the shoe. The Bal pattern canprovide more stability, but the entry is limited andmight not accept an orthotic device. The U-throat and

lace-toe patterns allow the shoe to open even widerand may be useful in accepting an orthosis or allow-ing entry into the shoe after hindfoot fusion.

Many lacing patterns can secure a better fit of theshoe (Fig. 4–6). Athletic shoes often have multipleeyelets to allow for different lacing techniques. Bychanging the lacing to avoid crossing the dorsum of the foot, pressure can be relieved over bony

RIB LASTING

TacksStaplesCement

Goodyear weltCement weltSilhouwelt

FLAT LASTING

TacksStaplesCement

Mc KayMc Kay weltLittlewayCementNailed

PRE-WELTEDLASTING

Tacks orholdingdevices

Pre-welt

ThreadCement

StitchdownOne soleTwo soleThree sole

LASTING UP

MOCCASINSEAM LASTING

TacksCementThread

Moccasin

LASTING DOWN Slip lasted

Thread

SLIP LASTING

STRING LASTING

StringsThread

String lasted(bottom view)

Turns

TacksThread

FORCE LASTING

TURN LASTING

Figure 4–4 Lasting techniques used to attach the upper to the sole. (Adapted from Gould N: Footwear: Shoes and shoe mod-ifications. In Jahss MH [ed]: Disorders of the Foot and Ankle: Medical and Surgical Management, ed 2, vol 3. Philadelphia, WBSaunders, 1991, p 2885.)

Blucher Bal

U-ThroatA B C D

Figure 4–5 Lace stay patterns. A, Blucher pattern, with no seam across the instep, has the advantage of allowing easy entryinto the shoe. B, Balmoral pattern may provide more stability, but the entry is limited and might not accept an orthotic device.C, The U-throat or lace-toe patterns allow the shoe to open even wider and may be useful in accepting an orthosis or allowingentry into the shoe after hindfoot fusion. D, Diagram of patterns of lace stays.


prominences or a high-arched foot. Wide or narrowfeet can be secured by different lacing patterns.

Once the proper material, shape, and lacing patternof the shoe have been determined, it may still be nec-essary to stretch the upper to avoid pressure over bonydeformities. With the patient standing and bearing fullweight on the affected foot, the area of impingementcan be identified and marked. A shoemaker’s wand canstretch the shoe at this area (Fig. 4–7).

Types of LastsShoe manufacturers have many different lasts, andthere is great variation in the fit of shoes that arelabeled with the same size. A shoe manufacturer mighthave 30 to 60 active last styles with 80 to 90 sizes foras many as 5000 different lasts.9 Thus it is difficult todefine a normal last.

The concept of a corrective last is not accurate becausethe last cannot correct a deformity. Lasts come inseveral general categories (Fig. 4–8). A conventionallast is made in right- and left-foot shapes. A straightlast has a straight medial border from heel to toewithout curving at the toe box. Women’s dress shoescan simulate a straight last on the medial side and havethe point of the toe box at the end of the great toe. The

outflare last, or reverse last, flares to the lateral side ofthe shoe and is often employed after treatment formetatarsus adductus. The inflare last curves mediallyand is used in athletic shoes, with a 7-degree curve toallow greater mobility of the foot.6

Types of SolesTraditionally, soles of shoes were constructed ofleather. In dress shoes this material is still commonlyused. Soles in athletic, work, and recreational shoes are

E F G

A B C D

Figure 4–6 Patterns of lacing. A, Variable for wide fit. B, Vari-able for narrow fit. C, Independent, using two laces. D, Criss-cross to avoid bony prominences. E, High arch pattern toavoid lacing crossing top of foot. F, Pull-up pattern to allowrelief of pressure on toes. G, Crisscross loop pattern to avoidheel blisters. (Adapted from Frey C: Shoe wear and pedorthicdevices. In Lutter LD, Mizel MS, Pfeffer GB [eds]: OrthopedicKnowledge Update: Foot and Ankle. Rosemont, Ill, AmericanAcademy of Orthopaedic Surgeons, 1994, p 78.)

