Pedorthic Solutions during Pregnancy
While expectant mothers may be most focused on their growing abdomens and the needs of their unborn children, they may be feeling the effects of pregnancy on their feet as well. Softening and relaxing ligaments, pelvic bone changes, weight gain, and a shifting center of gravity can cause a variety of foot complaints in pregnant women. The O&P EDGE asked a number of pedorthic professionals what type of foot complaints and issues pregnant women face most often and how pedorthic intervention can help to solve or alleviate these issues. They all agree that the most common conditions they address are plantar fasciitis, foot "growth," and edema.
"Foot complaints do tend to arise with women who are pregnant," says Janet Dixon, CPed, BOCPD, manager of Healthy Steps, a division of Foot and Ankle Associates of North Texas, Grapevine. "Plantar fasciitis seems to be the most common foot complaint among expectant patients."
The weight gain that women experience during pregnancy stresses the structural integrity of the foot, particularly the arch. The extra weight may cause the arch to flatten or the foot to roll inward excessively while ambulating, Dixon explains. That puts stress on the plantar fascia, and once the fascia becomes inflamed it leads to foot pain most commonly experienced in the heel.
Mike Forgrave, CPed(C), owner of Mike Forgrave and Associates, headquartered in Kitchner, Ontario, Canada, and a former president of the Pedorthic Footcare Assocation (PFA), agrees that plantar fasciitis is a prevalent foot complaint among pregnant women. He describes the plantar fascia as being similar to the bowstring on a hunting bow. Like the bowstring, the thick and fibrous fascia does not have a lot of stretch-a taut string maintains the curvature of the bow much like the tension of the plantar fascia maintains the arch of the foot. The arch acts like a shock absorber, and the plantar fascia stretches with the ground reaction force of walking and contact force of standing/weight bearing, lengthening the foot, and returning to its previous state once the force is removed. If a woman has a high arch, it means that the plantar fascia is short and tight and does not properly absorb shock, which leads to micro-fiber inflammation, Forgrave explains, as well as a rolling in of the arches. Conversely, if a woman has a low arch, the ground reaction force from walking and contact force from standing/weight bearing will pull on the plantar fascia and elongate the foot, which can also lead to inflammation.
Compounding the issue of the elongation of the foot is the hormone relaxin. Relaxin relaxes the ligaments in the pelvis during pregnancy to facilitate the movement of the baby through the birth canal. However, the relaxing effect is not limited to the woman's pelvic structure-all ligaments, including those in the feet, are affected. The loosening of ligaments in the feet causes the foot bones to spread. This is what leads many women to observe that their feet have grown during pregnancy, and while the ligaments will eventually tighten after the pregnancy is over, the feet will not return to their previous size.
Addressing Pregnancy-Related Foot Complaints
All of the pedorthists interviewed for this article say that proper footwear and foot orthotic use are the primary ways they address pregnancy-related foot complaints.
Dixon stresses that a foot exam by a podiatrist along with a shoe and orthotic fitting by a certified pedorthist can reduce foot issues that are caused or exacerbated by pregnancy. Pregnant women should have their feet measured frequently to ensure they are wearing shoes that fit properly. "You want to look at the shoe first," Dixon says. "Is the shoe the appropriate width and size? Is it the right type of shoe for the activity...?" A gait analysis performed by a certified pedorthist will determine the appropriate shoe, such as a neutral shoe versus a stability shoe. If more than a change in shoe type is warranted, she says her experience has shown that many over-the-counter (OTC) orthotics work well and offer a more cost-effective solution than custom orthotics.
Doug Goodhart, CPed, is a second-generation pedorthist. He joined his father's business in 1980 and became a certified pedorthist in 1987, jointly running the business with his father until 1990. He then spent three years in Germany and France, where he learned about German principles of foot care, orthotics, shoe manufacturing, modification technology, and proper footwear, which he now applies to his own practice and business, Goodhart Shoes and Foot Care, Overland Park, Kansas. In fact, he learned about the concept of "zero compression" when fitting shoes in Germany.
There are four kinds of compression, or pressure, Goodhart says: natural compression, which he says is the only acceptable form of compression on the foot, occurs when a person weight bears and the foot compresses naturally from underneath; side-to-side compression occurs if the shoe is not wide enough; front-to-back compression occurs if the shoe is not long enough; and top-down compression occurs if the shoe is pushing down on the dorsum, or top of the foot. "These last three are completely unnatural to the foot," Goodhart says. "The natural foot is barefoot, walking on open terrain...where there is nothing compressing the foot except the ground from underneath." This zero compression foot environment is what he tries to mimic with shoes and socks, he says.
