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Rearfoot posting for Reearfoot Varus/ Valgus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by jmarshal51, Dec 8, 2011.

  1. jmarshal51

    jmarshal51 Member


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    I have been told that a varus rear foot post will bring both a rear foot varus and a rear foot valgus into proper alignment. For some reason I fail to see how a varus post will bring both deformities into alignment.

    Does a varus rear foot post bring both into alignment or is there something that I am missing such as positive cast balancing?
     
  2. Were to start.

    1. who told you that ?

    2. what is proper alignment ?

    3. Orthotics don´t realign feet never had never will there may be a kinematic change but it is not a realignment.

    without being too blunt, but I really do not know how to say it any other way - it seems that both of you have some catching up to do re how orthotics work and why they should be used.
     
  3. Jake to help you out

    New Members interest in Biomechancis - where to start

    Are Root Biomechanics Dying?

    What is the "normal foot"?

    Biomechanical Explanation/Advice needed

    threads tagged with orthotic prescription variables

    Hope that helps - it does not answer your question but if you read this stuff you will see why your question is not important and hopefully help get you think bio-mechancis
     
  4. Mike:

    I can't agree with the above statement.

     
  5. efuller

    efuller MVP

    Rearfoot varus or reafoot valgus are not problems that need to be treated. Posterior tibial dysfunction and sinus tarsi syndrome are diagnoses that need to be treated. Now PT dysfunction foot may look like a rearfoot valgus and it would benifit from a medial heel skive and a rearfoot post to increase supination moment from the ground. Sinus tarsi syndrome may be caused by a partly compensated varus causing high pronation moment from the ground. (Because the foot cannot evert far enough to get enough medial load). This condition could also benifit from a medial heel skive orthotic with a rearfoot post (and forefoot varus post as well). So, your statement might get you the right results for the wrong, and confusing, reasons.



    Eric
     
  6. jmarshal51

    jmarshal51 Member

    Thank you both for your posts though I will admit it has not helped my understanding of the issue at all. So perhaps there is something else that I am missing. I will look through a copy of Valmassy's book when I get the chance. Maybe there is a defenitional issue I am having here.

    Mike:

    The question may not be important to YOU but it is important to ME because it relates to my job and I have people to answer to.

    I will be the first one to admit my understanding of these topics is basic at best but I am trying to improve that knowlege as best I can. How ever I can not make time move faster so I will have to do it the same way you all did, with time and effort.

    My first statement should answer your first question.

    As for your second question (and I have read through much of the thread about the "normal foot") it seems to me there is no answer to that question, just theories and models to help "interpret facts."

    And, in my humble opinion, there is no universal agreement on how an orthotic is to be best used for every condition, and what effect is has on biomechanics as a whole due to the individual nature of their effects, as Dr. Kirby's post demonstrates .

    So how would you define a "normal foot?"

    The definitions for varus (of, relating to, or being a deformity in which an anatomical part is turned inward toward the midline of the body to an abnormal degree) and valgus (of, relating to, or being a deformity in which an anatomical part is turned outward away from the midline of the body to an abnormal degree) are both positional (as is alignment: the act of aligning or state of being aligned; especially : the proper positioning or state of adjustment of parts (as of a mechanical or electronic device) in relation to each other). I will agree completely that orthotics effect kinematics (a branch of physics that deals with aspects of motion apart from considerations of mass and force).

    So perhaps the question should be this: How does a varus post improve the kinematics of two opposite positional abnormalities?

    And please understand I am not a podiatrist treating patients I am going through customer service training at an orthotics lab and trying to understand why I am being told to provide the recommendations I am being told to provide should these questions come up as I am attempting to help a customer order the appropriate device for the given pathology.

    how would any of you feel, as clincians, if you called a lab to have them make a device and had the person who answered the phone argue that your diagnosis is invalid and begin to start a debate about the nature of the pathology and the kinetic and kinematic effects of orthotics?

    i can promise you it would not go over well with those I answer to and I would guess that very few (if any) clinician would ever use our company again if that where to happen.

    I do, how ever, wish to know that I am doing my best to provide the appropriate answers to the questions I am given and why.
     
  7. jmarshal51

    jmarshal51 Member

    And thank you as well Eric. You posted while I was writting so I did not see it. I will consider this while I am lunch. I am sure it will lead to more questions as most of my readings do.
     
  8. In what way Kevin?

    That Orthotics don´t realign feet never had never will

    or there may be a kinematic change but it is not a realignment.

    to realign something we must have a normal and we do not have a normal of anything as far I know, we a subject specific normal. Which is really only a physiological window - ie the patient is pain free.

