The Gold Standard orthosis (Type A in my classification) is the functional foot orthotic device that you use the most and know the ins and outs of what it accomplishes. Nothing can change your Gold Standard since it is yours. Perhaps this is a good time for you to own what it means for you: How is the lab instructed to set the heel? How deep are the heel cups? What type of posting is attached to the orthotic shell? How do you cover it? Once you write that down, you should be able to follow the thought process of the different corrections I am discussing.
The Introduction here is largely from several weeks ago: With all patients, as I hear their complaints, and watch them walk and/or run, I am immediately designing the perfect orthosis in my mind. I categorize these patients by what correction I will need to achieve stability. These are A) need to achieve vertical (typically your Gold Standard), B) need to achieve less of an everted heel (discussed in the post entitled "When to Varus?"), C) need to achieve markedly less everted heel, D) need to achieve an inverted heel position, E) need to achieve less of an inverted heel position (discussed in post "When to we Valgus?"), and F) need to achieve markedly less inverted heel position (discussed in post "When do we Really Valgus?). Of course, the demands of the right foot may be totally different from the left foot. Yet, beginning to master these 6 basic orthotic devices will dramatically improve your orthotic practice.
To Summarize:
Type A: Gold Standard (for most getting the heel vertical by setting the heel vertical)
Type B: Designed to make an everted heel less everted
Type C: Designed to make an everted heel markedly less everted
Type D: Designed when the heel should be inverted
Type E: Designed to make an inverted heel less inverted
Type F: Designed to make an inverted heel markedly less inverted
The Gold Standard orthosis in the Root world of biomechanics consists of 2 major components with the rest to your discretion. The components of the Gold Standard consist of the laboratory setting the heel vertical and balancing out any forefoot abnormalities. Remember your cast or scanned image are representations of a stable foot architecture. Dr Root felt that this cast of the foot should be taken in subtalar joint neutral and the midtarsal joint maximally pronated. This method is used throughout the world, even in alternative methods of casting (semi-weight bearing, etc). When I use the Gold Standard, probably 1/3 of all my custom orthotic devices, I follow Dr Root's methodology as complete as possible, with amazing results. I use it when I know what feet will respond to the prescription. But, when do we use Type A, and when do we move away from it. Since your Type A may vary from the classic Root Golden Standard, it is important to know how you differ in case you need to make modifications down the line. If you have the luxury of time, and want to experiment, you can always send 2 casts or images for each foot, and ask the lab to make your Gold Standard and a classic Root Gold Standard. For forefoot varus deformities over 5 degrees, even Dr Root would modify, I know I have to. For forefoot valgus deformities over 10 degrees, most will lessen the support in the distal lateral forefoot, but some do not.
Image of a Fairly Vertical Heel that easily is helped by Type A. The higher the arch, the more that they tend to love it, since for once they have midfoot support. Type A is also helped when you think the varus inverted heel will be helped by balancing the forefoot everted deformity, and the valgus everted heel will be helped by balancing the forefoot inverted deformity. Remember when scanning, you can always ask the lab for the forefoot to rearfoot measurement you captured. With casting, it is easier to initially see.
The above image is of a pair of casts from an everted forefoot deformity patient. When the forefoot is everted to the rear foot, the heels invert to the ground when standing uncorrected. Root Balancing will take that forefoot deformity and balance it (or support it) so the heel is sitting vertical. This is Type A or the Gold Standard of foot corrections. The opposite correction would be for a varus forefoot deformity. The heels would sit in an everted position, and the balancing again would be to place the heel vertical. One common thought process is that you use Type A when the heel position of the patient at rest is standing in the range of 2 inverted to 2 everted by your resting calcaneal stance position. This four degree range is typically the 4 degrees of difference between you and me and others. Heel bisection is fairly straightforward, but some heels are really difficult. Get good at watching the patient walk barefooted, do one foot at a time, and decide if the heel is inverted, everted or perpendicular to the ground. Next Post will begin to discuss when to hold someone inverted (Type D).
