When Patients Complain About Orthotics Causing Medial Arch Pain

One of the biggest problems I hear from patients when they come into the office with orthotics from other practitioners is, “the arch of those orthotics hurt my foot.” I know I am not alone in this because when I first started out in practice, the main in-office modification I would make to my own orthotics was to heat the medial arch to flatten out the arch height for my own patients with these complaints.

I can now say that I have not done that modification with a heat gun for probably 15-plus years. Why do I rarely, if ever, have complaints from my patients about medial arch pain? I use first ray cutouts in practically all of my orthotics.

What you need to understand about the first ray in different patients is that it has varying degrees of stiffness or “hypermobility.” Kirby has advocated for a change in the nomenclature to call hypermobility of the first ray “first ray dorsiflexion stiffness.”1 I agree with him because stiffness is a “real” biomechanical and engineering term as opposed to “hypermobility,” which has no true definition. Regardless, increased dorsiflexion motion, or lack of stiffness, of the first ray translates into a lower medial arch height as this lack of stiffness allows the subtalar joint and the foot to continue to pronate in stance because the first ray essentially cannot stop that motion.

One way to stop this lengthening of the arch from occurring is to use a first ray cutout. Dananberg talks about the use of his kinetic wedge, which is essentially a first ray cutout with PPT or Poron backfill.2 He explains that functional hallux limitus will stop forward propulsion through the first ray and the first metatarsophalangeal joint (MPJ). His solution was to remove any hard material from an orthotic under the first ray to allow the first ray and first metatarsal head to plantarflex into the soft backfill material of PPT or Poron.

What this will also do is stop the orthotic device from pushing into a patient’s medial arches because he or she is no longer pronating into their orthotics. Once the first ray and first metatarsal can plantarflex and maintain their stability, then the subtalar joint will no longer pronate to the degree it had before or, at the very least, not for the length of time it had before.

I previously discussed how the peroneus longus works to plantarflex or stabilize the first metatarsal head against the ground in midstance.3,4 For the peroneus longus to work properly, the ankle joint must have adequate dorsiflexion in midstance and the first ray needs to be able to plantarflex or stabilize itself against the ground. A first ray cutout improves the effect on both the medial column of the foot and the plantarflexion of the first metatarsal head. It’s a win-win.

So, if you get a lot of complaints from patients about your orthotics being uncomfortable in the medial arch, consider adding a first ray cutout. You will be surprised at how many fewer complaints you will hear.

Don’t worry about the orthotic tipping over with use of the first ray cutout. It won’t do that since the foot's medial column support has improved.

Cheers until next month!

References

1. Kirby KA. Why the term ‘first ray hypermobility’ should be extinct. Podiatry Today. 2017; 30(4):66.

2. Dananberg HJ. Gait style as an etiology to chronic postural pain. Part I. Functional hallux limitus. J Am Podiatr Med Assoc. 1993; 83(8):433-441.

3. Williams B. Why ‘cuboid syndrome’ is a misnomer. Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/why-%E2%80%98cuboid-syndrome%E2%80%99-misnomer . Published April 6, 2018.

4. Williams B. Peroneal function and fibular translation: assessing their impact on the first ray and ankle range of motion. Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/peroneal-function-and-fibular-translation-assessing-their-impact-first-ray-and-ankle-range . Published May 2, 2018.