    Even the conclusion to the study showed that - Our study shows that the response to foot orthoses is variable between individuals which may mean there is a kinematic change in some but it that change making the patient realigned or not I do not believe we can answer that

    Also Your paper only looked at the STJ how do we know what happened at all the other joints in the foot?
     
  9. Nope. Just needs to change the alignment to have realigned it, or if you want to be pedantic: to bring it to an alignment it was previously at. Normal doesn't enter into it. While a kinematic change is not necessary for foot orthoses to work; a kinetic change can occur without a kinematic one and this might well bring about a positive treatment outcome. Yet this does not mean that kinematic changes do not occur with foot orthoses; we do have a number of studies which clearly demonstrate a change in kinematics in response to foot orthoses.

    I can't get "the kid who's dad told him something" out of my head, Kevin- you were bang on.
     
  10. Maybe it is words as I did say there can or cannot be a kinematic change in my 1st post ,

    to me realign would mean to put back to a position as a made the example a bent bar and then bent back into a straight position - which I believe most would think of a realignment, I am not saying a kinematic change will or will not occur

    A Kinematic change I would say is a change in alignment of the joints and therefore bone position

    realign would be make normal as getting your car wheels realigned


    So I said a kinematic change may occur I never said it would not .

    as the rest of the post was directed at me - was this as well, if so care to expand.
     
  11. Mike:

    Here is what you wrote:

    As Simon said, to realign a joint is to move that joint into a new position. Foot orthoses have the capacity to not only move pedal joints to new rotational and translational positions but to also change the kinematics of gait. This was the sentence I was disagreeing with.

    Also, just because we don't see large changes at the subtalar joint with foot orthoses, this does not also mean that relatively larger changes of translational and rotational position might occur at other joints of the foot. I would imagine that foot orthoses can have a profound effect at changing the alignment at the talo-navicular joint but, since this bone pin study has not been done yet (to my knowledge), then we really can't be so sure of this. My guess is that the talo-navicular joint will show very significant changes in alignment in standing with a foot orthosis that has a well-formed medial arch.
     
  12. Simon:

    Good to see you back contributing again. It's been a little quiet lately here without you. :drinks
     
  13. Yes, that's right.

    No, that's in your head.
     
  14. Lots going on, not least a puppy with liver failure, a mother with a mal-union to her fractured wrist, another burglary at the clinic, a ridiculous phone bill for using the internet in America `(£300 for 13 minutes), blocked sewers and a broken plasma screen, throw in the professional rugby players I'm now looking after and you'll appreciate that time has been at a premium. And also with age and wisdom, I've come to recognise when it's time to take a break from podiatry arena.

    Thanks for the acknowledgement though, it helps the ego.:drinks
     
  15. Jake:

    It is very good for you to keep asking these questions at your level of knowledge. This resource we call Podiatry Arena, is the best in the world at answering the types of questions you posed. However, you must understand that you will be continually challenged here. This is a good thing, because if you can take the heat from us, I doubt there will be many podiatrists that you interact with that will be more knowledgeable regarding these issues than the ones that frequent Podiatry Arena.

    As far as what you wrote above, varus and valgus may be both positional and structural alignment issues, not just positional issues.

    Varus orthosis posting may be helpful for a patient and may be harmful for a patient. As Eric stated, if the patient has posterior tibial dysfunction, then a varus rearfoot post or medial heel skive may help relieve symptoms. However, the same varus rearfoot post or medial heel skive may cause a patient with lateral ankle instability and/or peroneal tendinopathy to have more pain and disability.

    Who ever told you "varus rear foot post will bring both a rear foot varus and a rear foot valgus into proper alignment" is still living in the world of subtalar joint neutral theory and prescribing foot orthoses based on "foot deformities" as advocated by Root et al, rather than the more currently accepted and modern method of prescribing foot orthoses based on the concepts of tissue stress.

