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Lateral shoe collapse with valgus / flat foot?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by AdamB, Apr 21, 2014.

  1. AdamB

    AdamB Active Member

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    Hoping for some advice on a recent case. 40yr old healthy male referred to me by physiotherapist for management of "flat feet" and right calf muscle weakness (reduced muscle bulk) as well as patellofemoral pain. The pt was active and attended the gym regularly for weight lifting etc.

    On assessment, the following was noted:
    - valgus foot type / flat foot deformity in resting stance, right foot worse than left
    - significantly medially deviated subtalar jt axis
    - mobile subtalar jt, hyper mobile Mid tarsal joint, reduced dorsiflex stiffness 1st ray
    - early stage hallux valgus deformity R >L

    Most interesting though was the shoes he brought in. He runs a cafe and is on his feet for long hours and his current work shoes (Brooks Addiction Walkers) were 8 months old and were deformed /collapsed laterally.

    I have never seen this before - how is it possible to deform the shoe laterally to the point where the foot is laterally unstable in the shoe, with this foot type? I'm used to seeing medially deformed shoes with this foot type.

    Any thoughts welcome. Thanks.
  2. Adam:

    I would bet that your patient has a genu valgum deformity which will cause this type of shoe wear pattern due to the medially directed shearing force from the ground acting on the shoe during gait. In addition, in heavier individuals any sort of dual density shoe with the medial midsole of higher durometer will allow them to collapse out the lateral midsole much faster. I see this type of shoe wear pattern quite commonly in my practice.
  3. Brooks Addiction shoes have a super aggressive medial arch posting. Also, if the patient has a strong tendency toward forefoot abduction he may be sliding off the shoe in addition to compressing the lower durometer foam at the lateral border of the shoe.

    A better shoe choice would be the New Balance 993 - it has high density foam on both medial and lateral sides, forming a horseshoe shape around the heel. Similarly wide shoe last to the Brooks Addiction series
  4. camkitchen

    camkitchen Member

    During a linear walking gait analysis you will note that despite the propensity to over pronate displaying medial deviation that the vast majority of pronators heel strike laterally transferring load from lateral calcaneous and down the lateral column via base of 5th and then 5th MTPJ before the midtarsals deviate medially. So the lateral column of the shoe will then collapse and begin to act like a post further compromising lateral stability. Especially considering the amount of load incurred upon heel strike this becomes simple arithmetic sort of. Many over pronators also have weak or injured Peroneals and or lax or hypermobile ankle ligaments allowing for exaggerated supination/chronic inversion upon heelstrike. On uneven surfaces like ice/snow, grass, gravel and sand this can become very apparent that can't ambulate normally. Many Pronators also compensate by avoiding heelstrike altogether and to some degree midstance as well by toe walking. This allows them to transfer loads laterally onto the 4th and 5th and override the over pronation however the lateral side then often takes the beating instead.

    If you follow them around the cafe you'll easily see why. The are not walking in this linear fashion all day long, in fact rarely if at all. They move from counter to counter or around tables and then as they step to the next counter or work their way around the table the gestured motion is always onto the later aspect of the shoe. All of my patients who work at the Subway get this as well. They are constantly side stepping when they make your sub sandwich even those that are Pes Valgo Planus with Posterior Tibialis dysfunction ALL destroy the lateral aspect of the shoe as the upper deviates over the sole unable to keep them contained. They also pivot laterally instead of making a small step in a circle heading in their intended direction, forcing the foot ankle, knee and hip to torque laterally.

    Keeping the lateral aspect of the Orthotics corrected is just as important as the medial side especially if they have occupations that keep them moving laterally. There are many many occupations that force us to perform movements that are counter productive as such. I really prefer to offer those patients a full Orthotic with ample corrections for the medial and lateral deficiencies as well as a New Balance shoe like the 1540. Keep the loads under control on both sides and all will be well. The other option is to change the shoe more frequently so that it staves off this wedge like effect that takes place as it wears down and does not become the Achilles heel(pun intended):D

  5. Boots n all

    Boots n all Well-Known Member

    The thing's that stood out to me was you said his "work" shoes showed this pattern of "collapse" not wear, do his other non work shoes, show this same collapsed pattern?

    If they dont, the answer maybe simple, he is working in a cafe, behind a counter or as a Brewster which means he is most likely walking side ways all day.

    Next time you order a cappuccino, watch the Brewster, one step to the left one to the right, all day. This is a wear pattern we see in those that work in deli's and behind the counter type jobs and despite the foot type they all show lateral sole collapse, the bigger they are the more compression of the sole compound.
  6. AdamB

    AdamB Active Member

    Hi Kevin,

    Thanks for the response. Yes I would agree with what you have said, and it makes sense.... However this particular guy had no measurable degree of genu valgum deformity and he wasn't a particularly heavy guy at all. Thus I am still confused by this paradox. I need to understand the biomechanics properly so that I can prescribe an effective orthosis.
  7. AdamB

    AdamB Active Member

    Hi, thanks for the shoe suggestion. I will definitely look into that.
  8. AdamB

    AdamB Active Member

    Hi Chris,

    Thanks for the advice. I hadn't considered the type of movement he was doing with the cafe work and this looks like a definite contributing factor.
  9. MJJ

    MJJ Active Member

    I saw a great set of pictures a few years ago that showed this but can't for the life of my remember where I saw them. They cut away the heel counter of the shoe and you could see what was happening. The calcaneus was no longer centred in the heel of the shoe; but, due to the angle of eversion all of the pressure from the heel was lateral to the midline of the shoe.
  10. AdamB

    AdamB Active Member

    Any suggestions on how to design an orthotic that is going to address his valgus flat foot deformity but not going to cause even more lateral shoe collapse?
  11. Boots n all

    Boots n all Well-Known Member

    Rather than trying to use the orthosis to address the lateral sole compression, why not modify the sole with a mild lateral buttress or have the shoe sole modified to have a firmer compound along the lateral rear to mid foot?
  12. Dananberg

    Dananberg Active Member

    This is a classic response to Functional hallux limitus (Fhl). The reason for the confusion is the visual conformation of a very pronated foot in static stance, and believing that this MUST be occurring when walking.

