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Kevin A. Kirby, DPM

Hi, I'm Dr. Kevin Kirby, podiatrist in Sacramento, I've been in practice now for 39 years and I'm in a group orthopedic practice with another orthopedic surgeon.
 
What role does a medial heel skive play in an orthotic?
 
The medial heel skive is a modification that actually created back in the 1990s, so that was 34 years ago, where we modified the heel cup of the foot orthosis to add in a varus wedge. We can do different levels of varus wedges range from 2 mm of skive to 6 or even 8 mm of skive in extreme cases. And this is where we're shaving plaster away from the medial plantar heel in order to create an increase the varus contour of the heel cup. And that allows us then to add extra supination force on the subtalar joint by acting directly on the plantar heel. So it's basically like a varus wedge, a varus heel which placed inside the heel cup of the orthotic.
 
How can providers determine if their patients would benefit from this feature?
 
Well, the bottom line is that the heel skive can be used for any condition where the podiatrist feels that an increased varus wedge in the heel would benefit the patient. Things such as posterior tibial tendon dysfunction, sinus tarsi pain, plantar fasciitis, pediatric flatfoot deformity, any patient where there's excessive pronation of the foot during gait is causing pathology, the medial heel skive would certainly be recommended for adding to an orthotic in order to get the most out of the orthotic in preventing future problems and treating the current pathology.
 
Do you have any tips on evaluation or biomechanical exam?
 
Finding the subtalar axis location is helpful. I described this palpation technique for the finding the subtalar axis back in the late 80s. There's just knowing where that as the foot pronates the axis of the subtalar joint is going to become more medially deviated and anytime you find a patient that has a medial axis that's significant, then the medial heel skive typically would be able to be used either from mild like 2 mm to something more extreme like a 6 mm medial heel skive in order to improve the function of the foot and allow better gait function to occur.
 
How should accommodation differ between pediatric and adult populations?
 
A pediatric patient, because they have a larger amount of fat pad and lower body weight, typically they can tolerate an increased amount of medial heel skive. So it's not uncommon for me to use a 4 mm medial heel skive or 6 mm skive in a pediatric flatfoot, whereas typically for adults, especially those adults that may have some planar fat pad attribute in the heel, I tend to use 2 to 3 or 4 mm of heel skive. So you just have to be aware that when the heel skive is being ordered, the higher the amount of heel skive placed into the heel cup of the orthotic, the more pressure there will be on the medial heel.
 
So if they do have a really thin fat pad, there is increased risk of causing medial heel discomfort. You don't see that too often. You just got to not just go full go with 6 mm of skive with every patient because some people just may not be able to tolerate that much correction.