Common Indications for the Inverted Orthotic Technique Marked Heel Valgus What are it's present common indications for use: 1. Really Any Pronation Problem (part of this is to get the practitioner and maybe laboratory used to it then having the first one being 35 degrees) 2. Almost all running orthotics benefit from this inversion (except the 5% of runners that are supinators) 3. Moderate to Severe Pronation (this is for most practitioners) 4. Pronation from sagittal plane deformities (along with stretching equinus if appropriate) 5. Pronation from transverse plane deformities (along with strengthening external rotators if appropriate) 6. Posterior Tibial Tendon Dysfunction 7. Tarsal Tunnel Syndrome 8. Lateral Meniscal Syndromes 9. Increasing of Genu Valgum while trying to avoid knee replacement 10. Medial Shin Splints (caused by athletics) 11. Patellofemoral Syndromes (caused by athletics) 12. Juvenile or Adult Acquired Flat Feet 13. Juvenile Bunion Deformities Let us look at this list above briefly here to get an idea of its place in the biomechanical world. The basic premise of the Inverted Technique is that it works at the control of rearfoot pronation in contact and midstance phases. The practitioner has taken an impression cast capturing the forefoot to rearfoot relationship. If this relationship is the most important aspect of the pronation syndrome (say forefoot varus or metatarsus primus elevatus), and then a Root or Modified Root device is crucial if it can support the deformity captured. This is seen commonly when 5 degrees of forefoot varus can cause a 5 degree everted resting heel position. But, if the pronation is from other sources causing contact or midstance phase pronation, then the Inverted Technique is indicated. I have also always used the Inverted Technique with high degrees of forefoot varus or supinatus since supporting those deformities with Root devices can block first ray plantarflexion at times. Try accurately supporting 12 degrees of forefoot varus and not blocking first ray plantarflexion. #1 Really Any Pronation Problem-this is cavalier, but even mild cases of pronation can be helped with 2-3 degrees of inversion force. This would be prescribing 10-15 degrees Inverted Orthotic Devices. Of course, you can accomplish the same with Kirby Skives, or Root Devices setting the correction 2-3 inverted, but if you are new to the technique it is good to learn on smaller amounts of inversion. #2 Almost all Running Orthoses-95% of runners land inverted and pronate 8-10 degrees before resupination. Putting a 5 degree inversion force with a 25 degree inverted orthotic device is my standard running device. It is good to see if it helps the patient's symptoms and tolerated for comfort. Of course, a 25 degree Inverted Orthotic Device functions differently in a neutral shoe, a stability shoe, and a motion control shoe. Even power lacing of an athletic shoe can make a big difference in stability. Typical Inverted Landing #3 Moderate to Severe Pronation--typically any foot practitioner should be able to divide their patients who pronate into mild, moderate, and severe categories. The moderate and severe categories are the patients that this technique was designed for. If you are skilled in Root Biomechanics, you should be able to understand that the severe pronators are further from subtalar joint neutral than moderate pronators. But, for our discussion, let us just say that the severe pronators need a more Inverted starting point than moderate pronators. I look at orthotic devices as a process. Part of this has been influenced by the orthopedists or physical therapists I have worked with. It is totally fine to start moderate pronators at 25 degree inverted and severe pronators at 35 degrees inverted and see if it helps the patient. You progress the treatment on monthly intervals. #4 Pronation from Sagittal Plane Deformities-A strong teaching of Dr. Merton Root was that functional foot orthotic devices worked the best with frontal plane deformities, less with sagittal plane deformities, and worst with transverse plane deformities. In a triplanar joint like the subtalar joint, when we affect one plane, we do affect the other 2 planes. However, when the force creating that triplane pronation was in a sagittal plane or transverse plane, custom foot orthotic devices had the least effect. What sagittal plane deformities cause pronation? These include tight heel cords, tight hamstrings, metatarsus primus elevatus, and leg length discrepancies. #5 Pronation from Transverse Plane Deformities-I was paid one of the highest compliments from Dr. Root when he said that the Inverted Orthotic