Medial knee pain in a skier.   Considering an orthotic?  You had better know what you are doing! 

Can you guess why this gal has pain in both knees? Especially when skinning up a hill and skiing down? 

 Take a close look at the photos above and notice the orientation of her knee with her foot. Now look at you tuberosity and drop a line straight downward.  This line should pass through or slightly lateral to the second metatarsal shaft. Can you see how it falls to the outside of this? Perhaps even between the third and fourth metatarsal?

This gal has bilateral internal tibial torsion.  When she wears a standard foot bed (creates a level surface for the right for the foot) or an orthotic without appropriate posting, it pushes her knee outside of the saggital plane. This creates abnormal patellofemoral tracking  and appears to be a major contributor to her pain. 

 You will notice that we placed a valgus post under the orthotic(  a post that is canted from lateral to medial) which pushes her knee to the midline as the first ray descends.  You can see her alignment is better with her boots on and the changes. 

 The bottom line? Know your torsions and versions.  Posting a patient like this incorrectly could result in a meniscal disaster!