A

BFigure 4–7 A, Shoemaker’s wand. B, Stretching shoe withthe wand.


generally made from rubber compounds. Microcellu-lar blown rubber compounds and polyurethane areused for midsole and wedges. Black carbon rubber andstyrene–butadiene are very hard-wearing compoundsused for outsoles. Ethyl vinyl acetate is also commonlyused in running shoes for its flexibility and impact-absorbing properties. Manufacturers often combinethe blown rubber for impact resistance covered byblack carbon rubber for wear on the outsole. The supe-rior impact absorption of these rubber and syntheticmaterials can be used to decrease pressure and loadingof the foot and ankle. As a result, many manufacturersnow offer dress shoes with soles made of these materials.

Traction between the shoe and the floor can be influ-enced by the material of the sole and the pattern onthe outsole. Various patterns have been developed fordifferent sports (Table 4–2). The pattern and amountof friction can also influence how well a patient withbalance or proprioceptive loss can tolerate a shoe. Toomuch friction can cause a patient to stumble, whereasloss of friction with a slick surface can be equally dangerous.

The outsole of the shoe can be modified (Fig. 4–9).A medial wedge can be used to decrease forefoot ever-sion, and a lateral wedge can be used to decrease fore-foot inversion in a flexible foot.

Various metatarsal bars have been described fortreating metatarsalgia. The principle is to have the barplaced proximal to the metatarsal heads to adequatelyrelieve pressure under the area of greatest loading.

Rocker soles are often useful in unloading the forefootand decreasing the need for metatarsophalangeal jointdorsiflexion. Rocker soles allow a better gait patternwhen used with rigid bracing of the foot and ankle.

Types of HeelsThe materials used for the heel are similar to thoseused for the sole. The decision about the material usedshould stem from the demands placed on the foot.Many modifications of the heel have been described(Fig. 4–10). The Thomas and Stone heels were used to help prevent pronation. Medial and lateral heelwedges help block heel eversion and inversion, respec-tively. These wedges should be used with a rigid heelcounter to effectively grip the heel and produce thedesired effect. External heel wedges have an advantageover inserts by not raising the heel out of the counter,which allows for a better grasp of the heel.

Flared and offset heels allow for a broader base ofsupport in walking. These heels decrease the amountof subtalar motion in patients with arthritis. A lateralflare can help prevent ankle sprains in patients withchronic instability. The offset heel is often useful with bracing in patients with advanced hindfoot deformities.

The solid ankle cushion heel (SACH), or plantarflexion heel, is also useful with bracing when anklemotion is lost (Fig. 4–10G, H). It uses a wedge of softcompressible material within the heel. It may be com-bined with a rocker sole to compensate for decreasedankle dorsiflexion and plantar flexion. The degree ofrocker-bottom effect is controlled by the height of theheel, thickness of the wedge, and position of the rockerbottom.

Heel lifts are used to compensate for leg-length dis-crepancy. These may be all external or combined withan internal device on the shoe. These are often useful

A

C D

B

Figure 4–8 Lasts. A, Conventional. B, Straight. C, Outflare.D, Inflare. (Adapted from Gould N: Footwear: Shoes and shoemodifications. In Jahss MH [ed]: Disorders of the Foot andAnkle: Medical and Surgical Management, ed 2, vol 3.Philadelphia, WB Saunders, 1991, p 2903.)

TA B L E 4 – 2

Outsole Options for Athletic Shoes

Running Shoes Field ShoesWear-area reinforcement Multiclaw or stud designsCantilevered designs for Asymmetric studs

shock absorption

Court Shoes Hiking and Climbing BootsPivot points Traction and wear lugsHerringbone patternSuction-cup designsRadial edges

Adapted from Frey C: Shoe wear and pedorthic devices. In LutterLD, Mizel MS, Pfeffer GB (eds): Orthopedic Knowledge Update:Foot and Ankle. Rosemont, Ill, American Academy ofOrthopaedic Surgeons, 1994, p 295.


as a temporary device when the opposite extremity isplaced in a prefabricated walking cast. These walkingcasts usually have a built-in rocker-bottom and arehigher than the patient’s normal shoe. Patients whohave difficulty with this temporary leg-length discrep-ancy can be helped by application of a lift to the oppo-site shoe to compensate. A heel lift may also be usedwhen a SACH and rocker bottom have been appliedto the opposite shoe.

