Today I want to present a challenging patient which presents to our offices occasionally, although routinely as you get good at both the recognition of the problem and your fame spreads far and wide. This is the patient with both tendencies to pronate (here called “medial instability”) and supinate (here called “lateral instability”). At times their presentation to your office is pronation based, and other times supination based. By this I mean, your Working Diagnosis and treatment is pronation related or supination related. You should all be familiar with problems related to pronation and supination by now. This series on functional foot orthotic devices, now in #6, has outlined the problems related to these motions when excessive. You develop this sense by correlating injury or pain syndrome with individual biomechanics and then treating those biomechanics. You then connect the treatment to the response from the patient. Did their inserts for such and such function help their such and such injury or pain? This is how I do it and countless other practitioners in this field.
Here the right side shows problems with Supination and the left with Pronation
I have had several email exchanges with Dr Mark Warford who is also fascinated by these patients. The classic example is the patient who pronates on one foot and supinates on another. Dr Warford gave me a great example which I will present in one of the next two posts. Your treatment of each foot needs to be unique and very asymmetrical. I have found that the supination problem is more important to change than the pronation problem if you were to prioritize. My purpose here is simply to treat each foot separately as if both feet pronated or supinated. What does the pronated foot need and what does the supinated foot need?
Let’s review our prescription writing for each foot. For the pronated foot, some good inverted forefoot deformity support if they have and you use Root techniques, higher than normal medial heel cup, 2 mm medial Kirby skive, placing some inversion into the correction, wider than normal frame width, thicker than normal frame, less arch fill than normal, no motion in the rearfoot post, and full arch fill medially (to the ground). I am not suggesting you have to use all of these at once. Whatever you feel comfortable adding. When I say “from normal” it is from your Gold Standard orthotic prescription, or as the wise Dr Stefan Feldman called it “My Go-To Device”. You need to begin, if you don’t already, subdividing your pronators at least into mild, moderate, and severe, and have prescription variations that reflect that.
For the supinated foot, some good everted deformity support if they have and you use Root techniques, higher than normal lateral heel cup, lateral phalange, Denton modification (lateral frame fill), flatten the lateral ¼ of the device parallel to the ground, zero degree rearfoot post motion, narrower width than normal, higher arch fill than normal, 2 mm lateral Kirby Skive, and possibly setting the device 2 degrees everted. This is the same definition of “than normal” as before, and supinators should not be placed within 2 degrees of their MPP (maximally pronated position). This also has been described in a previous post. The risk for supinators is that you place them into MPP or worse yet sublux their joint by attempting to pronate them into a position that they can not go. I learned this when I joined an orthopedic clinic. The orthopods all wanted me to design valgus wedges for their patients with medial knee compartment syndrome in an attempt to avoid knee replacements. This was great and I was good at this. But, using our measurements of RCSP, NCSP, OCSP, and MPP I could avoid damaging their subtalar joints by going too far into subtalar eversion. If the patient stands barefoot on the device/wedge, see if they can evert further which is what you want to happen. Measure the RCSP on the insert, and then internally rotate that entire limb, and re-measure. You should have 2 or more degrees of eversion in your MPP measurement.
See you next week! Rich Blake
