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Hey everyone,

I know this has been a topic previously touched on but was hoping you would have some additional thoughts on a specific case.

GRF data during walking illustrates heightened force through the plantar hallux, with an absence of ground contact at the plantar 1st met heads. During standing examination the "forefoot varus" appears to be reducible through STJ pronation however during walking this is not utilised. RCSP is roughly 7 degrees varum. When the patient pronates STJ to get to forefoot plantar grade the calcaneal bisection sits approximately perpendicular to the ground. The patients hip internal rotation is severely limited, with Craig's test suggesting possible bilateral retroverted hip alignment.
The patient suffers relentless shortening of post leg compartment, hip flexors and lumbar erectors despite daily self myofacial release, ankle and hip mobilisation and glute and trunk strength work. There is a grade 1 Spondylolithesis at L5-S1 that is exacerbated by the shortening of the aforementioned muscle groups.

I am assuming an inability to fully engage windlass is contributing to this and was wondering if an orthotic device for daily wear would be of benefit. Kevin Kirby has recommended lateral heel skive and forefoot valgus correction and extra medial arch fill in the positive cast on a previous thread on related to this condition which I tend to agree with. However in light of the proximal pathology would this still be indicated? What are your opinions on a simple forefoot pad or even perhaps bringing the ground to the foot as the STJ pronation beyond perpendicular rearfoot alignment seems very limited? I do worry with this approach however that dorsiflexing the 1st may cause issues???

Thanks