When the outsole and heel of the shoe for posturalabnormalities are modified, the shank of the shoeshould afford some flexibility to allow the foot torespond to the correction applied. When arthritic con-ditions of the midfoot and forefoot are treated, theshank should be stiffened to decrease the motion ofthe foot.

The advances in shoe manufacturing and materialshave led to a new popularity of running and walking

A B C D

FE G HFigure 4–9 Outsole modifications. A, Lateral sole wedge. B, Medial sole wedge. C, Mayo’s metatarsal bar. D, Flush’s metatarsalbar. E, Denver’s heel. F, Hauser’s bar. G, Rocker sole. H, Extended rocker sole. (Adapted from Gould N: Footwear: Shoes andshoe modifications. In Jahss MH [ed]: Disorders of the Foot and Ankle: Medical and Surgical Management, ed 2, vol 3. Philadel-phia, WB Saunders, 1991, p 2907.)

CA B D

E F G HFigure 4–10 Heel modifications. A, Thomas heel. B, Stone heel. C, Reverse Thomas and Stone heel. D, Flare heel. E, Offsetheel. F, Plantar flexion heel. G, Medial wedge heel. H, Lateral wedge heel. (Adapted from Gould N: Footwear: Shoes and shoemodifications. In Jahss MH [ed]: Disorders of the Foot and Ankle: Medical and Surgical Management, ed 2, vol 3. Philadelphia,WB Saunders, 1991, p 2906.)


shoes. In general, these shoes allow better fit of theforefoot and greater cushioning of the foot and ankle.The popularity of these shoes helps in the treatmentof many foot and ankle problems without the need toprescribe the traditional orthopaedic oxford. Patientacceptance of this type of footwear affords greatercompliance with treatment.

ORTHOSES

Orthoses are devices that can be placed inside a shoeto help accommodate anatomic abnormalities or torelieve pressure or stress at a specific site on the footor ankle. They function by applying a force on thebody in a controlled manner to achieve a desiredresult, that is, transfer of pressure or restriction ofmotion. Orthotic devices range from simple shoeinserts to braces. The popularity of shoe inserts forrunners has led to many anecdotal claims about theefficacy of their use. There are few controlled studiesto confirm these claims.

It should be remembered that orthoses are accom-modative devices and not corrective devices. There isno evidence that an orthosis can correct or prevent thedevelopment of hallux valgus or other deformities orprevent knee, hip, or back arthritis. Given the correctindications, orthoses can be very effective in clinicalmanagement of many foot and ankle problems.

It is not always necessary to use a custom orthosis.For the accommodation of many forefoot- and heel-related problems, over-the-counter devices may beequally effective at a considerably lower cost. Theabuse and overprescribing of custom inserts has ledmost medical insurance companies to deny paymentfor these inserts. Familiarity with the over-the-counterdevices allows the treating physician to direct thepatient on how to use these devices effectively.

Custom OrthosesCustom orthoses can be rigid, semirigid, or soft. Rigidorthoses are generally used to diminish motion in thetreatment of arthritis of the midfoot or forefoot. Thedevice stiffens the shoe and functions similar to a steelshank within the shoe. Patients with plantar promi-nences or significant fat-pad atrophy might find thesetoo uncomfortable to wear. A rigid orthosis has beenprescribed to block pronation but may be no moreeffective than a semirigid device and may be more dif-ficult to tolerate. Rigid orthoses offer no shock-absorb-ing properties and should be avoided in patients withimpaired sensation.

Semirigid orthoses are the most commonly pre-scribed inserts. Unlike rigid orthoses, they offer shock

absorption and some flexibility while still providingtensile strength and durability. They are used tosupport and stabilize flexible deformities and relievepressure by weight transfer. Combinations of materi-als are often used; the inserts are generally thicker thanrigid inserts and might require the patient to wear adeeper shoe. The materials used include leather, poly-ethylene compounds, closed or open cellular rubbercompounds, cork, felt, and viscoelastic polymers.

