I recently saw a patient with pes cavus foot type for whom I had designed orthotic devices around 10 years ago. He simply was coming in to get his very successful orthotic devices (in his mind) refurbished, as this was long overdue. My office is and never was good at contacting patients for their yearly orthotic evaluation, something that I would always prefer. Before I do anything to an orthosis, I always watch a patient walk (and run if they are runners). Today there was no running as he had come from work in some $1000 suit, but did remember to bring running shoes. When I watched him walk, he was terribly rolled out (supinated). I asked him if he felt the roll outwards, and he said yes! I asked him if it bothered him, and he calmly said that these were his running orthotic devices and he never walked in them. I was relieved. His posts were all broken down, and he had placed his own mis-shaped top cover on at some point. I told him to schedule to return in 3 days so I could properly evaluate after I had them refurbished. Then he said he had left the walking pair at home, which he would bring in later, and wanted to order a dress pair that he never got around to ordering for tighter dress shoes.
Confusing? When I finally got his chart from storage (as we had changed to all electronics EMR 7 years ago), I understood the dilemma. He was a typical patient that walked with some lateral instability (needing one type of orthotic correction), and was a severe pronator when he ran. He had brought in, and walked in, his running orthotic devices with severe anti-pronation modifications (varus wedging with inversion in the correction with medial Kirby skives). There was a mismatch, but only due to my ignorance of the past. He was smarter than me and never wore his running orthotic devices to walk. He said that I had told him that as soon as the race or training was over, if you still had some walking to do, to remove these orthoses from his shoes and carry them.
After refurbishing the orthotic devices, I was able to work him into the schedule 3 days later. Again, I was a bit disappointed. Why? This patient was a severe pronator needing severe pronation control from both his orthoses and his shoes. He was in literal “garbage” due to some recent trend you all know about. I asked him when he made that change over the last 10 years since I saw him last. He sheepishly said he knew from our previous conversations that I would disapprove, but he had felt so good with them. I told him “good” is relative, I joked that I was sick to my stomach watching this. As it turned out, since changing to these shoes, he had had a series of running related problems that slowed him or stopped his running for a while. One particular bout of knee pain cost him a year of running, with negative MRIs, but an orthopod ready to explore his knee surgically. I bet all these issues, even the knee, could be tied into these shoes. Remember, a great orthosis needs a great stable shoe, and a terrible shoe makes a great orthotic device useless.
If you treat athletes, you can be more like their coach than doctor at times. Even their psychologist!! He had topped off the discussion on shoes with “But everyone in my running group is wearing them”. And, his running group was not made from our local Podiatry society. Within one month, every orthotic device was in order, including the new one for his dress shoes. He had had his old molds which I used for a second pair of running shoes for his convenience. I had originally made his walking correction, and then converted the molds for varus orientated running orthoses. When he asked for the dress pair, for walking of course, I re-casted his foot. This way, if he ever wants another pair of walking orthotics (which he uses for long walks with wife) the molds are ready.
This turned out to be typical for my practice. My orthotic patients usually over years required multiple types for different functions. This particular case does highlight how running can be so different than walking. I had originally designed some orthotic devices due to chronic peroneal pain post ankle sprain. The fact that the patient was a supinator walking was feeding into the problem. The patient got much better with the new anti-supination orthoses, and 6 months later came into the office with a shin splint problem. When I watched him run, I realized what a terrible pronator he was, and that my original orthotic devices would do nothing to help that issue. This is when we started the conversation on another pair for his running mechanics.
Severe pronation in running video
