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Pregnancy and Your
Feet
Vol. 1 N~. 3
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1'YW
,estside Podiatry Group takes pleasure in discussing foot pathology in
the pregnant mother. Pregnancy creates an increase in weight and
as a result of changes in the entire body during pregnancy, the feet are not
excluded. Pregnancy can create foot pathology which may be permanent
and may create pathological foot conditions for the rest of one's life. In this
issue of Foot Prints, we will explain some of the changes that take place and
also some of the measures that may prevent pathological foot condition
from becoming permanent. Just as it is important to have good medical care
during pregnancy, it is also likewise important to have proper podiatric care
to allow the feet to act as a proper support mechanism throughout one's life.
The doctors of Westside Podiatry Group can help in maintaining the
weight stresses throughout the foot in pregnancy from becoming permanent
initiators of deformity.
INSIDE:
Pedal Pathology
following Pregnancy
The doctors of Westside Podiatry Group
fxpectant moms
00' s and Don'ts
Answers to
Often-As~ed
Questions
Dr. Ron Freeling
Dr. Dan Caiola
Dr. Beth Freeling
Westside Podiatry Group
www.westsidepodiatry.com
I
I
GREECE
GATES-CHILI
2236 Ridge Road West
Rochester; NY 14626
585-225-2290
507 Beahan Road
Rochester; NY 14624
585-247-2170
BRIGHTON
919 Westfall Road, C-130
Rochester, NY 14618
585-506-9790
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Residual Pedal Pathology Following Pregnancy
BY BETH FREELlNG, D.P.M.
Bursitis, tendinitis, ulceration or abscess formation may occur secondary to the bunion deformity. As the bunion deformity progresses, the hallux may over or underlap the second toe. This may interfere with walking and balance, especially in older patients.
Surgical correction of the bunion deformity may be indicated
in individuals that have pain, disability, and fail to respond to conservative management, such as changes in shoe gear, padding and
strapping, stretching, orthoses, and physical therapy.
esidual pedal pathology is a common entity encountered after pregnancy. Symptomatology
including
an increase in shoe size, foot fatigue,
cramping, pronatory changes, and bunion
formation may result from pregnancy.
Multifactorial causes, such as hormonal
changes during pregnancy
increasing
joint laxity, compounded by weight gain and fluid retention, promote the pathological pedal changes following parturition.
Relaxin is a hormone produced during pregnancy to permit
relaxation of the pubic symphysis and prepare for parturition. The
mechanism of action, however, is unknown. Due to the high elastic
composition of the plantar calcaneal navicular ligament, relaxin
may encourage the relaxation and elongation of this ligament during pregnancy. In combination with weight gain, this scenario promotes plantar flexion of the talar head and subtalar joint pronation.
Biomechanical changes noted to accompany pregnancy include
an increase in the base of gait during ambulation and a more
abducted angle of gait. Due to the anterior displacement in the center of mass, it is hypothesized that a widened base of gait serves as a
compensatory mechanism to increase the functional base of support. The female may ambulate in a more abducted position because
weight is gained; and as thigh circumference enlarges, an increase in
hip abduction enables the limb to continue through swing phase
without obstruction.
The combination of muscle imbalance, increased joint laxity
compounded by weight gain, and compensatory ambulatory functions result in indelible pedal manifestations following parturition.
Examples of resultant foot pathology include bunion deformity,
hammertoe deformity, and heel pain.
R
Bunion Deformity
Hammertoe Deformity (Fig. 2)
Hammertoe is a sagittal plane flexion contracture of the toe at
the proximal and/or distal interphalangeal joint. In absence of a
neuromuscular disorder, a hammertoe is caused by an imbalance of
the extensor and flexor digitorum longus or brevis tendons of the
foot and may, over time, become a rigid or static deformity.
Radiographic findings include osseous changes and may confirm
the flexion contracture at the proximal and/or distal interphalangeal
joint. Clinical manifestations commonly include thickening of the
skin at the joint area along with occasional erythema and edema. If
symptoms are present, they are increased due to the pressure effects
of improper shoe gear. Conditions associated with hammertoe
deformity include bursitis, neuroma, and arthritis.
