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Monday, July 5, 2010

Inverted Orthotic Technique

I am currently reviewing the history of an orthotic device I designed in the 1980's, but continue to work on to this day. I will copy and paste the posts on this website called "Podiatry Arena". I use the technique approximately 1/3rd of the time, so if you are my patient, you may have such a device. I am not sure what the interest will be on this blog, but I do want to keep my cyberspace contributions under one roof right now.

Re: History of the Blake Inverted Orthosis (Part I)


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I am honored to be asked by Kevin (Dr Kirby) to address the history of the Inverted Orthotic Technique. Due to my time restraints at present, I hope I can gradually tell the story over the next week. Someone may have to help me find this thread again, as I am just beginning to use this wonderful forum. It was 1981 that I started at the Center For Sports Medicine at Saint Francis Memorial Hospital in San Francisco. I had just finished my two year residency, the 2nd year as a Fellow in Biomechanics under Dr Ronald Valmassy and Dr Chris Smith. Dr Kirby was a sophomore during my 2nd year, and I stayed on teaching at the California College of Podiatric Medicine for the next 11 years. When I started at Saint Francis Hospital, I was hired by Dr James Garrick (who is still my boss 29 years later). The sports center was an orthopedic clinic, and I was the first podiatrist. Patients can in flocking in not to see me, but to see the famous Dr James Garrick for their knee injuries. Dr Garrick had started in 1968 the first sports medicine clinic within a medical school at the University of Washington. Dr Garrick was/is tenacious about only operating after all conservative treatment was tried. He loved podiatry, and my first year was filled with knee injury after knee injury. I came to Saint Francis armed and fully trained with classic Root/Weed knowledge. I ended up spending 10 years studying under Dr John Weed, and worked closely with Dr Merton Root on my original paper the Blake Inverted Orthosis. It was my frustration with helping one particular patient in the fall of 1981, that I began experimenting with positive cast inverted positions that were then considered radical. In my next post, if you allow me, I will go from here.

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Rich Blake, DPM



Re: History of the Blake Inverted Orthosis (PartII)

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As I discussed in Part I, I started at the Center For Sports Medicine armed with Root/Weed Biomechanics ready to conquer the world. My first few months in the fall of 1981 met with a few challenges, but most patients fell within the biomechanics controlled with Root Balanced Orthotic Devices. Then, Patient X was referred to me by Dr James Garrick to help control his foot pronation and hopefully delay or eliminate the need for a knee replacement. A left lateral tibial plafond fracture with collapsed lateral joint line placed his knee in marked valgus with a strong pronatory force on the foot. His whole knee was swollen, but his symptoms remained lateral joint line. As I began attempting to change his biomechanics, he was also in physio and experimenting with various ineffective knee braces. His resting calcaneal stance position was 8 deg evertd left, and 0 or vertical right. Since I had only several experiences with partially compensated rearfoot varus patients needing a 4 degree inverted pour, and Dr Root taught never to invert the cast more than 5 degrees or lateral instability would ensue, I decided to pour the casts 4 inverted left, perpendicular right. All my rearfoot posts in those days were 4 deg inverted with 4 deg pronatory motion. So, I fully expected at least 50% reduction in the pronation and symptoms.

At dispense, the right orthotic device was very stable. I used normal widths (standard) and 4.0 Rohadur (based on his weight) and 18 mm deep medial and lateral heel cups (standard for men's athletic shoes). On the left side, watching him walk with the new orthotic, did not make sense. He was worse!! He was more stable with just his shoe. The orthotic device merely lifted him in the shoe aggravating his pronation. He did not leave the office that day with his orthotics. But, even though I had experienced my first biomechanical failure, to the nth degree, the patient loved the process, remained positive, encouraged me. What to do? Would changing the correction to 5 or 6 degrees inverted make any difference when 4 degrees was such a failure? I decided to try a 6 degree inverted correction. I remember thinking if the patient became laterally unstable with this severe degree of cant, I could narrow the width some, lower the medial heel cup, and inflare the medial post. More on left orthotic dispense Take 2 on my next post. Rich Blake

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Rich Blake, DPM

: History of the Blake Inverted Orthosis (Part III)

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Part II showed that my suspected 50% correction of the severe pronation on his left foot with a 4 degree inverted orthotic device proved to be an utter failure. But I was so indocturnated with Root/Weed biomechanics that I then attempted a 6 degree inverted cant/pour. Again, a total failure in controlling the extreme pronation caused primarily by his acquired genu valgum force. I then proceeded to make a series of orthotic devices in 2 degree increments not knowing any way of predicting how much supinatory force I was needing to apply. He would come in every week on Friday for a new and possibly improved left orthotic device (in those days I was only working Fridays at Saint Francis). I again had complete failure at 10 degrees inverted and 12 degrees inverted. At 10 degrees inverted his arch became sore as he tried to get used to it with the radical arch support as his knee drove the pronation downward collapsing the arch. The pronation was still winning, although the pronation was becoming less noticeable in gait. He was no longer worse with the orthotic device, but he was only slightly better. And his knee still hurt just as much.