Technique was the best at helping pronation from transverse plane deformities. What transverse plane deformities cause pronation? These include metatarsal adductus, high vertical subtalar joint axis, internal or external tibial torsion/position, and internal or external femoral torsion or position. #6 Posterior Tibial Tendon Dysfunction-It is not the place here to discuss the 4 stages in great detail, but Stage 4 is to be avoided and typically requires surgery. Therefore, when patients present with stages 2 and 3, I feel great pride and motivation to have them in the right orthotic device. #7 Tarsal Tunnel Syndrome-this can be related to excessive pronation with heel eversion and a compression of the posterior tibial nerve under the laciniate ligament at the ankle. The nerve can also be compressed by inflammation in the anti-pronation tendons (PT, FHL, and FDL) that run under the laciniate ligament. It can be partially a Double Crush problem, where pronation slightly irritates the nerve at the foot and ankle, but the main issue is sciatic nerve compression above the foot (behind knee, within the hamstrings, piriformis, or low back). #8 Lateral Meniscal Problems-typically varus correction of the heel, opens up the lateral joint line and decompresses the stress on the lateral knee compartment or lateral meniscus. It can be tricky, as you sometimes have to over correct the foot to help the knee, so watch for signs and symptoms of excessive supination. #9 Increasing Genu Valgum-This is how the Inverted Technique started with compression of the lateral compartment and medial collapse of the knee. It can be a temporary device while the patient waits for a knee replacement, or worn for a longer period indefinitely. #10 Medial Shin Splints-In 1984 I first presented the Inverted Technique to the Root Laboratory Seminar. In 1985, at the next meeting, Dr. Ross Leonard from Oregon presented to the group that he had gone back and remade orthotic devices on 19 of his patients that the original orthotics had not helped their shin splints. He reported success at resolution of the medial shin splints in 18 of these 19 patients. #11 Patellofemoral Syndrome-When I first started at Saint Francis Memorial Hospital in San Francisco, I was the only podiatrist in an orthopedic clinic. Most of my patients had knee problems, like patellofemoral syndrome. The problem was a transverse plane issue of the femur coming medially too far, and the tight vastus lateralis subluxing the patella laterally. The power of the Inverted Orthotic Device needed to stop medial motion of the femur by placing a laterally pushing force on the medial side of the heel. I had to push the device as far as possible in inverting the heel without causing lateral instability. These were my first group of patients that I learned to protect the lateral column. #12 Juvenile or Acquired Flat Feet-By 8-9 years old, Dr. Ronald Valmassy of the California School of Podiatric Medicine said that children should outgrow any heel valgus they previously had. So, 8-9 years old has become the age when deciding on surgery or orthotic devices. Parents of these children who have been managed in OTC prefab orthotic devices are shocked to learn their child at 9 now needs flat feet surgery. Children outgrow orthotic devices quickly (about every 2 shoe sizes) and need replacements. However, a growing child's foot is precious, and I would not trust its development in a prefab. The goal should be a vertical heel unless high rearfoot varus dictates the heel to be in 2-3 degrees of varus positioning. By measuring the heel position with and without orthotic devices, and all through the growth of the child, you have endeared these parents to you forever. I make custom Inverted Orthotic Devices in patients as young as 2 (actually my son Christopher started at 18 months when my wife complained she had to carry him too much for a healthy child). Adult Acquired Flat Feet from Posterior Tibial Tendon Dysfunction or collapse from equinus forces or gradual breakdown from injury or ligamentous laxity, etc, can tolerate high corrections even at 75 years old or older. Some of my senior patients for some reason or another are not surgical candidates, at least in their minds. My job is literally to keep them moving and they can be totally surprised and overjoyed at how well they are doing. One of my best examples recently is Steven. Steven presented 14 everted right side and 18 everted left side with collapsed midfoot and 25-30 degrees angle of gait. His shoes were severely broken down and everted at initial presentation adding to the problem. At present, his heel positions in the orthotics...
