Having a very hard time with a "problem" patient. She has pes cavus (bilaterally) with a semi-rigid to rigid plantarflexed 1st ray, hallux abductovalgus, and retracted toes 2-5. In weight-bearing stance the anterior view would appear as if she is a classic supinator as I expect to see with this cavus foot. But, from the rear her calcaneus is everted with 4 degrees of valgus in neutral and 7 degrees of valgus in relaxed stance. Measuring her forefoot was very tricky (more than than usual with a PF 1st ray) as I usually reduce the plantar flexed 1st ray to measure it. She was rigid enough that I couldn't do that. After second guessing (even a 2-5 varus), I measured a 2-5 forefoot valgus (2-3 degrees), which is more what I expected with the cavus. Her plantar callus pattern, though, also shows medial shearing, with calluses on the medial aspects of bilateral 1st met heads and on the medial hallux on one foot-- more indicative of pronation problem. The other foot had a callus on her 5th met head, not on the 1st. Mid tarsal joint is rigid in PF, so in gait she excessively dorsiflexes her toes to clear the ground.
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Has anyone else seen this type of presentation? I am stuck here trying to decide on what to do on her prescription for the lab and not sure what to do. Typically, I would post laterally for excessive supination with a pes cavus foot. But, this one is stumping me. Should I post the rear foot at all? If so, it would be medially. And, forefoot-- a 2-5 valgus/lateral post with a 1st ray cut-out? An arch fill would likely be necessary as my lab tends on molding the shell lower than the actual arch height. I will definitely get a deep heel cup to control the calcaneus and because these are strictly for athletic shoes. I'm guessing a semi-rigid/semi-flexible device would be appropriate.
Any help would be greatly appreciated.
Thanks,
Kathy
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