Here are the 6 types of orthotic devices I prescribe for my patients. This post and last post, and next week's post, will discuss the Type D.
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
Type D above all the types requires the precision of heel bisection. So, in your busy day, you have to pick and choose whom to measure heel bisection, the inverted heel is the crucial one to measure. You need to see what makes sense. Do I put them at heel vertical to gain stability? Are they unable to get to heel vertical, so I must keep them inverted? If I am keeping them inverted, by how many degrees and by what technique?
There is great heel to start off the conversation. We know this heel is inverted to the ground. We know that is an unstable position that a functional foot orthotic device can help. What we must be able to measure it, and then decide if the patient can get to vertical (Decision #1). We then must decide if vertical, in itself a more stable position for this patient, is maximally pronated which can very devastating (Decision #2). Why? If you think you are achieving stability by maximally pronating a patient, you are just opening them up to both pronation problems, shock absorption problems (making them too rigid), and pronatory torque problems up the leg (a topic for another discussion). So, now let us review heel bisection technique (which can be done on the floor or on a small platform).
I will review the prone heel bisection technique. The initial objective will be to get the posterior surface on the heels aligned parallel to your eyes.
Getting the posterior surface of the heel parallel to your eyes is crucial. Now we are ready to bisect.
You must find the medial and lateral borders of the heel. Go just below the achilles tendon body onto the posterior surface of the heel bone. Draw the first of three points that will represent a bisection of the medial and lateral borders.
One thumb stays with one border as your pen moves to the point you believe bisects the heel. After you put one or two points, check your borders and the invisible line you are drawing to see if they match up.
Preparing for my third point.
Third Point made
Different view
After the three points, you connect the dots to make you bisection line. All the while, you have been checking the points and now line with the medial and lateral borders to decide how close you are. Students, learning with good technique, should be within a 2 degree margin of accuracy. So, how we are ready to measure many positions, along with subtalar joint motion, but let us focus on the how the heel bisection helps us decide where to put this inverted heel. Let's stand the patient up for the Relaxed or Resting Calcaneal Stance Position.
Here a 5 degree Inverted heel is measured with a standard tractograph. There are apps for your phone (like Bubble Level XL) or other measuring devices. The big thing when you stand a patient up, to make sure you first look at the heel from 3-4 feet away and see if it looks like it is vertical, everted, or inverted. Then take your measurement. Next week's post will go over the 3 tests you can use to tell if the inverted heel is Maximally Pronated, so you would not want to attempt heel verticality. You will just place a pronatory moment with the orthosis on an inverted pronated foot. But, we will discuss next week.
