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Monday, May 11, 2020

Podiatry Question #1: What 3 common orthotic RX would help the foot below?

This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are: 
  1. Unilateral pronation placing a strain on the posterior tibial tendon
  2. Some inherent weakness in the tendon 
  3. A Habit of wearing poor quality non supportive shoes
When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories? 
  1. An Orthotic Device with some inversion
  2. A varus foot wedge external or internal to the shoe
  3. A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
  4. Stable shoes, stability or motion control, with some heel elevation 
  5. Aircast Airlift PTTD brace
  6. Posterior Tibial J Strap for Inversion Support

It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include: 
  1. Anterior Tibial Tendon
  2. Intrinsic Musculature
  3. Peroneus Longus
  4. Gastrocnemius and Soleus
  5. Sartorius
  6. Lateral Hamstrings
  7. External Hip Rotators
And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation? 
  1. Mueller TPD orthotic device
  2. Inverted Technique with Kirby Skive
  3. Modified Root with Kirby Skive
  4. DC Wedge

This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.

What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are: 
  1. Too much correction in the heel fat pad for the body to tolerate
  2. Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
  3. You modify the Kirby skive, or the medial arch, for comfort losing support in the long run
The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.