    I know this may be very confusing for you, but at least you are being told about this now, early on in your career, versus having to figure it out on your own for the first decade of podiatry school and practice like I had to.:drinks
     
  16. Work up very very early thinking about realign as a word

    re·a·lign (r-ln)
    tr.v. re·a·ligned, re·a·lign·ing, re·a·ligns
    1. To put back into proper order or alignment.
    2. To make new groupings of or working arrangements between.

    but

    Verb 1. realign - align anew or better; "The surgeon realigned my jaw after the accident"

    and

    realign [ˌriːəˈlaɪn]
    vb (tr)
    to change or put back to a new or former place or position

    seems to be still confusing 1 says put back into proper alignment which could be seen as normal

    The rest change in position not really that important I guess funny what wakes you up a 3 am :morning:
     
  17. Mike:

    The point is that the term "realign" is not the best word to describe how foot orthoses change static position of the pedal joints since it does imply that there is an ideal foot alignment which is certainly a point of much contention.

    Rather, if you simply said that foot orthoses may alter the translational and rotational positions of the pedal foot joints during static stance then nearly every one will be able to understand you quite clearly.
     
  18. I'm with mike on this one for two reasons. One semantic and one pragmatic.

    Semantically, I'm unhappy with the word align, or re align for what othoses do. To me it implies a singular kinematic change we simply would not see in vivo. Let's say a 5 degree orthotic causes the rscp to change by 2 degrees in static wb. Has it changed the position of the joint? Yes. Will it be in the same 2degree more inverted position if I come back and test it in a week? Probably not. Will the calc be 2 degrees more inverted throughout gait? I really doubt it.

    Pragmatically, the term harks back to the bad old days. The paradigm shift to thinking in terms of the "right position" rather than how the forces changed. Words shape thought and the more words like "re align" get used the more people think in those terms. Any oppertunity to challenge that should be taken IMO!
     
  19. Returning to the op, short answer, no.

    The kinematic effects of orthoses are unpredictBle and always much smaller than the size of the wedge. Thus a 5 degree medial wedge may only cause a 1 degree inversion of the heel. Or a 0 degree inversion. Or even a 1 degree eversion! Thus I'd say it's misleading to think a rearfoot post will realign a rearfoot.

    In a fantasy world where a 4 degree rf wedge will move an rscp to 0, and where the ff valgus is 4 degrees and rigid, then yes. But that theory contains equal amount of empirical validation and pizza.
     
  20. You missed the point Robert. The point is whether the word "realign" necessitates a change in alignment to a normative value, or does it just refer to a change in alignment. If you look at the dictionary definitions it could mean either. I would argue that if skeletal alignment is changed at all by a foot orthoses then the foot orthoses have realigned the skeleton; can you resist this argument? This is certainly the context in which re-alignment is used within Nigg's latest book.
     
  21. I heard a rumour that resistance is futile...

    I just think it sounds horribly static.
     
  22. No resistance isn't futile when an argument is unsound. The key here is we both know the argument is sound.

    Nope, no-one said it had to change the alignment in static stance.

    Here is my "biomechanics pearl of wisdom" for 2011: I think many people have jumped on the "its about kinetics, not kinematics" bandwagon, without truly understanding the relationship between kinetics and kinematics (or either of these individually). You cannot ignore alignment any more than you can ignore forces; indeed only by studying the two together do we really learn anything useful.

    The notion that alignment is not important is utter cobblers; that foot orthoses do not realign feet is cobblers too.

    Challenge: can someone show me a paper in which there was absolutely no difference between the subject kinematics with and without orthoses in situ? I don't mean statistically significant difference, I mean absolutely no differences. When we find it, we'll look at which joints they didn't measure the kinematics of. Like Robert said, perhaps "resistance is futile".

    Here's a thought for all: lets go back to modern biomechanics 101 and the role alignment has in tissue stress. Think forces in a vertical column versus identical forces in a bent column...

    When is Eric and Kevin's chapter coming out???
     
  23. Simon:

    Thank you for these pearls of wisdom. Your comments exactly reflect my thoughts on this subject. Thoughts like this show why you are so important to our profession.:drinks
     
  24. True enough. THen again, can anyone show me a paper in which there was absolutely no difference in kinematics between multiple observations without an orthotic in situ?

    I have some thoughts on this, but they're not ripe yet so I'll hold onto them for a bit. I will say this. Semantics are important. There is a world of difference between

    "Kinematics is important" is a world away from "Orthotics work by realigning the feet".

    Now I know you didn't say the latter so I'm not having a dig at you, but that is the sort of thing which you and others have spent a long time arguing against. We should by no means ignore kinematics, but I don't think there is any risk of that. We're both conditioned and hardwired to think in kinematics. I still think the bigger risk is to underplay the kinetic side of things, and not to put words in Mike mouth but I suspect that that is what he meant.

    I'm perfectly happy with orthotics changing postions. Even altering alignment. But re-aligning has an ambivilent meaning. The "re" could mean altering it from what it was, but to many people it means returning them to what they should be.
     
