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Sunday, June 8, 2014

Inverted Orthotic Technique: Email Advice

Hi Dr. Blake! 

     I am a Certified Pedorthist out of Fort Worth, Texas. I have the opportunity to 
speak to resident podiatrists/physical therapists regarding foot orthotics. I am 
writing to inqure about how I can present your technique for the inverted orthotics. 
What I am in the dark about is who qualifies for these orthoses?
Dr Blake's comment: Thank you so very much for inquiring. Most podiatrists will use it when their initial orthotic device does not bring about the symptom relief and the pronation control combined. When the patient is still pronating on the device originally made, the Inverted Technique may help. Typically, most orthotics designed set the heel vertical to slightly (1-2 degrees) inverted. A standard 25 degree Inverted Correction gives the heel about 5 degrees of correction, thus over 150-200% more support. Someone like you, and the students you teach, will begin to see patients that need the technique right from the get-go. Many patients with moderate to severe pronation are started at 35 degrees, equivalent to a 7 degree inversion correction. Runners, who typically needed 5 degrees correction (25 degree cant) in their stability shoes, now need 35 degrees cant in their neutral/transition/minimalist shoes since the shoes give less support for pronation. However, pronation control is not the only reason to use the Inverted Technique. The varus positioning you get with the Inverted Technique helps many patients with frontal plane problems like Tibial Varum and Genu Valgum. 

 What conditions are indicated and which are contraindications? 
     I understand the simple rigid vs. flexible deformity, but which diagnoses have you come 
across that can benefit from this, apart from PTTD, unless that's the only one? 
Dr Blake's comment: It is really an understanding of pain syndromes that lead you to know about what matches up. When you watch someone walk, you typically can tell if their pronation is mild, moderate, or severe. The Inverted Technique, which ranges from 15 degree cant to 50 degree canting with medial column corrections and medial Kirby Skives, is for the moderate to severe pronators. And these pronators get into problems in many ways affecting the weakest link in the chain. What problems are related to pronation that I treat (you may ask?!! LOL)?
  1. Bunions are increased with over pronation
  2. Hallux Limitus/Rigidus pain is increased with over pronation
  3. Morton's Neuromas symptoms are worse with pronation
  4. Arch Strain is worse with over pronation
  5. Lisfranc's pain is worse with over pronation
  6. Cuboid pain, and instability, is worse with over pronation
  7. Anterior Tibial tendinitis, and shin splints, are worse with over pronation
  8. Plantar Fasciitis is worse with over pronation
  9. Lateral ankle and subtalar joint (sinus tarsi syndrome) impringement syndromes are worse with over pronation
  10. Achilles Tendinitis and Hamstring strains are worse with over pronation
  11. Tibial Stress Syndrome and Fibular Stress Fractures are sometimes related to over pronation
  12. Iliotibial Band Syndrome is sometimes related to over pronation
  13. Lateral Knee Compartment pain is sometimes related to over pronation
  14. Chondromalacia Patellae is sometimes related to over pronation
  15. Piriformis Syndrome and Ilio psoas strain can be related to over pronation
  16. Some cases of Low Back Pain are related to overpronation
The contra-indications to this technique are two fold. Most patients do not need it, because they have mild pronation, or are supinators, or poor shock absorbers, or their symptoms are related to limb length discrepancies. But, secondly, a contra-indication has to be the ability for the lab to design it properly. I have reviewed at least 10 labs, and most can learn, or do it well. But some, just do not get it. They typically make a painful over-exaggerated arch which hurts. When done correctly, the Inverted Technique, which emphasized heel correction over arch correction, is very comfortable. 

Also, is there a chart maybe that could show the different correction angles compared to the 
eversion angles that you find or is it all the 5 to 1 rule?
Dr Blake's comment: If you understand the eversion angles, and your measurement of 0-3 degrees everted is mild pronation in gait, 4-7 degrees everted is moderate pronation in gait, and over 7 degrees severe pronation in gait, we probably measure the same and the 5 to 1 is appropriate. I will try to do a series of videos on it soon explaining the various anti-pronation cast corrections.  
You can see all the cast corrections for the over pronators

     Is there a rule about the arch height change other than to make sure it begins to make its descent distal to the 
medial cuneiform for the first ray drop? That is, do you increase the arch or measure it pre-modification and add to/take away from any of that height? 
Dr Blake's comment: I am attaching a couple of posts on arch height. The arch height gradually gets bigger with increasing inversions, or adding a medial column correction, but a 15 degree inverted cast probably has the same arch height as a Root Balanced with minimal arch fill. You will see in my cast corrections video over the next couple of weeks how the arch gets higher. I will try to do that video for you first. You hit the nail on the head perfectly by saying that the most important thing is to make sure the maximal arch height is at the medial cuneiform to insure first metatarsal plantar flexion in propulsion.

If there is a clear/ to the point document that I could show them, that would be great. Otherwise, I'll direct 
them to your blog. By the way, I am becoming a fan of the technique as I just recently had 
a patient with severe PTTD who has not been comfortable in anything (Richie style, Arizona 
gauntlets, UCBLs etc.). I made him some orthotics using your technique, along with the 
use of work boots to give extra stability, and he loves them!  Sorry for so many questions, 
but I was so excited from seeing the outcomes in that patient that I want to spread the word 
about this in an accurate/appropriate way. 
Thank you sir! 
Dr Blake's comment: I am just ecstatic it helped. Most of the readers will not know how uncomfortable, or just big, these other devices are. Being able to take a patient that most who put in a AFO, Arizona Gauntlet or UCBL, and make an Inverted Orthotic device work, is a wonderful gift to that patient. The Inverted technique also allows the most normal function of all those techniques, thus the best chance for good strength to be re-established. 

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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.