Soft orthoses offer the most cushioning and impactabsorption and reduce shear forces of friction in theinsensate foot. They can be used to accommodate fixeddeformities and may be combined with a semirigidmaterial to gain better mechanical properties. Theseinserts are generally thicker than the rigid orthoses andrequire the use of an extra-depth shoe. The materialsused are polyurethane foam, polyvinyl chloride foam,and latex foam.

There are several commonly prescribed footorthoses made in accordance with these various rigidi-ties (Fig. 4–11). Shaffer’s orthosis, made of rigid orsemirigid materials, incorporates a concave heel cup,convex longitudinal arch support, and medial heelwedge and is prescribed to control hindfoot prona-tion. Mayer’s orthosis is a three-quarter-length inlay ofsemirigid material with a metatarsal pad to relievepressure under the heads of the metatarsals. TheWhitman orthosis is a rigid orthosis prescribed toblock pronation. It consists of a concave heel cup,medial convexity under the navicular, and lateral wallflange at the cuboid. The pump, or cobra, insert allowsthe calcaneus to rest on the insole and uses a cuppedheel and medial support to stabilize the hindfoot. Its low profile allows its use in a pump dress shoe.Morton’s orthosis, of semirigid material, extendsbeyond the first metatarsal to redistribute weightbearing under the metatarsal head.

The Levy mold is a full-length orthosis that extendsfrom the heel to the tip of the shoe. It is made from apositive mold of the foot in subtalar neutral positionand can incorporate various corrections to accommo-date fixed deformities and weight transfer. It can bemade of a combination of rigid, semirigid, and softmaterials and requires the use of an extra-depth shoe.The full-length cushioned inlay is made of compress-ible soft materials and reduces compression, friction,and impact on the foot.

Over-the-Counter InsertsWith the advances in material used in shoe manufac-turing, it is often possible to accomplish many of thegoals of orthosis without the expense of custom-molded inlays. Several companies offer padded insolesfor shock absorption and heel cushioning (Fig. 4–12).


A

B

D

F

G

C

EFigure 4–11 Types of orthoses. A, Shaffer, to reduce hindfoot pronation. B, Whitman with medial and lateral flange, to preventheel valgus. C, Low profile University of California Biomechanics Laboratory (UCBL) insert, to control hindfoot motion. D, Semi-rigid full length. E, Cobra, or pump, insert for dress shoe. F, Three-quarter-length rigid with leather cover. G, Plastazote, PPT,Nora composite in sole.


Spenco, Viscopeds, Dr. Scholl’s, and other companiesprovide padded insoles and inlays that can be effectivein providing relief for metatarsalgia and fat-padatrophy. The addition of metatarsal supports, such asthe Hapad longitudinal metatarsal pad on a cushionedinlay or in a shoe with a soft sole, can effectively relievemetatarsalgia or neuroma symptoms. Various heelinserts, such as Visco heels or Tuli heel cups, are oftenhelpful in treating plantar heel pain. These devices arereadily available through medical supply catalogs andare often found in pharmacies and athletic shoe stores.Patients should be educated on their proper placementand use.

Once the patient has been evaluated and the desiredcorrection chosen, the proper footwear should be

selected. In some instances, this may be all that isneeded. If additional correction is needed, off-the-shelf items should be considered. The cost to thepatient is considerable for custom orthoses, and moreinsurance companies now refuse payment for anyorthosis that does not cross the ankle joint. If adequatecorrection cannot be accomplished, custom orthosescan be prescribed.

BRACES

Three types of braces that have proved useful in treat-ing foot and ankle problems are the ankle–footorthoses (AFO) of either molded polypropylene or

A B

C D EFigure 4–12 Over-the-counter inlays. A, Visco heel cushion and Tuli heel cup. B, Hapad longitudinal metatarsal support. C,Spenco liner. D, Combination Spenco liner and Hapad. E, Viscoped.


double-upright construction, Marzano braces, andUniversity of California Biomechanics Laboratory(UCBL) inserts.

