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

https://youtu.be/w3FXx4OFqec

https://youtu.be/AcSSyBfFocE

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. 

Monday's Image of the Week: Temporary Kirby Skive for Pronation Control

This photo above is the left foot orthotic device of a patient that pronates excessively. Many times when I am dispensing orthotic devices, I fall short in controlling the excessive pronation enough based on stability required or continued symptoms. I have added in this image a 1/4 inch beveled wedge in the medial heel area of the left foot orthotic device on top of the plastic.I call this a Temporary Kirby Skive. It will give me more correction temporarily to the orthotic device in controlling pronation motion. Eventually I may decide to place that Kirby Skive into the plastic itself. The typical material used for this wedge is Korex, grinding rubber, or EVA. The top cover in the right of the image will be glued back on.

http://www.parisorthotics.com/hcp_lectures/STJA%20Loc%20and%20Rot%20Equil%20Theory_PAC2001.pdf

Improving Pronation Control with Kirby Skives and Medial Column Corrections

When you dispense custom made orthotic devices, you should evaluate the stability they contain separately for the right and left feet. Be somewhat critical of your great prescription writing, and grade yourself on how well you have done. When you are trying to control pronation forces, and the orthotic device dispensed work well on one side vs the other, try to get the function as even as possible. The body loves symmetry. This image shows that the right orthotic device is being marked for 10-15% more pronation correction. The K means adding a Kirby Skive and the MCC means adding a medial column correction. Medial Column Correction stands for more arch support. These are plaster modifications applied before the plastic is heated and pressed. 

Podiatry Talk: Over Pronation in the Left Foot

Dr Blake's Intro: This very dedicated podiatrist was so kind to call me about 3 patients she was going to prescribe orthotic devices for just prior to my July 4th Holiday. You can sense the passion and kindness that all of us would like to find in the doctors/therapists that help us. Don't worry if the numbers or abbrev are confusing. I will try to explain the gist of it.

Here is the back of a right foot (could not find a left in my immediate files) very pronated (EV) or everted. The ruler represents vertical or straight up and down (where you want your foot to be in general)

Here is Julio's same right foot very pronated with the goniometer we can use to measure the exact angle from vertical. Comparing the right to left can give you a great understanding of the degree of arch flattening of one foot over another.

Dear Rich,


I wanted to Thank-you for trying to reach me on Th am before your ( much deserved vacation for the 4th of July ). I know what is like on the last day at work before an upcoming holiday/ vacation/ absence planned. It seems as though "everyone and their mother" + grandmother + father+ child+ ...uncle... needs you... Pun intended : )

So many people in pain or in precarious weight bearing situations- (like the pts I described to you ) rely on your expertise and it all takes time. It was very thoughtful of you to squeeze me in as well.

Dr Blake's Note: my voicemail must have been cut off, however this form of communication should prove more useful.I listened to your VM to me & I am not sure what happened, but you broke off in mid sentence and the recording abruptly ended. I thought I might be able to reiterate what you would do with the patients I presented and you could let me know if I have down your complete answer.  Below I have included a recap since it has been awhile.

Dr Blake's Note: The podiatrist describes the complicated biomechanics of three patients all in their 70s and all with collapsed (everted or pronated) left feet. I think there are 2 common forces that produce unequal wear and tear on our musculo-skeletal system as we age: The presence of limb dominance produced by being right handed or left handed where right handed people have the left side as their support leg and break it down quicker, and the limb dominance of having a short leg. 80% of people have a short leg and it seems to me the majority have the long leg on the left. The longer leg has more compression forces as the body levels itself out at the spine throwing more weight to the left. The limb dominance seen in a long left leg in an adult is typically greater weight bearing on the left.



PT Backgrounds/Recap: The patients are 75+ yrs. in age with c/o recent balance problems. Each patient has their mid arch L ft collapsing with palpable bone plantarly. All have slightly boney dorsal prominences at 1st met heads.

Dr Blake's Note: There are 2 major reasons for balance problems (ie the patient feels unsteady on their feet. With one foot beginning to have arch collapse only on one side, the delicate symmetrical balance between the feet are thrown off and instability ensues. And pure arch collapse on one or both sides leads to great feelings of unsteadiness. From a patient's standpoint, they have a difficult time knowing where the instability is coming from. The medical world also wants to blame things like this on their age, failing to recognize it can be a simple (ha ha!!) foot problem, with a sometimes simple solution. Evaluation of foot structure, especially looking for anything assymmetical like uneven pronation, should be part of any balance program/fall prevention program.