  25. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    "When I use a word," Humpty Dumpty said in rather a scornful tone, "it means just what I choose it to mean -- neither more nor less."
    "The question is," said Alice, "whether you can make words mean so many different things."
    "The question is," said Humpty Dumpty, "which is to be master - - that's all."

    (Through the Looking Glass, Chapter 6)
     
  26. Ninja11

    Ninja11 Active Member

    How delightful! While the Veterans continue to squabble over biomechanics, kinematics, and both the scientific and artistic merits of orthoses treatment... I rest easy that I shall continue to have a job. Because when the The Big Guns (Veterans) have an agreed answer to these questions, it will mean all people will be born with exactly the same feet, that respond in exactly the same way. THANK GOD all feet are different - what a boring world - what a boring job podiatry will become! Always an interesting read guys. Thanks. :good:
     
  27. Do you have a point?
     
  28. :good: beat me to it.
     
  29. Jeff Root

    Jeff Root Well-Known Member

    The terms varus and valgus rearfoot posting are some of the most ambiguous terms in the orthotic industry. They can be used to refer to:
    1. An extrinsic heel post (i.e. crepe or other materials) which have a flat plane (a no motion or zero degree rearfoot post) or an angle ( i.e. 4 degree) or some other contour (to encourage motion) placed in it.
    2. The position of the heel of the positive cast after the cast is “corrected”, “modified”, “prepared” or “balanced”. For example, “balance the heel five degrees inverted (i.e. varus)”, but using what reference? Heel bisection or what? You need a stated reference.
    3. Some individuals refer to intrinsic rearfoot posting as the act of grinding an inverted (varus) or everted (valgus) angle into the plantar surface of the heel of the “corrected” orthotic shell in order to create a small flat spot on the shell. The size of the flat spot is directly influenced by the thickness of the shell material.

    Before this esteemed group can offer any meaningful discussion on the potential influence of a varus or valgus rearfoot post, you must first define what a varus or valgus post is because you might otherwise be debating about the influence of different orthotic modifications or different orthotic features. In addition, in my example above, it is possible for all three of these “posting” techniques to be done on one orthosis.

    Thanks,
    Jeff
     
  30. Jeff Root

    Jeff Root Well-Known Member

    And while I’m at it, here is another beauty. A pair of negative casts arrives at a lab with the instructions “Post to cast”. This is not at all uncommon in the U.S. What does that mean other than to tell the lab to do whatever in the hell you want with my casts! :wacko:
     
  31. Jeff Root

    Jeff Root Well-Known Member

    Jake, it is possible for individuals with a rearfoot varus condition (i.e. an inverted neutral position) to function excessively supinated, excessively pronated, or neither. One important factor to consider with regard to orthotic prescription writing is the range of motion (ROM) of the STJ. For example, an individual might stand with their heel (heel bisection) vertical but that might be the maximally pronated (maximally everted) position of the heel and STJ. Many practitioners would observe this type of foot in relaxed stance or during gait and conclude that the patient does not pronate excessively simply because the heel doesn’t appear everted, when in fact, the patient is functioning maximally pronated. In this case, you may want to correct the positive cast with the heel of the cast in some degree of inversion. Why? Because your goal in this case might be to promote motion at heel strike in order to reduce shock if the patient is functioning maximally pronated and doesn't demonstrate adequate shock absorption just after heel strike.

    Let’s back up and define some terminology in your original question. Rearfoot varus and rearfoot valgus are structural conditions of the foot in which the neutral position of the STJ, based on the open chain ROM of the STJ, is either inverted (rf varus) or everted (rf valgus). Clinicians frequently use these terms improperly, so you as a lab person need to learn how to read their mind or how to properly interpret their terminology so that you can effectively communicate with them and not alienate your customer. It presents a good opportunity to educate the practitioner if they are receptive to it or at a minimum, to make sure you understand them and what they want.

    To repeat part of your question, you said: “I have been told that a varus rear foot post will bring both a rear foot varus and a rear foot valgus into proper alignment.” Let me rephrase this question to: Can a rearfoot varus post make an inverted heel function less inverted or an everted heel function less everted? The answer is that you don’t use a rearfoot varus post alone, you use an orthosis. That orthosis does not only influence the STJ, it influences the midtarsal and other joints as well. For example, a foot that functions with the heel inverted might also have an everted forefoot condition such as a true ff valgus or a plantarflexed 1st ray. These conditions can influence the functional position of the rearfoot. Therefore, it is possible that orthosis influence at the forefoot might also influence the functional position of the rearfoot by altering retrograde forces. I think there may be too many variables to answer your original question accurately. The most important variable in this case is probably the patient, not the orthosis or the “rearfoot varus post”.