Due to the irritation of shoe gear, a hammertoe may present
with pain with or without ambulation and may have a buildup of
callus (hyperkeratotic) tissue at the area of the deformity. There also
may be an absc~ss or ulceration present due to the constant pressure
from the shoe.
Patients with hammertoe deformities who are asymptomatic or
have minimal symptoms require only advice concerning appropriate foot wear. For symptomatic patients, conservative therapy with
change of shoe gear, appropriate padding and strapping, and
debridement
of callus (hyperkeratotic)
tissue is appropriate.
Surgical correction of the hammertoe deformity may be indicated in
individuals that have pain and who fail to respond to appropriate
(Fig. 1)
conservative therapy.
Bunion or hallux valgus is a deformity of the first metatarsophalangeal joint involving a medial prominence at the first
metatarsal head and a lateral deviation of the hallux. Radiographic
examination is rarely appropriate or necessary in a primary care setting. Osseous changes, usually at the first metatarsal head, occur and
are seen in moderate, severe, and chronic deformity. Clinically, individuals may present with complaints of pain, inflammation, callus
formation, stiffness or inability to wear conventional footgear with
comfort. Bunions have a strong hereditary basis and seem to be
more common among women than men. Certain foot types (especially flexible flatfoot) predispose to the development of hallux valgus and are considered the primary etiology of bunion deformities ..
Other contributing factors include inappropriate shoe gear.
Range of motion at the first metatarsophalangeal joint may be
restricted due to arthritic changes in the joint and osseous changes.
Westside Podiatry Group
Heel Pain (Fig. 3)
Heel pain is a common condition characterized by pain, tenderness and discomfort at the plantar and/or posterior aspect of the
heel, which can radiate to other areas of the foot. There are many
different mechanical and systemic causes of heel pain. The differential diagnosis may be include inflammatory conditions such as:
plantar fasciitis with or without calcaneal spur, fasciitis, unspecified
calcaneal stress fracture, foreign body, tarsal tunnel syndrome,
rheumatoid arthritis (rare) or enthesiopathy.
Clinical manifestations may include pain at the plantar aspect
of the heel upon initial ambulation in the morning, continuous
and/or progressive pain throughout the day, pain or discomfort
2
Footprints
upon palpation at the plantar and/or posterior aspect of the heel
which may radiate to the arch area an and edema and/or erythema
at the plantar and/or posterior aspect of the heel. Pain due to
Achilles tendinitis is a different symptoms complex and is not
included in this discussion. Radiographic findings may include
osseous spurring or lipping at the plantar and/or posterior aspect of
the calcaneus. Laboratory studies should be considered if there is a
suspicion of infection or a systemic disorder such as vascular disease, metastatic disease or primary malignancy.
As there are numerous mechanical causes of heel pain, an
examination should be performed on every patient who presents
with these symptoms. Inappropriate footwear is also a contributing
factor to heel pain. The ligamentous flexibility in the foot and collapse of the arch encourage traction of the plantar fascia on the calcaneal tuberosity and bursal formation. Conservative management
may consist of changes in footwear, over-the-counter arch support
devices, heel cups, non-steroidal anti-inflammatory drugs, stretching exercises, orthoses, steroid injection, physical therapy, immobilization by casting or splinting or non-weight bearing with use of
crutches for a short period of time. Padding, strapping and night
splints might be recommended by specialists following initial failure
of treatment. Whatever the diagnosis, the great majority of patients
can expect significant improvement within eight weeks with conservative management.
Surgical intervention for some causes of heel pain may occasionally be indicated in individuals who have pain, disability, and
fail to respond to conservative therapy. Many therapeutic failures are
due to non-compliance by the patient.
Foot orthoses may serve as a prophylactic device during and
after one's pregnancy term.