University of California BiomechanicsLaboratory InsertsThe UCBL insert controls flexible postural deformitiesby controlling the hindfoot.9 The brace should bemolded with the heel in neutral position. To work suc-cessfully, the brace must be able to grasp the heel andprevent it from moving into valgus. By keeping the calcaneus in neutral position, the brace stiffens thetransverse tarsal joints, and pronation and forefootabduction can be diminished (Fig. 4–13). It may benecessary to add medial posting to the heel and frontof the brace to keep the heel out of valgus. As medial

posting is added, it may be necessary to lower themedial trim line to avoid impingement on the medialmalleolus.

In fixed deformities, such as arthritis of the midfoot,a UCBL insert can decrease motion and relieve pain.The manufacture of the brace is modified for thisapplication. The foot is molded in situ, and thepolypropylene should have a relief over the area ofbony prominence. The brace can be lined with a mate-rial for pressure absorption such as polyurethane foam(PPT) in the relief, and then the entire brace can becovered with a material such as polyethylene foam(Plastazote) to resist shear forces (Fig. 4–14).

Marzano BracesThe Marzano brace (Fig. 4–15) combines a UCBLinsert with an anterior shell and a hinged ankle. It hasbeen employed to treat various foot conditions. It pro-vides greater support than the UCBL and allowsmotion of the ankle.

Ankle–Foot OrthosesAFOs can be made from double uprights attached tothe shoe or molded polypropylene either as a poste-rior shell or incorporated into a leather lacer (Arizonabrace) (Fig. 4–16). The molded AFO is more effectivein most instances. The brace can be made with a fixedor hinged ankle. The brace is manufactured from apositive cast of the lower limb and can be lined withshear-resistant material such as Plastizote. Modifica-tions can be made through reliefs over bony promi-nences to accommodate fit, and these can be linedwith PPT under the Plastizote to afford pressure relief.These modifications of the brace allow better controlof deformities and expand the use of these braces torigid, as well as flexible, deformities.

TN

CC

CC

TN

Figure 4–13 Function of the transverse tarsal joint, asdescribed by Elftman, demonstrates that when the calcaneusis in eversion (left), the resultant axes of talonavicular (TN) andcalcaneocuboid (CC) joints are parallel. When the subtalarjoint is in inversion (right), axes are nonparallel, givingincreased stability to the midfoot.

A B CFigure 4–14 University of California Biomechanics Laboratory (UCBL) insert lined and with posting and relief. A, Front view. B,Rear view showing medial posting. C, UCBL insert controlling heel valgus.


The molded AFO can provide stability to one orseveral joints of the foot and ankle complex. The trimline can be modified, depending on the rigiditydesired. To diminish ankle motion, the trim linesshould extend anteriorly to the midline of the malle-oli, but the foot plate can end at the metatarsal heads.If one is controlling subtalar or transverse tarsalmotion, the trim lines can be cut behind the malleolito allow some ankle motion. If one is controllingmidfoot arthritis, it may be necessary to use a full footplate. A SACH heel can provide a smoother gait patternfor most patients. If a full foot plate is used, a rocker-bottom sole should be considered. In patients with anormal ankle joint, a hinged ankle may be employedto allow ankle motion.

The Arizona brace AFO can be constructed witheither lace or hook-and-loop (Velcro) closures. It pro-vides stability to the hindfoot through three-point fix-ation similar to a short-leg cast. It has the advantage

of being lower than a standard molded AFO and mighthave better patient acceptance.

APPLIANCES

Various appliances have been developed for the treat-ment of forefoot deformities. Pads and cushions canbe effective in relieving pain but will not correctdeformities. Padding is effective only if the shoe is thecorrect shape and material. Pads take up additionalspace within the shoe and can increase pressure if thetoe box is too small.

A toe crest can be effective in relieving pressure onthe tips of the toes from hammer toe and mallet toedeformities. Corn and callus pads can also relieve pres-sure but are more effective if the overlying callus andcorn tissue is removed and the shoe is stretched overthe offending prominence or a wider toe box isemployed. Foam or gel (Silipos) sleeves can also effec-tively relieve pressure (Fig. 4–17). Toe separators canbe used, but lamb’s wool can be equally effectivebetween the toes and has the advantage of betterabsorption of moisture than the separators have.

