Rearfoot varus

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I would be grateful if someone could link me to any posts on rearfoot varus or inverted calcs. and orthotic prescription. Otherwise I would love to know if anyone has any tips in regards to orthotic prescription that I should be mindful of when prescribing an orthotic with someone who has inverted calcs?

 

Goodaye agallan, firstly why would you necessarily want to issue foot orthoses to this someone?

 

Hi,
he has been suffering from chronic plantar fasciitis, male 45 yr old, office worker, wears good shoes. Pes cavus foot type, reduced ankle ROM, Hallux limitus.

 

calcs are very inverted and I havent seen many patients with this type of foot, just wanted to see if anyone had any tips with prescribing foot orthotics with this type of foot

 

Hx of recurrent lateral ankle sprains?

 

Pt reports minimal but does have bilateral ankle swelling, used to play alot of football when younger

 

STJ axis transverse plane orientation? ..... use the lunge test for rearfoot dorsiflexion stiffness?

 

Will have to do this assessment when I see the patient in a week. I know each patient has specific needs but in your experience, what sort of scripts have you done for pes cavus feet with excessive rearfoot inversion?

 

Treat the injury not the measurements

Cronic plantar fascia injury related to too much tension in the plantar fascia. Treatment plan = reduce tension in the platar fasia and aid in healing

 

So forefoot valgus posting but no rearfoot varus posting in this case, treating as if increase in external STJ pronation moments needed?

 

FF Valgus or reverse Morton extension
but you could use a 3 mm or so medial skive depending on how high the pronation moment is.

without getting more information it would be only speculation.

Things like plantar fasica group or not would also be important to consider and of course what soft tissue program you will use

 

I thought that if the stja tp orientation for laterally deviation proved so a medial heel skive would be contraindicated?

 

Plantar fascia Group so telephone = Plantar fascia groove

Soft tissue work

Gastroc and soleus stretching/massage

PF stretching or strengthening, massage, manual therapy, taping etc

TP ?

 

Apologies Mike, not sure what it is termed; the transverse plane orientation of the STJ axis, mark

 

Sure if the STJ axis is laterally deviated during weightbearing

But you would need to assess that, plus the Supination resistance/ or force required to cause supination

But a Pes Cavoid foot on non-weightbearing can be a lot different weightbearing and if the pronation moment is high enough and a large amount of force required to cause supination at the STJ a smaller skive is very useful

The other useful thing with a skive is that you can have a higher arch device without the the same Plantar fascia irritation. or the same size as planned but less chance of Plantar fascia irritation

 

I've read through the posts here and with limited information available, I disagree wholly with the assessments. First, I would love to have a weight-bearing lateral x-ray...that would be helpful. Mike Weber gave you advice to treat the symptoms...not the deformity. I couldn't disagree more strongly. Have faith in your abilities to diagnosis and treat.

The plantar fasciitis may very well be just a symptom of a larger problem. Without venturing down the path of surgical intervention, (a medializing calcaneal osteotomy, for example), if this patient has an uncompensated rear foot varus deformity, that means he is functioning at the end of his STJ ROM. It is likely that he has RLS or had growing pains as a child...just ask him next visit.

The Rx for the orthotic should hold the patient's calcaneus even MORE inverted than he is at RCSP, (more neutral). Look at his foot from the rear and the side while in NCSP to get an idea of the goal. My experience is that these types of patients are a wealth of information. Hope this helps.

 

Treat the injury Matt (not the symptoms ) was what I wrote

As fir the rest that stump has been beaten to death

 

Starting with basics. Both a rearfoot varus and a forefoot valgus can cause an inverted calcaneus. You can have one or the other or both. Are you familiar with the Coleman block test or the maximum eversion height test?

A rearfoot varus is unlikely to cause plantar fasciitis by itself. Feet with forefoot valgus and inverted heels often have a laterally deviated STJ axis (See Kevin Kirby's paper on palpation of the location of the STJ axis) The reason that these feet get plantar fasciitis is that there is late stance phase pronation caused by higher than average activation of the peroneal muscles. With this late stance phase pronation there tends to be high medial forefoot loads on the first metatarsal. High loads on the first metatarsal will strain the plantar fascia. A forefoot valgus wedge, or intrinsic post, will reduce the strain in the plantar fascia. Adding a medial heel skive can make the late stance phase pronation worse when there is a laterally deviated STJ axis. You need to know the location of the STJ axis to decide whether or not to add a medial heel skive.

Eric

 

Thank you all so much for your responses, it has given me a lot of insight and some additional useful assessments to do when I see the patient next week. This was my first time posting and I'm so glad that I did, you have all furthered my knowledge and I am very grateful for that.

 

It's the symptoms of pain, (injury), that brought the patient into the office seeking help in the first place. If one merely treats this, they are, IMO, missing a bigger picture.

It also appears that many involved in beating that stump still don't have it right.

 

Eric, the definitions I have read advise placing the 'block' beneath the lateral side of the foot.
The 'block' ONLY has to be beneath the lateral forefoot to be effective as a test of the rearfoot doesn't it?, thanks, mark

 

Typically, the Coleman Block Test is done only under the lateral forefoot, but certainly, the lateral midfoot and rearfoot could also be wedged laterally with the block.

A much better test, in my opinion, is the Maximum Pronation Test, where the subject is asked to pronate their feet maximally with their knees extended, to see the position of the posterior calcaneus in the maximally pronated subtalar joint position versus the relaxed calcaneal stance position. I first described the Maximum Pronation Test in a book chapter from 26 years ago (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

 

I agree with what Kevin wrote and would like to add some explanation of the Coleman Block test. The test is placing an object under the lateral aspect of the foot to shift the location of center of pressure under the foot more laterally (increasing pronation moment from the ground). In those feet that reach equilibrium with some pronation range of motion available, there will be pronation to a new equilibrium position. In those feet at end of range of motion, there will be no motion.

With that in mind, you could think up some really odd foot conditions where the Coleman block test would not work. Perhaps eversion could be limited so much that the entire foot is medial to the STJ axis. In that case, the Block might not cause eversion. So, to answer your question, the block has move the center of pressure far enough lateral to increase the pronation moment. That will be different for different feet and dependent on the STJ axis location. To be sure it works you could put the block under the part of the foot that is farthest lateral to the STJ axis. (Or you could really get old school and draw a line on the back of the heel and the back of the leg...)

In the maximum eversion height test which is pretty much the same thing as the Maximum pronation test that Kevin described, the peroneal muscles create the pronation moment that attempts to cause further eversion. Of course, this won't work if there is no peroneal strength.