Relaxed Calcaneal Stance Position
Measurement showed over 10 Degrees of Heel Everted Positioning
The Relaxed Calcaneal Stance Position (aka Resting Position or RCSP) is utilized for understanding of Pronation Syndrome, Supination Syndrome, Poor Shock Absorption, Limb Length Discrepancy compensations, Tight Muscle compensations, Weak Muscle gait patterns, and other issues. Therefore, I always perform this test due to its importance. Here are some images showing how to bisect the heel in a prone position before standing the patient up (my preferred way).
Here is the Typical Starting Point of Bisecting the Heels for Subtalar ROM and RCSP or NCSP with the Patient Prone Heels Angulated
It is so Crucial to Make Sure the Posterior Surface of the Heel is Aligned (Parallel to) with Your Eyes so the Opposite Leg is Bent and Externally Rotated and the Patient may need to roll over on their hip (side being measured)
By Palpating the Medial and Lateral Borders of the Heel Three Times from Superior to Inferior The Examiner can Bisect the Heel
Here is a Close Up of My 3 Bisection Points and the Solid lines represent the Medial and Lateral borders of the Posterior Surface which are Divergent (They are Never Completely Rectangular)
Here the Bisected Heel on the left is Stood Up and the Heel is Measured either Vertical, Inverted, and Everted (The Right Side will be slightly to significantly different to the Left Side)
This crucial examination technique is to bisect the center of the heel prone, and then stand the patient up and see if the heel is vertical, everted, or inverted. This test can also be done with the patient standing, but I prefer to start with the patient prone. This is very useful in the initial evaluation for orthotic devices in writing your prescription to make a biomechanical change. It is also used when orthotic devices are dispensed, by having the patient stand with and without their orthotic devices to check if the orthotic corrections are achieving the desired results. However, you also have to correlate standing correction to walking change to make sure that they substantiate each other. One of the highlights of my career is when I use a relaxed standing position measurement to follow the development of a growing child as I progress to less pronated feet through orthotic support (as originally taught to me by the renowned Dr. Ronald Valmassy). It is also used in the preoperative and postoperative evaluations of flat foot surgeries. And, as you can see from the syndromes that it helps with at the start of this discussion, it can really help you understand a lot about the biomechanics of a patient. The change in the relaxed calcaneal stance position can help you understand corrections in pronation, supination, compensations for short leg syndrome, if someone is a poor shock absorber, if I am supporting a posterior tibial tendon dysfunction patient enough, or allowing a genu varum patient to have less stress on their knees, etc. I would put it as my number one test overall.
The posterior surface of the calcaneus or heel bone is usually flat and will be angled from posterior lateral to anterior medial on weight bearing (and this does not take into account the angle of gait). You must keep the posterior surface of the heel bone in line with your eyes. You must find the medial and lateral borders of this posterior surface and put your fingers so they align right along those borders from superior to inferior.
Fingers Flush with the Medial and Lateral Calcaneal Borders and 3 Points Placed 1 inch Apart to Bisect the Heel
Your fingers should be flush with the medial and lateral borders in the middle of the calcaneus from superior to inferior, and clearly just on the medial and lateral edges, not on the posterior surface of the heel bone. Then make 3 points about one inch (2.5 cm) apart from superior to inferior bisecting the two sides.
After Each Dot Applied Continue to Check the Sides to Make Sure of Your Bisection
2 Bisection Points Made
When Placing Your Points, Leave One Hand on One Side to Not Lose Your Reference
Here All 3 Points are Checked with the Medial and Lateral Heel Sides to Insure a Great Bisection
After the 3 Points, Draw a Straight Line Connecting the Points
Draw a straight line downward connecting these three points. This can be done weight bearing or non-weight bearing (one method will feel easier to you although I prefer non-weight bearing). When you are learning, do this and other measurements with others to see if you agree. Examiners when learning this technique tend to align/favor one of the two borders, even when those borders are divergent. When the patient is non-weight bearing, please remember the posterior heel is best measured when completely parallel to the plane of your eyes, so angle their body to bring the posterior surface to this reference (helped by bending the opposite knee and placing over the knee on the side you are examining). The typical orientation of the posterior heel’s medial and lateral edges will be like a rectangle with straight parallel edges, or more rhomboid with divergent edges (as in the photos on this page). After a few feet, students get the feel of this quite easily. It is such an important measurement that you should check your line several times.
Once the heel has been bisected, extend the line as straight as possible another centimeter superiorly and another centimeter inferiorly. When the patient stands, look at the back of the heels and make sure your line looks straight all the way from inferior to superior, and make sure the line looks like it matches what the heel looks like (you will be able to see vertical, inverted, or everted heels without lines someday). By this I mean, when you stand several feet behind the patient, does the heel and line both look straight, both everted, both inverted from right to left, or with asymmetrical feet some combination of these 3 positions. With weight bearing, use an angle measuring device that is parallel with the posterior surface of the heel running posterior lateral to anterior medial (I use both a tractograph and an app called Bubble Level XL). Now you are ready to measure the heel position to the ground. This measurement is typically done without orthotic devices, called the resting calcaneal stance position, or resting heel position. But, it is used to see how your orthotic devices, or surgery of some sort that should affect the heel, has done its job. An orthotic device, even with a deep heel cup, will not distort this line.
Measurement of RCSP using Bubble Level XL app
Here the same measurement staying on top of custom orthotic devices (Dr Kevin Kirby calls this "Orthotic Calcaneal Stance Position" or OCSP)
I hope this refresher was worth it for you. I hope my "Fun With Numbers" posts and other discussions involving the RCSP will tell you why it is the single most important measurement that we most learned in our education. So keep on measuring, learning, classifying, changing, and re-measuring.