TREATMENT

ArthritisBracing can be effective in the treatment of arthritis ofthe foot and ankle by decreasing the pressure andmotion across the affected joint. Braces should becustom molded and padded appropriately over anybony deformity. The patient must understand that abrace does not cure the problem but can offer an effec-tive means of controlling symptoms if he or she wishesto avoid surgery.

Figure 4–15 Marzano brace.

A B C DFigure 4–16 A, Molded ankle–foot orthosis (MAFO) with standard foot plate. B, MAFO with full foot plate. C. Arizona bracewith lace closure. D. Arizona brace with hook-and-loop (Velcro) closure.


For ankle and subtalar arthritis, a molded AFO witha fixed ankle or Arizona brace is most effective. Insome patients with normal ankles and diseaserestricted to the subtalar joint, a molded AFO with ahinged ankle or a UCBL with high trim lines can beused. Often, these patients use the AFO for heavy activ-ities and the UCBL for light activities of daily life.

For arthritis restricted to the transverse tarsal and tar-sometatarsal joints, the same principles apply, but thesuccess rate of the UCBL is much higher. A SACH androcker-bottom sole can increase the effectiveness of thebrace and afford the patient a more normal gaitpattern. Patients often need to change the lacingpattern on their shoes to avoid pressure over dorsalspurs.

Tendon DysfunctionChronic tendon tears can lead to significant pain anddeformity if left untreated. Although surgical recon-struction has proved successful, some patients are not

candidates for surgery because of concomitant medicalconditions, whereas others wish to undergo surgicalintervention. For chronic dysfunction of the Achilles,peroneal, and anterior and posterior tibial tendons, acustom-molded AFO4 or Arizona brace,1 usually linedwith Plastizote, can effectively control symptoms.These braces can be combined with a rocker bottomor SACH heel to give a better gait pattern, although arunning shoe may be satisfactory.

Patients should understand that the purpose of thebrace is to control the position of the foot and hope-fully prevent progression of any deformity. If signifi-cant tendon damage is present, the brace will not becurative and the patient can decide between using apermanent brace or having reconstructive surgery.

In instances of tendinitis or early tendinosis, pro-longed use of a molded AFO for ambulation can allowfor healing. This has been successful in managing earlytendinosis. Bracing is continued until the swelling,bogginess, and tenderness have resolved, and thenprogressive mobilization and physical therapy are

A

C

B

DFigure 4–17 Examples of common forefoot appliances. A, Toe crest, to elevate tips of toes. B, Silipos digital cap, to relievepressure on toes. C, Tube foam, to relieve pressure on toes. D, Callus pad.


prescribed. If the objective changes have not resolvedwithin 6 months, bracing has proved not curative andthe patient has the option of continuing with bracingas the elected form of treatment or choosing surgicalcorrection.

In patients with complete tendon rupture, bracingcan be effective for pain relief and providing increased,although not normal, function. With long-standingrupture there is often a fixed deformity of the foot andankle complex. For bracing to be effective, the moldmust incorporate reliefs and padding over bonyprominences. An outflare heel may be needed tosupport the brace in the shoe and provide an adequatebase of support in advanced deformities.

Heel PainThe role of inserts in treating chronic heel painremains controversial. It is an area with an abundanceof anecdotal treatment but a paucity of scientificknowledge. Part of this problem comes from the diffi-culty in diagnosing a specific cause of heel pain. Recommendations for inserts for heel pain vary fromthe use of a rigid orthosis to soft pliable inserts.12

Recent studies cast doubt on inserts being effective inthe treatment of heel pain, but this might reflect theoverprescription of these devices without the properindications.7,8

In patients with atrophy of the heel fat pad, softinserts and a well-padded shoe would be indicated. Forchronic plantar fasciitis, soft inserts may be indicatedfor shock absorption if overuse is a causative factor.Over-the-counter devices and appropriate shoes can beas effective as custom devices at significantly less cost.This treatment should be combined with other treat-ment modalities.

Night splints for the treatment of chronic plantarfasciitis has been shown to be effective.15 Although the original studies were performed using a custom-molded AFO with full foot plates, over-the-counteralternatives are now readily available and appear to beequally effective.