It was when he came in to get the 12 degree inverted orthotic device that he told me the 10 degree inverted device really was hurting his arch. And here I had an even higher arch to give him. Oh boy!! As I examined his foot, it was really obvious that it was the medial slip of the plantar fascia that was getting sore. I ground the orthotic device along the sore area (can not remember if I marked his foot then like we do now with a non permanent magic marker) making a nice temporary PF groove. With rohadur this weakens the plastic, so I knew it was temporary. He instantly felt so much better. For the next 10 years, until I transitioned to polypropylene, plantar fascial grooves were placed on all of my inverted orthotic devices routinely--whether the patient needed them or not. I never dispensed the initial 12 inverted device without a groove, but the next week I designed a 12 degree inverted device with a PF groove already built in. The first of thousands of inverted orthotic devices with PF grooves. I will talk about PF grooves and the continual saga of the first inverted orthotic device success in later posts. Thank you.

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Rich Blake, DPM

History of the Blake Inverted Orthosis (Part IV)

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In the initial 3 posts on the History of the Inverted Orthotic Technique, I reviewed the first patient I had that pushed the limit of Root/Weed biomechanics. I had designed a 12 degree inverted orthotic device with a PF groove to prevent arch irritation for severe acquired genu valgum and knee pain and collapsed arches. But the pronation was barely being affected. Our training said if you place a patient in a 12 degree inverted orthotic that they would function 12 degrees inverted temporarily until they sprained their ankle. This patient however had an extrinsic cause of pronation, a force I learned was much more difficult to control. I had learned that extrinsic forces were harder to treat than intrinsic forces. And I had learned that frontal plane forces were easier to treat than sagittal or transverse plane forces. But, there had never been any quantification of the correction needed. It would take me 2 years of studying these forces to determine the force correction was somewhere between 3 to 8 times greater than simple intrinsic frontal plane forces (while I waited for Dr Kirby to graduate). What a ride I was in for!! More on this to come!! But, yet I digress.



Patient X failed at 12 degrees inversion, but I could see some gait improvement. Patient X failed at 14 degrees inversion, but at 16 degrees definite pronation stability was being changed and symptomatically the patient was feeling better. I only made 3 more left orthotics for this patient. The 20 degree inverted orthotic device with PF groove controlled the patient over 80%. The 24 degree inverted orthotic device with PF groove controlled the pronation 90-95% but was too uncomfortable to a misfitting groove. I decided to recast the patient and remark the PF and made a more comfortable 24 degree inverted orthotic device. At 20 degrees the knee stopped swelling, and at 24 degrees the knee pain was mild, and function was much better. The correction of Patient X proved to be a 3 to 1 ratio, it took 24 degree correction to change the RCSP from 8 everted to vertical. This correction was also influenced by his knee bracing and high top boots we were using. The correction was probably more 4 or 5 to 1.



Part V will begin to explore the journey with Root Lab, the podiatry profession, Kevin's skive revelation, etc. Hope you will stay tuned.

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Rich Blake, DPM

History of the Blake Inverted Orthosis (Part V)

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In my previous posts I explained the situation around the first inverted orthotic device of 24 degrees inverted with 4.0 Rohadur and a PF groove to prevent arch irritation. This was December of 1981. The patient's knee symptoms had improved and I was excited about the findings. It would 2 more years until I gave my first local presentation on the technique as I began to discover what patients needed more correction than typical Root/Weed biomechanics had to offer.

During those days, I spent time almost weekly learning from Dr John Weed. He was only 45 minutes down the road from San Francisco, and was the smartest human I had ever talked to. I would bring patients routinely down to his office in the early 1980s to discuss their orthotics, whether they needed surgery, etc. But in Dec 1981, I called John and asked if I could talk to him about Patient X and my discovery. So, I drove to San Jose excited about discussing my findings. I had also had 2 or 3 other patients that I had used 12 to 16 degrees of inversion with good results, so I knew it had some merit. With sports medicine, varus wedges were routine to help runners slow pronation, but these were never more than 4 degrees or less.

My conversation with John Weed was disheartening. He was my mentor, and was not impressed, I could tell he didn't understand how my claims were possible. He sent me over the Root Orthotic Laboratory, which was next door to his office in those days, to explain what I was doing to Jeff Root and Elaine Root (office manager ---can not remember exactly if she had married Mert by then). They immediately had Mert Root on the phone with me.

Now, Mert Root was a god-like figure. I was in awe of him. What he had done, and what his influence on the world of biomechanics continues to do, made every one uneasy. He was on a different plain of consciousness in biomechanics. And now I was going to actually talk to him. He kindly listened to my excited recourse of the events of the first 24 degree inverted orthotic device and that I was beginning to take some of the theories learned and use on other patients. He spoken for a few minutes, but I only remember the phrase--"they will never work, and they will cripple those you give them to." I was devastated!!

The response I got at the California College of Podiatric Medicine, Department of Biomechanics, where I taught until 1992, was of uninterest. Nothing these leaders of Biomechanics were excited about. So, I continued to make and learn and remake hundreds of these orthotic devices in 1982 and 1983 without the support of my colleagues. My students, Dr Kirby, Dr Fettig, Dr Christiansen, Dr Hannaford, Dr Denton were my friends and sounding boards. More on their influences on me later.

It was a patient I saw with John Weed in late 1982, that began to change his mind, and then Dr Roots. Dr Merton Root became by greatest supporter by middle of 1983.

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Rich Blake, DPM

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.