    Jeff
     
  32. efuller

    efuller MVP


    A few posts back I wrote:
    This is a good example of two different paradigms choosing the same treatment for different reasons.

    Eric
     
  33. RobinP

    RobinP Well-Known Member

    It would appear that Mike's paraphrasing of the OPs comment

    to include the word realign is misleading. I know what Mike meant but I can't disagree with Kevin's/Simon's comments on realignment meaning simply a change in alignment

    I don't think anyone contributing to this thread is under any illusions that kinetics and kinematics are completely independant of each other. The original poster, however, is making reference to kinematic elements only. In a later post, he rephrased the question to be

    Again, reference only to kinematics and assumptions about positional variables

    A post/wedge, however defined, cannot improve kinematics unless a normal position can be defined(which it can't)

    The two opposing positions cannot, for the same reason, be defined as abnormalities.

    So, and this is really to Jake, the question you pose is inherantly flawed and largely moot without a definition of the norm. That is why Mike is questioning your need to answer such a question

    If you have a kinematic goal that will reduce the stress on a pathological tissue, then realigning(not properly aligning) is accurate terminology and potentially valid, although, as pointed out several times before, you don't need to have a realignment(kinematic change) to reduce pathological forces

    In my mind this makes sense but may not to anyone else reading this

    Robin
     
  34. Jeff Root

    Jeff Root Well-Known Member

    Let’s try to stick to the intent of Jakes original question. In that effort, let me again attempt to rephrase his question since I think I understand his intent.

    Rephrased version: Can an orthosis with a rearfoot varus post be used to reduce the inverted attitude of an inverted heel and the everted attitude of an everted heel so that the sagittal plane bisection of the posterior surface of the heel is less angled when compared the bisection of the distal third of the tibia? And if so, then can someone explain mechanically how a varus rearfoot post can make an inverted heel less inverted and also make an everted heel less everted?

    Ok Jake, I have I restated your question in a manner that makes sense to you and that might be easier for others to understand or attempt to answer? In order to proceed, we first need to have a common definition of what a varus rearfoot post actually is. I’m not confident that we can get that far, but I hope someone will give it a shot! And for the sake of simplicity, let’s assume that "alignment" for purposes of this question means that the bisection of the heel is closer to paralleling the distal third of the tibia (which is a subject of debate that we can temporarily exclude from Jakes question).

    I tend to agree with Robin that the question is inherently flawed, but for a different reason. I don’t think we can isolate the influence of a “varus rearfoot post”, let alone define it. To the best of my knowledge, no one has provided a definition for the sake of this question. Why even begin to attempt an answer if we can’t define varus rearfoot post?

    Now, put your self in Jakes place. He is asked to take a customer service call from a doctor of podiatric medicine who asks him a question about the influence of “varus rearfoot posting” because that’s a term the doctor was taught in podiatry school. Jake needs to start production on the orthotic today. What should Jake say? That is the reality of working in an orthotic lab.

    Jeff
     
  35. RobinP

    RobinP Well-Known Member

    Thanks for the Jeff - very clear and unambiguous

    I suppose it depends on what Jay is.

    If he is a lab technician, then I would be inclinied to agree with everything you are saying Jeff

    If he is a clinician, trying to figure out the effects of a rear foot varus post, then my(and Mikes) question remains. What is the value of knowing the kinematic effect of a rear foot varus wedge on a rear foot valgus or rear foot varus? The effect will be subject specific

    What you can say is the effect that placing a rear foot varus wedge under the foot will likely shift the centre of pressure more medially(although there is a brain attached to the foot which can change that)This may or may not have a kinematic effect, which may not be that predictible, but will certainly have a kinetic effect

    As usual, more questions than answers
     
  36. There are a number of problems with Jake's original question, but this is not Jake's fault since he is being taught things about orthoses that would be confusing to anyone.

    Let's look at Jake's original question:

    First of all, as far as currently accepted orthosis terminology is concerned, a rearfoot post is plantar to the orthosis shell and can be made with a varus posting position and/or a varus biplane grind so this part of the question is ambiguous and confusing.

