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Nov 28

Written by: Larry Huppin, DPM
11/28/2011 2:09 PM

 I spoke to a ProLab client today who had a patient with an osteochondral defect of the ankle. He performed a scope and the patient was doing better, but she was still having what he thought was lateral impingement. She had a calcaneal varus and an ankle valgus. He wanted to know if there was anything we could do with orthotic devices to reduce her symptoms.

As far as I know, there are no studies that would indicate what orthotic prescription would be best for this situation, but we can use the idea of decreasing tissue stress to help determine what might be the best orthotic device. For example, we have fairly good studies showing that in many cases of medial knee pain or medial knee arthritis, a valgus wedge on an orthosis will help to open up the knee and help decrease pain. The opposite is true of lateral knee pain which is often helped by a varus wedge.

Like a lateral knee problem, a patient having lateral ankle pain will probably be better off with a varus wedge on their orthotic to slightly invert her heel. A medial skive is an example of a varus wedge. It is not really relevant that she has a calcaneal varus and is already inverted in stance. The fact is, if she has compression of the lateral ankle we still want to invert her more.

What works theoretically, however, does not always work in clinical practice. So, before we make this orthosis, what I recommended to our client is that he bring her back into the office and first apply a low-Dye taping to her foot and incorporate a varus wedge using felt to basically create a medial heel skive. He then should note whether or not she feels better. Then he should apply another low-Dye, but this time incorporate a valgus wedge by applying felt under the lateral heel. Once we do these two tests, we can determine if one or the other is likely to make her better or, possibly, make her worse.

Sometimes, one day of taping is not an adequate test and you may want the patient to be able to try these modifcations for a couple of weeks to really get an idea of whether or not they are effective.  In this situation, we suggest using a prefabricated orthosis with wedging. The best prefab for this is one with a post such as the P3 Functional Prefab. It also comes with a 2mm medial heel skive which will act a a medial wedge.  In this situation, use the following three week trial to determine the best orthotic prescription:

  1. Week 1:  Use the P3 posted prefab in a stable shoe.  No additional wedging.  If the patient improves, then you are likely going to want to incorporate varus weding via a medial heel skive into your orthotic prescripton. If the patient does not improve, steps 2 and 3 will help you determine if a different orthotic prescription will be more effective. 
  2. Week 2:  Using self-stick 3mm felt, add a varus wedge to the rearpost of the P3 prefab. This will help you determine how much varus wedging will be most beneficial for your patient.  If the additional wedge provides greater relief, you will want to incorporate a greater amount of varus wedging in your orthosis. A 6mm medial skive, for example. If the pain does not decrease with the use of the prefab, and / or the prefab with additional wedging, then you should see if valgus wedging is effective at providing pain relief (see step 3).
  3. Week 3:  Remove the varus wedge and add a valgus heel wedge to the post of the P3. Also add a forefoot valgus extension using the self-stick felt. If this provides relief then we will incorporate valgus wedging into the orthosis prescription with a lateral heel skive and valgus forefoot extension.
Once he has completed those tests, he is going to give us a call back and we will work with him on designing the best possible orthotic. Keep an eye on future blog post for updates on this patient.

ProLab takes a scientific approach with our orthoses by integrating evidence-based medicine into orthotic therapy. Our team of Medical Consultants regularly evaluates the medical literature pertaining to orthotic therapy and biomechanics. ProLab clients are encouraged to contact a medical consultant whenever they have questions about an orthotic prescription.

For an easy way to stay up-to-date on evidence-based orthotic therapy, subscribe to our free E-Journal. Your will receive a monthly email synopsis of the research that impacts your practice.


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