    One of the compensation for Fhl is to shift weight laterally away from the 1st MTP joint during the majority of the support phase. When the heel lifts off the ground, the foot is deviated laterally, and is quite unstable. The pronation you see in static stance occurs at this time, heel off, in the gait cycle, when only the forefoot is in ground contact. Pronation during heel lift, with a foot with weight far lateral, will produce the issues you describe in your patient.

    The last thing this guy needs in his orthotic is a varus posted rear foot. This will only perpetuate his laterally based compensation. Try a neutral type RF post, and a valgus forefoot post with 1st ray cut out. Shell density should be moderate. He may also require a fascia groove to accommodate the medial slip of the plantar fascia. These tend to be very prominent in this foot type, and the orthotic will become painful along the medial plantar fascia.

    This next part of the Rx is important. He will also need some type of forefoot extension to the toes, or else the orthotic will move medially in the shoe as it is being forced into this position during the lateralization of this gait. This is an ideal time to use either a kinetic wedge or reverse Morton’s extension in the forefoot.

    I would also look very carefully at his leg length, and correct accordingly. Small differences (3mm) make a difference is this type of foot.
    The last comment is his ankle joint ROM. He may be mildly to moderately in equinus. This will have an inhibitory effect on his peroneals, further exacerbating the lateralization process. Manipulation of the ankle will go a long way to improving this situation.

  13. AdamB

    AdamB Active Member

    Thanks Howard. I have altered my prescription accordingly, however he does report medial arch / foot pain toward the end of his work shift related to his valgus foot type and excessive pronation.... If I don't I increase ORF medial to the STJ axis how will I reduce his symptoms?

  14. Dananberg

    Dananberg Active Member


    Mark the area of arch pain on his foot with a transferable marker like lipstick. Hold the device and press against his foot.. See if the transfer point is along the medial slip of the plantar fascia. If so, deepen or add a 1st ray cutout and see how he does. Be gradual with the adjustment as a little can make a significant difference.

  15. AdamB

    AdamB Active Member

    Thanks Howard. Won't get the devices back for another week, but will check this.
  16. sorefeetseepete

    sorefeetseepete Welcome New Poster

    When I get feet like this I always try to stop the excessive lateral wear with the right shoe and the correct orthotic. If then not possible to get the right combination I will modify the shoe ( I did do a shoe making course after I finished uni, but this is not necessary).

    The reason this is my last option is people replace shoes far more regularly than orthotics and I personally would find it a hassle to have to get your shoes modified every time you buy one. Not to mention the cost.

    If your shoe / orthotic therapy isn't working then modify the shoe to stop the excessive lateral compression. My personal preference in this case is to use the brooks addiction (if possible) as it is easy to peel away the outer sole, not completely, leave it attached at the front. That way the sole never comes off. You can then easily grind away the softer density EVA it replace it with whatever you want ie- harder. You may also consider a very slight 2-3 mm lateral wedge in the sole at the same time, just in the last 3 inches on the shoe.

    For really severe cases a lateral flange is needed to be added to the sole of the shoe.

    The addiction is such a great shoe to modify for so many problems.
    But I leave this for those difficult cases.

    All the best Peter

    P.S. In terms of marking the location of any problem with orthotics it is always best done weight bearing in the shoe. This is because the location changes from the chair to the ground, and then again when the shoe is in play.

    I have a little saying,
    especially in forefoot HK /HD deflection placement.
    Maybe its a Sydney real estate thing.
  17. Amelie

    Amelie Welcome New Poster

    Hello Howard,

    I'm interested in your orthotics for this type of patient but english is not my native language and I don't understand some "technical" words. Please, could you, or another member, send a picture?

  18. Amelie

    Amelie Welcome New Poster

    Howard or any other volunteers :)
  19. RobinP

    RobinP Well-Known Member

    Not uncommon in cases where a significant amount of the sub talar joint pronation is taking place in the transverse plane

    As mentioned, the heel translates laterally in the shoe and the shoe effectively rotates around the foot. in the clockwise direction causing marked lateral deformation of the lateral quarter of the shoe.

    I tend not to medially post people like this greatly, instead using modifications such as mentioned by Howard to alter centre of pressure and medial heel skives to increase the external supination moments without necessarily trying to kinematically alter the angulation of the heel or the "amount" of pronation.

    If despite employing said techniques, the only thing to do may be to protect the footwear by laterally floating the heel and butressing the lateral quarter of the shoe. Difficult to do this cosmetically with a trainer or any other shoe that is high street without it starting to look a bit "special" (David Sutton could probably show a good example of how this could be done cosmetically)

  20. Boots n all

    Boots n all Well-Known Member

    Thank you Robin for your kind words.

    Dont have any pics to hand, but my minions have one in the workshop to do, l will take a pic when its done.

    Lateral flares and buttress are by far the hardest to do, if its too prominent the client wont like it and if its not prominent enough it wont work.

    This is the only modification we do off the shoe and attach later, all other modifications are done on the shoe.

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