The use of accommodative foot orthotics to attenuate weight bearing also tops his list of pedorthic solutions to foot issues that women may experience during pregnancy. He explains that the added weight of a pregnancy overloads the acceptable pounds-per-square-inch ratio of the foot, and custom-made orthotics can help disperse this weight over the entire bottom surface of the foot.
While Forgrave also recommends that women trade their high heels for more comfortable shoes with some toe spring, he says that custom-made orthotics provide the best solution for plantar fasciitis. With custom-made orthotics, the pedorthist can control the abnormal biomechanics, absorb some of the extra shock of the added weight, and prevent the arch from dropping as much. "By not allowing the arch to drop as much, you are actually reducing the stress on the plantar fascia and then the body will... heal itself," he says. "When you take the stress off the structure, that structure will get better." While there are several studies that have shown that OTC orthotics can be effective for minor arch drops, by the time these women are referred to him, they "are beyond that little bit of pronation...and they need custom-made orthotics to help control the abnormal function of the foot and reduce the stress," he says. Another reason women should wear orthotics during pregnancy, he adds, is to help the knee caps track properly. The pronation of the arches in conjunction with widening of the pelvic girdle can cause the tibias to internally rotate-oftentimes leading to anterior knee pain such as patella femoral pain syndrome.
Chris Shippy, CPed, says that many of his pregnant clients comment that their feet have gotten bigger. He explains to these clients that their feet have changed shape during pregnancy- becoming slightly longer and wider-often as a result of the hormonal changes taking place in their bodies-but their feet have not actually grown. Shippy, a practitioner in the family-run business Rosendahl Foot and Shoe Center, Boise, Idaho, recommends that these women wear bigger, more forgiving shoes with a more supportive foot bed, perhaps with adjustable straps or laces to accommodate for the increased width. Absent of a major structural anomaly, he, too, says that an OTC foot orthotic should provide sufficient support for the foot's bone structure.
The biggest complaints Shippy receives from his pregnant clients are about achy, tired, sore, and swollen feet.
Many pregnant women experience edema, or swelling of the feet and legs, our experts say. Edema results when excess fluid collects in body tissue. Standing or sitting for extended periods of time, hot weather, high salt intake, crossing the legs or ankles while sitting, and socks or hosiery with tight bands around the calves can contribute to the swelling. In addition to looser, more accommodative footwear, our experts recommend that pregnant women who experience edema do not stand or sit for extended time periods, reduce their salt intake, avoid crossing their legs or ankles while sitting, do not wear socks with tight bands, prop up their achy, tired feet when they are able-and wear compression socks or hosiery.
Shippy is also a certified compression garment fitter, and about 75 percent of the women he sees who complain about swelling take his recommendation and wear compression socks or compression therapy hosiery. "We always urge the patient to consult with her physician before starting to wear lower-extremity compression garments," he says, adding that the compression socks and therapy hosiery "absolutely help."
Dixon, who is also certified to fit compression hosiery, says that pedorthists at Healthy Steps also might suggest the use of compression hosiery for swelling caused by edema. "We follow the lead of the doctor for specific compression levels for the patient," she says, adding that compression hosiery might even help with pregnancy-related foot cramps. "The cramps are caused by an increase in blood volume and relaxation of the blood vessels, and that slows down circulation," Dixon explains. Another cause of foot cramps, she says, is that the veins in the pelvis become compressed from the added weight, which can also affect circulation in the feet.
The Education Component
The professionals we interviewed agree that education is paramount when discussing the reasons for purchasing shoes in a larger size or width. They explain that secondary problems-such as blisters, calluses, hammertoes, ingrown toenails, metalarsalgia, and heel spurs-might arise when women wear shoes that are too small or too tight or from not using foot orthotics as part of their pre-natal care. Having a pregnant woman try on a pair of more comfortable and appropriately fitted shoes is often the tipping point. Generally speaking, it is not difficult to convince a pregnant woman to toss vanity issues aside and begin wearing bigger shoes, our experts say.
"We work with people by speaking to them," Goodhart says. "I want them to conceptualize and understand the zero-compression shoe fit and orthotic principles I am trying to teach them before I actually fit them with proper footwear and orthotics. I am going to leave them with more space and more support in their shoes than they've ever had before, and I need them to get their minds around that concept."
It is a matter of balance between fit, function, and style, Dixon says, adding that comfort and orthopedic shoe manufacturers are becoming more style conscious. "In all honesty, by showing [women]...the structure of the shoe-here is what it does, how it feels-and take the look out of the equation and do not mention the size," most are on board with her recommendations. "If your feet are not supported, [it is similar to] a faulty foundation that affects the rest of the house," Dixon says. "Orthotics and the appropriate shoe can help."
Laura Fonda Hochnadel can be reached at firstname.lastname@example.org