So, this post on holding some feet inverted has sort of gotten away from me, so I will attempt to rein it in. You have heels that you have bisected (post Type D: Part 2), measured RCSP and NCSP, and need to decide if you want to hold that patient inverted or attempt to move them towards vertical. One question to ask is: What are their symptoms? Are they pronatory or supinatory? I have listed below the list of symptoms that are supinatory, as most Podiatrists understand well pronation symptoms. Patients that are maximally pronated, but inverted, you want to invert their orthotic devices two degrees more inverted than maximally pronated. I will review the 3 ways commonly utilized to decide if someone is maximally pronated another post. The Root concept that Subtalar joint neutrality is the best for the body means that within a few degrees of neutral they will get the least symptoms. I have found this very true, especially these inverted feet.
Let us imagine that we are looking at the back of a patient's heel and in Resting Position they stand inverted by 2 degrees or more. Most of the time when we see an inverted heel, we want to push it towards vertical. This post finishes our discussion of those feet we want to remain inverted. Type D is needed in a patient that either can not get their heel to vertical, or heel verticality would be maximally pronated, or within 2 degrees. Type D is the first orthotic device I have mentioned that you really must measure RCSP and previously in talking about Type D (Part 2) I reviewed how to bisect the heel and measure RCSP.
It is rare to see an inverted heel that does not give some symptoms from the patient of rolling to the outside of their foot. This requires an understanding of the position of being inverted (due to Subtalar, Tibial or Genu Varum) which is what the patient is born with, to the motion of lateral instability or varus roll outwards of the patient. I submit to you that it is the motion of supination much more than the position of being inverted that gives a patient problems.
Checklist for Supination Produced Problems
1. Hammertoes
2. Lateral Metatarsalgia
3. Tailor’s Bunions
4. 4th/5th Metatarsal Stress Fractures
5. Cuboid Pain
6. Lateral Ankle Instability
7. Peroneal Strain
8. Haglund’s Deformity
9. Medial Ankle Impingement
10. Fibular Stress Fractures
11. Proximal Tib-Fib Sprain
12. Medial Knee Compartment
13. Knee Arthralgias
14. Lateral Knee Collateral Ligament Sprain
15. Lateral Hamstring Strain
16. Iliotibial Band Syndrome
17. Femoral Stress Fractures
18. Hip Arthralgias
19. Sacroiliac joint inflammation
20. Low Back Pain
When the patient stands in Resting Position here 5 degrees inverted, I have the patient attempt to lift up their lateral column and 4/5 toes (Kirby maneuver) to pronate more, or have them continue standing and internally rotate their entire lower extremity without lifting the lateral side of the foot up to see if they can get the subtalar joint more pronated. You can also use the Coleman block test (as well as your fingers) under the 4th and 5th metatarsals to see if you can evert their heel (which works wonders in understanding how everted forefoot deformities can invert the heel at stance.
I feel safe here since teaching the RCSP (heel bisection) is one of the simplest things for young podiatry students to learn. Yes, there are some exceptions, some odd shaped heels we all ponder at. Let's finish here with 3 examples of a 5 degree inverted heel in RCSP on the right side all with medial knee joint problems attempting to avoid surgery.
Patient #1:
Right Foot
RCSP 5 Inverted
Coleman Block Test RCSP changed to Vertical
Maximal Pronated Test RCSP changed to 3 everted
NCSP 2 Inverted
Treatment: Type A Orthosis set to Vertical
Patient #2
Right Foot
RCSP 5 Inverted
Coleman Block Test RCSP changed to vertical
Maximally Pronated Test RCSP changed to 1 inverted
NCSP 9 Inverted
Treatment: This will depend on what we can do to influence the knee
These are my medial-lateral instability patients
They have have potential for high pronation, and can be laterally unstable due
to the 9 degrees Inverted NCSP
If you treat the STJ for better alignment, I want them within 2 degrees of
neutrality. My highest starting point is 7 inverted with high
lateral heel cup and Denton (lateral frame fill) modification.
If you want to pronate them to not crowd their medial knee compartment,
I would put them 3 inverted (vertical is too close to being maximally pronated)
Patient #3
Right Foot
RCSP 5 Inverted
Coleman and other Max Pronated Testing RCSP still 5 inverted
NCSP 11 Inverted (typically seen in high degrees of Tibial and Genu Varum)
Treatment: 7 inverted by technique of choice to hold foot 2 degrees away from maximally pronated