LESSER METATARSALS

Calluses And CornsCallus and corn formation occurs in response to exces-sive pressure over a bony prominence. This may be theconsequence of a loss of the normal fat pad withoutdeformity, secondary to pressure developing inresponse to deformity, improper footwear causingpressure in an otherwise normal foot, or wearingimproper shoes on an abnormal foot. Adequate man-

agement of these problems requires patient educationand acceptance of appropriate shoes. Removal of theoverlying hyperkeratotic tissue by paring the lesionproduces significant relief of symptoms16 (Fig. 4–18).To prevent recurrence of the lesion, the shoe must bemodified to keep pressure off the affected area.

For plantar callosities, recurrence can be preventedby an appropriately sized metatarsal pad placed prox-imal to the lesion. The pad can be placed directly inthe shoe or on a padded inlay that can be transferredfrom shoe to shoe. For dorsal corns, after the removalof the hyperkeratotic tissue, toe sleeves or toe crestsmay be effective (Fig. 4–19). Stretching the toe boxabove the affected toe also helps relieve pressure anddecreases the rate and incidence of corn formation.

The commonly found corn over the dorsal andlateral aspects of the fifth toe without deformity is seenin patients wearing pointed dress shoes. Paring is ini-tially effective; however, the lesion recurs if thefootwear is not modified. If the patient is unwilling tochange his or her footwear, the shoe should be pre-stretched with a shoemaker’s wand over the affectedtoe to help decrease the pressure. Surgery in thisinstance is rarely successful if the patient is unwillingto change his or her shoe style. The success of shoe

A

BFigure 4–18 A, Number 17 blade for paring callus has nosharp points but rounded edges. B, Paring callus.


modifications when accepted by the patient makessurgery rarely indicated.

In some patients, a tongue pad can prevent thepatient’s foot from sliding forward in the shoe whenwalking and can increase the effectiveness of the othermodalities (Fig. 4–20). This is also helpful when ham-mering has progressed from instability of the metatar-sophalangeal joints to subluxation, dislocation, orcrossover deformities. In these cases, the addition of ametatarsal pad is indicated to relieve plantar pain.

Taping can add stability to the metatarsophalangealjoint with a hammer toe deformity. A strip of 1/4-inchtape can be looped over the base of the toe to mimicthe force of the intrinsic muscles and plantar plate(Fig. 4–21). This loop should be applied in themorning and removed at the end of the day. It can helppatients with crossover deformities and subluxatinghammer toe deformities.

NeuromasInterdigital neuromas can often be successfully treatedwith appropriately placed and sized metatarsal sup-ports (Fig. 4–22). A custom-molded orthosis is rarelyindicated. If a custom orthosis is prescribed, rigidmaterial at the distal end of the orthosis should beavoided. In my experience, a longitudinal metatarsalHapad has proved most effective. When using thesepads, the patient should be instructed to break in thesedevices gradually. A protocol starting with 4 hours the first day and then increasing by 1 hour per day isusually successful. In most instances, patients startwith a small size and may increase the size of the padif their symptoms have not been relieved once they arewearing the pad all day.

BunionettesBunionettes can often be treated successfully by pre-stretching the shoe to avoid pressure over the bonyprominence. A rounded or squared toe box can helpprevent progression of the deformity.

FIRST METATARSOPHALANGEALJOINT

Hallux ValgusHallux valgus deformities cannot be prevented or cor-rected by orthotic devices, and such devices should notbe prescribed for that purpose. In patients with exces-sive pronation, an orthotic device to reduce pronationmay be indicated and can relieve valgus stress on thegreat toe. Nonoperative treatment of hallux valgusrevolves around the choice of proper footwear toaccommodate the present deformity and prevent

A

BFigure 4–19 A, Extra-depth shoe to accommodate forefootdeformity or allow room for foot and insert or appliance. B, Running shoe with mesh top to accommodate forefootdeformity.

