Key Points:
- The simple measurements of RCSP and OCSP are vitally important in our basic understanding of the patient and their orthotic correction
- Pronatory degrees and pronatory caused symptoms are explored
- Discussion of when an orthotic change may be considered, especially in light of inadequate symptom response
- The patients who need ideal control and who flood your offices
Let’s now talk about the progression of orthoses. I make claims to exact degree(s) (+/-) knowing well that you will measure differently than I. This is why I emphasize the simple measurements of RCSP (Dr. Root) and OCSP (Dr. Kirby) during the orthotic dispense visit. I can also not assume that your orthotic laboratory will make it the same as mine. But, these measurements will help especially in our B, P, S and ML orthoses. P4 orthos, when I make them, predictably give me 7 degrees of pronation correction (and you may have to adjust up or down for your lab). ML4 predictably provides 5-6 degrees of pronation correction. For me, this is wonderful. For now, until you see the results of your Rxs, just know that if you order a B orthosis for a pronator, you can get progressively more pronatory support as you advance to BP, then P1, then P2, then P3, etc.
This brings us to my next point in your understanding of biomechanical orthotic therapy. A patient presents with a problem which you tie to their pronation tendencies. You prescribe your gold standard pronatory device (let’s say it is a BP design). Their symptoms are greatly improved, and the pronation reduction from RCSP to OCSP is 6 everted to 4 everted. Since the symptoms are better, you allow a return to running program and they do fine with a complete return to pre-injury running levels (Example 1), or are limited to 3 miles of running before the pain returns (Example 2). You advise in Example 1 that it is fine to leave the correction alone, which is not adequate in Example 2. We can either convert the orthosis to achieve more pronation control by adding a temporary medial heel skive, forefoot and rearfoot varus postings, and/or medial arch reinforcement.This can change OCSP closer to heel vertical, and dynamically provide more pronation control. In this scenario, the patient became asymptomatic running all the 10Ks and half marathons they wanted. Many of my patients want the original orthotic device converted back for better shoe fit, and a 2nd version made with these new successful specifications. If we tie biomechanics to symptoms, and we understand how to gauge biomechanical success with symptom relief or lack thereof, we will be able to know when to offer lesser or greater corrections. Many times it is ultimately up to the patient. Even if you think the insurance will not pay for a second pair, you have to inform the patient that you can improve the stability and probably the symptoms as the next option. I would grade my orthotic devices at dispense, A, B, C, etc, based upon how ideal from perfect stability they had become. If they were an A, but their symptoms were not improving at all, treating the mechanics further is not going to help in general. You must get a better diagnosis, or add neuropathic or anti-inflammatory treatments.
Biomechanical treatment can take a long time when you are treating patients. This scenario is typically not your plantar fasciitis for 2 weeks patients with mild pronation, but your moderate to severe deformity patients with chronic, sometimes disabling conditions. These patients flood our podiatry offices. These patients are really needing our care and the reason why I never limited by practice to orthoses or runners. I wanted no limits. I would much rather help these patients. They can present as one of the 5 to 10 worse pronators that you will see this year (and will possibly need multiple versions of corrections), or their biomechanics and symptomatology is both a complex mixture of frontal, sagittal and transverse plane deformities combined with pain syndromes produced mechanically, inflammatory, or neuropathic in origin. Here is where biomechanics can literally change lives. These patients are why I go to seminars, read articles, and pray often.
