Secrets To Biomechanical Considerations In Static Stance

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When it comes to evaluating biomechanical considerations in static stance, Nicholas Sol, DPM, CPed, says it is important to keep in mind that a patient may have over 30 different standing postures.
This vinyl SBR insert, with the vinyl dorsal side shown on the right, will mold to the patient’s foot in the shoe, allowing the physician to see amount of pronation control needed. It will also show pressure points of plantar contact, according to Anthony
Secrets To Biomechanical Considerations In Static Stance
Guest Clinical Editor: Nicholas Sol, DPM, CPed

   A: If a patient’s pathology is not that severe, Dr. Borgia uses a flexible type orthotic and gradually adds medial reinforcement as necessary. He opts for 1 to 2 degrees of rearfoot posting since he notes that more varus posting would increase the likeliness of the patient straining the Achilles. To prevent Achilles tendonitis, Dr. Borgia uses a 1/8- to 1/4-inch heel lift. He notes that patients with severely pronated feet do not tolerate rigid or semi-rigid orthotics, even when their feet are flexible, especially if body weight is a factor.

   For patients who are in static phase for a significant part of weightbearing time, Dr. Borgia will use a high density foam or a multicork and leather orthotic with a higher medial flange.

   In general, he will use a very inexpensive combination sport mold made of vinyl Styrene/Butadiene/Resin (SBR) and see these patients for three or four weekly visits. During these visits, Dr. Borgia says he gradually incorporates adhesive foam into the arch, which controls its height, and also posts the orthotic according to the patient’s specific need for control. At the last visit, he normally increases the heel height to a 1/8-inch foam adhesive pad in order to diminish pull on the Achilles. He emphasizes stretching exercises in the posterior muscle group during and after treatments. Temporary orthotics, which last over a year, cost patients about $30 and cost DPMs less than $12 for materials, notes Dr. Borgia.

   Dr. Sol advises emphasizing increased frequency of weight shifting and accommodation of ground reactive forces when correcting pathomechanics of static stance. For a patient without equinus or limb length discrepancy, he often uses a small heel lift of about 1/16-inch on both orthotics.

   For those with limb length discrepancy and/or equinus, Dr. Sol says he often intentionally overcorrects. In some of these cases, Dr. Sol notes he will adjust the heel lifts to a slightly undercorrected modification. Such an adjustment addresses joint stiffness by inducing more frequent left-to-right and front-to-rear weightbearing shifts. For these patients, he says one should stay aware of any changes in postural complaints, such as low back pain, and tailor modifications accordingly.

   As far as accommodating ground reactive forces, Dr. Sol notes one may need extra cushioning above and/or below the orthotics. If there is limited space in the shoe, he often uses a cushion insole under the orthotic and an accommodative forefoot extension that molds to the shape of the forefoot. Dr. Sol points out that left and right feet require different combinations of modifications.

   Dr. Stern says orthotic modifications depend on patients’ occupations. He notes a patient working on an assembly line requires support in the side-to-side plane to help stabilize the foot in static stance. Accordingly, one should try to control the heel position, the amount of lateral movement and any areas of pain such as heel bursitis or metatarsalgia, according to Dr. Stern.

   For these patients, he suggests employing a medial Shaffer plate to control abnormal side-to-side motion and a deep-seated heel cup to control rearfoot motion. Dr. Stern adds that a deep-seated heel cup will control rearfoot motion while a heel cutout filled with absorbent material can control heel bursitis. He notes that one can accommodate specific forefoot pain with a metatarsal pad or cutouts for specific areas.

Dr. Sol founded the Walking Clinic, PC and practices in Colorado Springs, Col. He is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American College of Foot and Ankle Orthopedics and Medicine.

Dr. Borgia is Chief of the Podiatric Section, Department of Surgery, at University Medical Center in Las Vegas, Nev. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.

Dr. Stern is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.

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