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I'd like to hear your thoughts and advice on something that I have been thinking about. I had a woman in my office accompanied by a script for 'bilateral, lateral heel wedges' from her ortho (spinal, shoulder, knee specialist).

She complains of right heel pain (not PF). In evaluating her both feet exhibit very laterally deviated STJ axes and uncompensated rearfoot varus, greater on the right painful foot. She has a lot of tibial varum as well. There is no pronation ROM available at the STJ in stance, although there is more available in supination it is painful to her.

My thought in looking at her casts is that it should be poured inverted as found uncorrected; varus forefoot and rearfoot and modified to increase GRF medially.

I am not being specific because I feel that I know what to do for her, the problem is it conflicts with the ortho's orders. She was originally referred to the large O&P outfit locally, no idea why the script wasn't filled, it could be financial as she is on Medicare and CFO's are not a covered benefit. Itc ould also be that they felt as I do that this is not going to be pleasant for her? She only walks around the house and she does have some knee pain (no specifics).

I have communicated with the ortho's PA prior. Do you feel I should call and explain why I feel the script should be amended and offer my reasoning or just fill the order knowing she won't be happy based on experience?

Thank you

__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

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David, Lots to think about in your post.

If it's not plantar fasciitis, what do you think the right heel pain is? Tissue stress and all. Figure out why it hurts and then design the orthotic.

You also mentioned that there was some knee pain. Tibial varum can cause high compression of the medial compartment of the knee. It may also cause strain of the lateral collateral ligaments. Where does the knee hurt and does adduction of the tibia on the femur reproduce the symptoms?

If she is sitting at the end of range of motion of the STJ then she should have all of her STJ range of motion available in the direction of supination. Why, and where, does it hurt when she supinates?

The valgus wedge in the heel would be appropriate for knee pain caused by a tibial varum. Even with an uncompensated varus you can add a valgus heel wedge (unless you think that the heel pain is caused by overload of the plantar lateral heel from the extreme varus position of the heel.) The valgus wedge in the heel could also help any lateral instability from the laterally positioned STJ axis.

The forefoot is a different issue. You can have a forefoot valgus at the same time you have a rearfoot varus. So, you should assess load on the medial forefoot in stance before you choose to load up the medial forefoot. If there is no eversion available of the forefoot, I would tend not to add a forefoot valgus wedge as was requested.



This brings up a bunch of questions. Would they ever look at your device to see if you did what they asked? How often do they refer to you. Does this patient have a lot of friends who might need orthoses that work?

Is the prescription for the knee pain or the heel pain? That would be a good starter question for the return call. If it was for the Knee pain, you could mention some foot concearns.

Just some thoughts.

Eric

I feel the lateral column is completely overloaded and the majority of her pain is on the outer edge of the right foot. I also feel that a lateral heel wedge may increase load on the lateral column (a lateral forefoot wedge even more so).

Her foot complaint is greater than her knee complaint. She has generalized OA of the knee, not just medially and it is a global complaint.

Yes this is accurate Eric and yes dramatic supination in gait is observable during late midstance and causes her pain in the lateral foot.


I agree Eric. She doesn't walk much, mainly around the house but her lateral foot hurts when walking. She complains less of the knee but it is a concern. The script was non-specific and the PA said the doc wasn't sure n orthotic would help (her words)

Eric if we used a traditional model the lab would correct the rearfoot to forefoot in the cast correct? In this type of foot I ask the lab to pour it inverted as it is a non correctable deformity. The load is high on the lateral foot and very low medially. She does have supination available but nearly no eversion available in stance. I feel bringing the ground up to the foot medially is the best option, I cannot change her biomechanics her feet are too rigid. She is actually diabetic but relented on being certified for the Medicare Therapeutic Shoe Bill. Compliance is an issue here unfortunately nd she rarely wears shoes. She came in Crocs and I suspect that is all she will wear.


I doubt they would look at it carefully no. I know this doc and just didn't want to alter his recommendation without speaking to him or his PA. His PA was very open to my recommendations. I guess I was asking as podiatrists do you ever come across this where a referral is sent with a script that you just know is not going to provide a good outcome and how do you approach it when the patient is referred and the ortho orders something specific?

Eric I just called his PA and explained briefly why I felt I should recommend a different script and fortunately it seem to have worked out. Now we'll see if the orthoses help her at all.


Thank you for your detailed response.

__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

It sounds like you have a combination of a rearfoot varus and a laterally positioned STJ axis. A difficult combination to work with. Sometimes, by itself, the more laterally deviated STJ axis foot will supinate very easily and when it does this it will put a high load laterally. These feet can have lots of eversion available or almost no eversion available. If there is a laterally positioned axis, a forefoot varus wedge may continue to tip the STJ into supination and you would still have the lateral overload. You could make the orthotic with no forefoot varus wedge and then gradually add forefoot varus extension over a couple of visits to see what works the best.


Traditional lab work: If there is a forefoot valgus perceived to be in the cast then traditionally, when the heel is balanced to vertical, you will get an intrinsic forefoot valgus post. Since she has no eversion available, I agree that one way to ensure that you don't get an intrinsic forefoot valgus post is to tell the lab to balance it as it sits. Now, when a traditional lab does this, they will also tend to let the heel cup invert (assuming a forefoot valgus cast.) You may not want this if she also has a very laterally deviated STJ axis. So, you could ask for a lateral heel skvie to remove any inversion in the heel cup. Since you are not making this your self, talking to the lab tech directly would be a good idea.

In one of your posts you mentioned reluctance to add a valgus heel wedge. In this case I see no problem doing this. It would be good for a laterally positioned STJ axis, good for the tibial varum and I don't see how it would increase lateral forefoot load.

I agree that Crocs are hard to work with to alter the mechanics. I can also see how the softness of the Crocs could help the lateral column overload. You could try a valgus heel wedge and see if she likes that.

Hope it works out.

Eric

Eric,

Thank you for talking me through this, it has helped a lot. I am opting to attempt a lateral heel skive initially (no cast correction) and see how she fares.

__________________
"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.