PATIENT #1: RS
R.S.= Pt Male:175lbs, 5'10 The gentleman has more severe balance issues in that he shuffles,uses a walker and does not walk much. He has severe gout with tender tophi on his great toes IPJs. B/L: Tibial valgum and Extensor Substitution

Left: Tight plantar fascial band upon palpation with Pl Fasciitis pains in arch and more distal than heel region; slight hip drop, hits EV on heel strike
STJ: 14 Inv, 10 Ev ; RCSP: 2 Ev NCSP: 90 Foreft (FF) is 3 Pronated/Ev on Rearft (RF)

Right: STJ: 12 Inv, 4 Ev ; RCSP:1- 2Inv NCSP: 4Inv FF to RF is 90 ; slight Rt shoulder drop

Dr Blake's Note: Simply put the left arch is collapsed with the heel everting (see photo above). The left hip drop show limb dominance to the left, therefore more compression forces, further collapsing the left foot. The slight right shoulder drop is typically seen in a right handed individual.

PATIENT #2: CH
C.H.= Pt Female:156 lbs, 5'6 States that she feels a "pulling" & feels like she is "walking on rocks" in and out of shoes. Likes to walk for exercise.

slightlyskewed-shaped,very pronated Left: STJ: 16 Inv; 9 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 11 Supinated/Inv on RF slight L shoulder & hip drop

Dr Blake's Note: She is more everted than the first patient. She has the same left sided hip drop increasing the compression forces on the left. Uniquely, she has a very tilted or supinated Forefoot to Rearfoot relationship. This is opposite of the heel angle. The more supinated or inverted the forefoot is, the more eversion or pronation force is placed on the heel. The higher this number goes, the worse the problem.
RT: STJ: 30 Inv; 4 Ev ; RCSP: 2-3 Inv NCSP: 2 Inv FF is 19 Supinated/Inv on RF
Dr Blake's Note: I find this foot very unstable. The right foot has such higher forefoot supinatus or inversion, yet can not evert the heel. See the heel still a few degrees inverted. When the numbers don't match up, the body can not do something important to life and it begins to break down. This patient has two bad feet and not a good leg to stand on. Here symptoms match this degree of instability.

PATIENT #3 JP
J.P. = 82yo. rode a bike until 75yrs. leans to L in gait female: 170 lbs, 5' genu valgum
Dr Blake's Note: Here is the third patient with the lean to the left side. Is it the chicken or the egg?
slightly skewed-shaped,very pronated Left: STJ: 23 Inv; 15 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 4 Supinated/Inv on RF slight L shoulder & hip drop


RT: STJ: 22 Inv; 4 Ev ; RCSP: 90 NCSP: 2 Inv FF is 1 pronated/Ev on RF


Dr Blake's Note: When I was left the telephone message, there were no specifics. Now that we have the specifics, the RX can be more finetuned.
So Rich your recommendation was to use a polyprop shell, covered with pink plastizote, with leather glued as the topmost cover. The poly shell should be at: A) 5/32" if I have a grinder such that I could grind down the arch if needing more flexibility/softer tics or B) 1/8" and the following materials could be added: korex (1)Thickness?)  (Dr Blake: 1/4 inch) or grinding rubber? could be added under the arch-how far along the device? (Dr Blake: from just in front of the post to the highest part of the arch) to the  to add more stability as needed, but the point was to hold that arch up as much as can be tolerated.

Dr Blake's Note: The 3 biggest problems I see with these patients that can lead to poor correction of the foot mechanics are:

1. The pronation or arch support correction is placed equal with no real difference in correcting the more everted foot. Big Mistake!! The flatter foot should end up with the higher arch support (Newton's Law: The side that has more force to flatten the arch, should have a higher support to unflatten it).
2. When you are over 70 years old, no matter how much support you need, it is assummed you must only be able to tolerate less supportive soft supports. Big Mistake #2.
3. You are not treated like a 20 year old, where perfection is sought in all treatment areas. Good enough is too often accepted, when better may be alot better. What do you expect for your age? And when medicare does not pay for orthotics, low expictations abound. Not if this is my mom or dad or me???