Foot Orthoses
Figure 1:
Bunion
Figure 2:
Hammertoe
(Fig. 4)
Figure 3:
Heel Spur
Foot orthoses are devices used to support, align, balance and
improve function. Each of the many types of devices available serves
a unique purpose. Although commonly used to correct compensatory joint motion with its associated symptoms, they also delay or
prevent deformity. They may also preclude surgery or prevent recurrences of deformities after surgery in some cases. Foot orthoses may
be over-the-counter arch supports or custom fabricated from casts.
Foot orthoses allow the body to function more efficiently and
effectively. They may help resolve soft tissue inflammatory conditions such as: plantar fasciitis and shin splints. The high-arch foot
(cavus foot type) such as seen in Charcot-Marie-Tooth and the flattened arch (pes planus) may benefit from the shock accommodation
and absorption properties of foot orthoses. Athletic footwear provides shock accommodation and absorption properties as well as or
better than over-the-counter arch supports in many cases.
Foot orthoses may help control symptoms from the aforementioned pathologies by providing mechanical control and accommodations. Orthotics may also serve as a prophylactic measure in pregnancy to provide support to the vulnerable foot.
Footprints'
Figure 4:
Foot Orthoses
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Westside Podiatry Group
Questions and Answers with Dr. Beth Freeling
second and third trimester, the foot ligaments can be irreversibly stretched and ultimately the woman's shoe size
increases.
ne ow, two ouch, three ooh ... not what you want to hear
in an aerobics class. Unfortunately those were the
sound effects coming from my two aerobisizing mates
during our low-impact class. Of course, sympathy for aching
feet overwhelmed me so our ''Apres aerobic class" consisted of
icing my cohorts' feet and a question/answer session over a jug
of cold water. I was flabbergasted with the pains my comrades
had been experiencing and classifying as "normal". Foot pain
is not normal, and I thought I would share some of the questions they had in case you were of the same belief that foot
pain is to be expected with age.
O
Q: Why does the bump on the side of my big
toe hurt during activity?
That is a bunion which is a common deformity that progresses as we get older. Muscle imbalance has been created. The
inside muscle of your foot is weakened, and the muscle that
pulls your great toe towards your second toe is strengthened.
Consequently, the great toe joint surface becomes exposed and
malaligned. Propulsion during gait and activity at this joint
encourages inflammation, pain, and degenerative changes.
Q: Isn't it ideal to walk barefoot?
Walking barefoot is the most detrimental activity to your
foot's health. Walking barefoot or even in flimsy shoe gear
encourages foot collapse, inappropriate stretch of the soft tissue, and inflammatory changes. As we age, our ligamentous
elasticity decreases; and as a result, the foot widens and loses
its structural integrity. Therefore, supportive shoe gear is
essential.
Q: How can I limit the resultant pedal problems encouraged by pregnancy?
Because of the physiologic changes that take place in pregnancy, a new set of criteria for foot care must be understood to
prevent foot deformity or enhancement of an inherent symptom. Proper shoe gear such as supportive sneakers versus flimsy sandals are necessary. Never walk barefoot. Foot orthoses
may be used as a prophylactic measure to maintain proper
alignment of the foot. Limitation of stress on the body's superstructure by changing one's workout regimen is important.
For example, switching from high-impact aerobics to lowimpact aerobics, running to walking, strenuous stairmaster to
water-resistant exercises are more foot-friendly.
Q: Why did my shoe size increase by one
whole size following pregnancy?
There is a hormone called relaxin secreted during pregnancy.
Relaxin encourages stretch of ligamentous tissue, especially
the pubic symphysis, to allow for parturition of the baby.
However, it concurrently weakens the ligaments of the foot;
and with the extra weight the woman maintains during the
DON'T
DO
Wear good, supportive
Decrease workout
Never go barefoot.
sneakers.
Don't exercise in excess; moderation
the key.
from high-impact
to low-impact.
Don't wear flimsy shoes or sandals.
Consider custom-molded, supportive
inserts in your shoes.
Don't wait for minor foot problems to
become major before consulting a podiatrist.
Consult a podiatrist about proper foot care
in the beginning of pregnancy.
Don't force your post-pregnancy
your pre-pregnancy shoes.
Expect some permanent changes in your
feet after pregnancy.
Footprints
is
4
feet into
Westside Podiatry Group