A BFigure 4–20 A, Tongue pad placement in shoe. B, Tonguepad keeps foot in rear of shoe to prevent forefoot pressure.


increased valgus pressure on the great toe to reduceprogression. The choice of shoes is determined by theseverity of the deformity. To prevent development ofhallux valgus or to accommodate a mild deformity, thepatient should wear a shoe built on a straight last. Pre-stretching of the shoe above the first metatarsopha-langeal joint can be useful to relieve pressure.

In moderate-to-severe deformities, an extra-depthshoe may be required. The shoe can be prestretched

over the bunion, and a soft leather upper or Thermoldshould be used. A tongue pad can also keep the footseated in the shoe.

Hallux RigidusHallux rigidus is an arthritic condition, and nonoper-ative management involves accommodating the dorsalexostosis and decreasing the motion at the joint. An

A BFigure 4–21 Toe taped for instability of the metatarsophalangeal joint. A, Dorsal view. B, Plantar view.

A B

Figure 4–22 A, Diagram oflocation of Morton’s neuroma at the level of the transversemetatarsal ligament. B, Padplacement to relieve pressureproximal to the neuroma.


extra-depth shoe with a steel shank and rocker bottomcan be used. If significant dorsal exostosis is present,the toe box might need to be stretched. A full-lengthrigid orthosis can prevent motion at the metatar-sophalangeal joint but should be used with a rocker-bottom shoe.

REFERENCES

1. Augustin JF, Lin SS, Berberian WA, Johnson JE: Nonoperativetreatment of adult acquired flat foot with the Arizona brace. FootAnkle Clin 8:491-502, 2003

2. Bordelon RL: Correction of hypermobile flatfoot in children bymolded inserts. Foot Ankle Int 1:143-150, 1980.

3. Bordelon RL: Hypermobile flatfoot in children. Comprehen-sion, evaluation, and treatment, Clin Orthop Relat Res 181:7-14,1983.

4. Cavanagh PR, Ulbrecht JS, Zanine W, et al: A method for inves-tigation of the effects of outsole modifications in therapeuticfootwear. Foot Ankle Int 17:706-708, 1996.

5. Choa W, Wapner KL, Lee TH, et al: Nonoperative treatment ofposterior tibial tendon dysfunction. Foot Ankle Int 17:736-741,1996.

6. Frey C: Shoe wear and pedorthic devices. In Lutter LD, MizelMS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot andAnkle. Rosemont, Ill, American Academy of Orthopaedic Sur-geons, 1994.

7. Gill LH, Kiebzak GM: Outcome of nonsurgical treatment forplantar fasciitis. Foot Ankle Int 17:527-532, 1996.

8. Gill LH: Plantar fasciitis: Diagnosis and conservative manage-ment. J Am Acad Orthop Surg 5:109-117, 1997.

9. Gould N: Footwear: Shoes and shoe modifications. In Jahss MH(ed): Disorders of the Foot and Ankle: Medical and Surgical Management, ed 2, vol 3. Philadelphia, WB Saunders, 1991, pp73-88.

10. Henderson WH, Campbell JW: UCBL shoe insert: Casting andfabrication. Univ Calif Biomech Lab Tech Rep, Series 53, August1967.

11. Janisse DJ: The art and science of fitting shoes. Foot Ankle Int13:257-262, 1992.

12. Mizel MS, Marymount JV, Trepman E: Treatment of plantarfasciitis with a night splint and shoe modification consisting ofa steel shank and anterior rocker bottom. Foot Ankle Int 17:732-735, 1996.

13. Perry JE, Ulbrecht JS, Derr JA, et al: The use of running shoes toreduce plantar pressures in patients who have diabetes. J BoneJoint Surg 77A:1819-1826, 1995.

14. Rozema A, Ulbrecht MB, Pammer SE, et al: In-shoe plantar pres-sures during activities of daily living: implications for thera-peutic footwear design. Foot Ankle Int 17:352-359, 1996.

15. Wapner KL, Sharkey PF: The use of night splints for treatmentof recalcitrant plantar fasciitis. Foot Ankle Int 12:135-137, 1991.

16. Young MJ, Cavanagh PR, Thomas G, et al: The effect of callusremoval on dynamic foot pressures in diabetic patients. DiabetMed 9:55-57, 1992.

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