You discussed a discounted intro pair and what would the intro pair be made from? Do you recommend using cork or crepe as a shell?
Dr Blake's Note: When I am prescribing orthotic devices and I am unclear of the right inital correction to give, I typically tell the patient that the first pair is my trial pair (which I may hit the mark on the first try, or may have to learn from). Since I figure both I and the patient are teammates in this endeavor, we should share equally in the costs for any orthotic that is truly transitional (although without we would have not been able to get to the final result). I would leave the cost discount to the patient in each doctor/therapist's hands. I did not mean to imply that the trial pair was of any material different than what you feel is best for the patient. I use three common materials in this quest: plastazote for some support and max cushion, 1/8 inch poly for some support and cushion, and 5/32 inch poly for significant support (for heavier patients the 5/32 inch is changed to 3/16 inch poly).


You also pointed out that you would RF post and with a hi RF valgus you might pour inverted (the Blake) & / or Kirby skive. At what point do you decide to do either or both? Then you were cut off.

Dr Blake's Note: So much of this is up to the skill level of the lab. I have toyed around with this for years and have concluded many things. These include:

1. When the Resting Heel Position is over 2 degrees valgus/everted, you can not just rely on arch support, the medial side of the heel must take some of the force to control pronation. This, of course, can be accomplished by either some form of inverted pour, or a Kirby skive. There are many sublties that can effect the correction like FF supinatus/varus vs FF pronatus/valgus, whether the heel is rounded or flat on the bottom, and whether their is a low arch or high arch.
2. When the presenting complaint is in the arch, the patient normally likes more heel correction (Inverted vs Kirby) and less arch correction.
3. Less arch correction can be accomplished with sweet spots,  plantar fascial grooves, or softer materials, but it is a mistake to low the entire arch.

I usually like to make an actual dell in the orthotic device to semi off weight this most depressed point of the arch in order to support it & alleviate pressure. This would match the weight -bearing position. Around the "dell for the boney prominence" I just created, I leave ~1cm raised unskived doughnut section.(unskived immediately adjacent to the "dell for the boney prominence" Then I gradually skive around a ~1cm doughnut which is full thickness to blend with the arch. Dr Blake's Note: Here is a nice example of a Sweet Spot being created.

I am very interested in whatever you have to say and appreciate your thoughts and time.  I  thank you for your pearls of wisdom. I hope you had a great vacation. I look forward to hearing from you. Take Care.

Sincerely, Karen

Karen, Thank you and I know I am late with this response. I hope taking this time on my blog will prove more meaningful than my cursory voicemail comments. So of all of the orthotic devices we have available what should be done.

With as long winded as this post, I best get right to the point. I hope you can follow based on the earlier discussion points. I will try to always prescribe differently for the right and left feet, so we have 6 feet presented to prescribe the initial orthotic to, and learn from. With this learning process, we may have hit gold early, or at least seen how the patient responds to the certain correction. All these orthotic devices should be with 5/32 inch poly to start, 0 degree birkocork rearfoot posts, with 23 mm Heel Cups Left and 21 mm Heel Cups Right and unless I mention a change or possible modification below.

RS #1 Left Pour 2 degrees Inverted or 2 mm Kirby Skive (Skive best effect with a rounded plantar heel and pour inverted best with flatter heel), maximum arch support with minimal fill yet sweet spot accommodation created.

            Right Pour Vertical.

CH #2 Left With the High FF Supinatus on both feet with CH I use the resting heel position to calculate the Inverted Pour. Here 25 degree Inverted pour will correct for 5 degree Ev RCSP. Maximum Arch Support with minimal fill and sweet spot accommodation.

            Right 15 degree Inverted Technique with Maximum Arch Support.

JP #3 Left 4 mm Kirby Skive with maximal arch support or 5 degrees inverted pour. It is good when you have the negative cast to look at the heel and arch from the medial side and imagine how the arch would change when you add a Kirby vs just Inverted Pour. Remember the Higher the Arch initially, the more effect an Inverted Pour with Maximal Support would have over a lower arch. This is also true with a flatter heel. Kirby Skives are better with rounder heels in general.

          Right Pour Vertical.

Karen, I must go for now. Took 3 nights to answer your great email. Hope it makes some sense. Rich