Valgus Tilts are used to get patients less inverted in RCSP or especially to attempt to stop the patient from supinating in contact phase.
The 3 common times to valgus a patient (creating pronatory moments into your orthotic device) are 1) attempt to prevent or slow down symptoms related to abnormal supination (peroneal strain, cuboid syndrome, iliotibial band tendonitis, etc, 2) attempt to eliminate lateral instability and frequent falls or sprains, and 3) hold a patient with rearfoot valgus near subtalar neutral.
For over 50 years, designing an orthosis off an impression around subtalar joint neutral and midtarsal joint max pronated position has made a stable orthosis. I have personally designed 20,000 pairs of these in 40 years, and know of their power and limitations. Yet, the cast or digital scan only captures the forefoot tilts present and the architecture of the foot. You still have to know where to set the heel. When I design an orthotic device, part of the estimation is learning which heels will do as you say, and which heels need alittle extra push.
The Introduction here is largely from last week: With all patients, as I hear their complaints, and watch them walk and/or run, I am immediately designing the perfect orthosis in my mind. I categorize these patients by what correction I will need to achieve stability. These are A) need to achieve vertical, B) need to achieve less of an everted heel (discussed last week), C) need to achieve markedly less everted heel, D) need to achieve an inverted heel position, E) need to achieve less of an inverted heel position (today's topic), and F) need to achieve markedly less inverted heel position. Of course, the demands of the right foot may be totally different from the left foot.
I have defined my Gold Standard (Type A) orthosis as setting the Heel Vertical and any forefoot deformities balanced out. If you measure RSCP, this is typically accomplished in the range from 2 degrees inverted to 2 degrees everted. If you do not measure, the heel simply looks vertical to slightly off in either direction. This is called the Root Functional Orthotic Device or the Root Balanced Orthotic Device. This is how A is obtained to make a very stable orthotic device. Balance the heel to vertical and balance out all forefoot deformities (with casts or digital scans the lab can find the heel bisection, and set the heel bisection vertical to the ground easily).
Last week we discussed Type B with a 3 degree varus tilt applied by some technique. Today we will discuss Type E (need to achieve less of an inverted heel). Type E may be achieved by my Gold Standard if there are everted forefoot deformities producingmy heel inverted position by compensation. You can always ask the lab what forefoot deformity was measured by the cast or digital scan before finalizing your Rx. So, if you see an Inverted heel, and it goes to vertical with the Coleman Block Test (I typically use my fingers under the lateral forefoot), Type A will work. But, if we need rearfoot support (no high forefoot valgus or plantar flexed ray seen), the common orthotic variations different than Type A are: 1) slightly narrower orthotic width, 2) higher lateral heel cup, 3) no motion ground into the rearfoot post, 4) Denton modification, 5) inskive 1/2 of the medial rearfoot post, 6) slight lateral phalange extending 1 inch further distally than post, and 7) tell the lab no fill under the lateral column that would separate the orthoses from the foot (in plaster terms, no covering of the plantar surface of the cuboid and 4/5 metatarsal bases).
Now, I need your help. What has worked for you to achieve our goal today of a less inverted heel position? We will be talking about Type F next week where we typically need to the big guns for anti-supination: Lateral Kirby skives, lateral only rearfoot posts, very narrow orthosis, lower medial arches, full lateral phalanges, everted pours, and valgus wedges. This will be discussed next week in the topic: "When do we Really Valgus?"
Denton Modification to resist contact phase supination and heel inversion applied to the plantar surface of the right orthosis.