    Secondly, in feet with a rounded plantar heel, inverting the heel cup of the orthosis has little effect on the orthosis reaction force (ORF) acting on the plantar heel since rotating a curved surface, in this case, will not necessarily produce a varus heel cup shape. In order to produce a reliable increase in varus in the heel cup then a medial heel skive or MOSI modification is necessary. Inverting the orthosis will increase medial longitudinal arch height, however, which will tend to produce the increase in medially directed ORF that would be desirable if the goal of the orthosis was to increase subtalar joint supination moment.

    Lastly, the biggest problem is that someone is suggesting to Jake that there is a "proper alignment" of a foot without discussing the nature of the pathology the patient is presenting with and their specific gait function. Without a knowledge of the subtalar joint axis location and the prevailing subtalar joint pronation/supination moments in the patient's foot, there is no way for Jake or anyone else to know how a rearfoot post, varus heel cup or valgus heel cup for that matter will be a desirable orthosis modification for a patient. In addition, the orthosis may do little to nothing for the kinematics or "alignment" of the patient's foot but may still favorably alter the kinetics so that their symptoms improve with a varus influence in the heel cup of the orthosis.

    Jake, it's frustrating at times to be in a situation like you are in....but if you simply hang in there...it will all make good sense to you with time.
     
  37. Jeff Root

    Jeff Root Well-Known Member

    In Jake’s position as a customer service representative for an orthotic lab, he might be asked to provide:
    1. Pure technical advice (i.e. how do I order a heel lift, what is the heel cup depth of your orthosis, what guidelines do you use for shell material thickness, etc.?)
    2. Biomechanical advice (i.e. the patient has these symptoms or this condition, how can I design my orthosis to achieve this objective: off load 2nd met, improve windlass mechanism, etc.) or (what is the best orthosis for this condition: a pathology specific type of approach)
    3. Medcial/diagonostic advice
    4. Some combination of the above

    One of the challenges that we face in the orthotics industry is that custom orthoses are relatively inexpensive. There is a very small profit margin on an orthoses, so volume is about the only way most labs can survive. They can only afford to hire highly modestly compensated manufacturing employees and customer service people who typically acquire all of their knowledge through on the job training. Most customer service people have worked their way up through the lab from a production role to a service role. This gives them a good foundation for understand orthotic design. However, practitioners often expect them to have the knowledge of a DPM. That is the reality of it.

    I have always instructed my staff to never, ever try to bluff or b.s. your way through it. If you don’t know, tell the doctor that. For example, tell them that I’m new to customer service and I don’t know the answer, but let me check into it and call you back. Or, let me get someone who might be better able to answer your question. If you try to bluff your way through it you will likely get dragged into it deeper and deeper until it is obvious that you don’t know what you’re talking about and then your credibility is gone!

    It takes years for a good customer service person to acquire the depth of knowledge and practical skills and experience to do the job well. Some are just better at it than others because they have better reasoning or because they can think in mechanical and practical terms better. And on top of it, they need to be good on the telephone!

    So here is how I would have approached Jake’s issue. I would have asked the person, can you please explain to me what you mean by a varus rearfoot post. I’m not sure exactly what you’re talking about. I would then attempt to walk them through the fabrication process step by step from negative cast to positive cast (describing related correction options), orthotic shell creation, and then any extrinsic forefoot or rearfoot posting. The doctor needs to think like a technician, not the other way around! Once they learn to think technically, then they can start to apply logic and will require less technical support as time goes on.

    I know this might seem obvious to most of you on this form, but for a lot of doctors were not taught much if anything about orthoses in school, so they don’t know how to develop a logic based orthotic prescription. After walking through the production process on a step by step basis, you can point out that what they are referring to by the term “rearfoot varus post” is actually a combination of orthotic manufacturing options, such as pouring or cast balancing position, extrinsic cast modifications (forefoot platforming, etc.), intrinsic cast modifications (i.e. Medial/Kirby skive), orthotic shell configuration, and extrinsic rearfoot posting.

    Now, as to why a seemingly similar orthosis might be able to reduce excessive supination and excessive pronation? Physics! Why do some people with an everted forefoot to rearfoot relationship supinate while other pronate at the STJ? Physics! The devil is in the details!

    My advice: Don't get trapped into using ambiguous terminology. Make sure that your customer really knows what they are trying to ask or help them find an unambiguous way of asking it.

    Jeff
     
  38. Jeff Root

    Jeff Root Well-Known Member

    Correction to my posting above. It should have read: They can only afford to hire modestly compensated manufacturing employees------
     
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