Inverted Technique for Flat Foot Children

Hello Dr.

my daughter has severe overpronation and has been using a sole with your inverted technique for 2 and a half years and she has improved a lot.

her feet is bigger now and need a new sole.

I read somewhere in your blog 3 years ago you have a very good friend in fort Lauderdale fl.

I would like to take my daughter to see someone that know very well your technique, could you please provide his clinic phone number, address and web page, is any? please.

he probably can do a good assessment of my daughter, because the dr in Miami just took her cast and that's it.

in case you know another Dr.  in Miami that know very well your technique please let me know also.

thank you very much for your work and dedication, its really  making a very good difference in my daughter.

regards,

Dr Blake's response:

Pronation noted in the back of the heel of the right foot. Ruler denoting vertical, and the heel bisection line shows marked eversion which flattens the arch.

This same right heel in the Inverted Technique attempting to center the heel. 

http://www.aapsm.org/members-south.html

Mari, above is the members in Florida of the AAPSM. I looked at the list and 5 names popped up. They are not in any order:

Matthew Werd

James Losito

Russell Rowan

Brian Fullem

Joseph Agostinelli

You would have to call their offices and inquire. 

You can also get the names of who uses the Inverted Technique alot by calling the 4 Labs I know use it alot:

Root Functional Orthotic Laboratory

http://www.root-lab.com/

Richey and Company

http://www.richeylab.com/

Allied OSI Lab

http://www.aolabs.com/

ProLab USA

http://www.prolaborthotics.com/

The labs would have the doctors names in your area. Please let me know what you found out and thank you for your kind words. I am very happy to hear that the technique is helping your daughter. Rich

Inverted Orthotic Technique: Email Questions

Dear Dr. Blake,

sorry for my bad english,

 I'm an Italian podiatrist; I very interested about inverted technique. I have some questions to ask:

- Is it right to think Fettig modification only with inverted technique? and then, is it only used to correct a forefoot valgus associated with rearfoot varus? if no, when and how?

- Denton and Feehery modification are similar, when apply one or the other?

- In your daily treatment, do you often use these modification?

Thanks for your patience!

Dr Blake's response:

     Thank you for the kind email. I am happy to teach you. Please feel free to take the information I give you and ask any more. I will combine with this posting.  My wife and I hopefully will go to Rome next year on vacation. The Fettig Modification is a modification of the Inverted Technique only and used for the many patients with both a pronation tendency and a supination tendency. The Fettig can only be used in forefoot valgus (everted) feet, as it uses the forefoot valgus correction to be an anti-supination instrument. When the inverted technique controls rear foot pronation, the Fettig can grab that lateral column and slow down or stop mid stance to propulsive phase supination. The supination tendency can come from many causes one of which is rear foot varus, another unstable lateral column, or weak peroneals, or chronic ankle sprains, etc. The Denton modification, her sister lives in Rome, is an extrinsic lateral arch fill that wonderfully fills up the lateral arch  and helps block a supination tendency. The Feehery is an intrinsic raising of the cuboid and lateral anterior calcaneus that does the same, but you cut into the cast. Like the Kirby skive laterally, you have to learn when to violate the cast and when not to. I make orthotic devices as a process typically only violating the cast on the second modification when needed. This is the same general principle I typically use for the Kirby skive.
     Let us say that you have a patient with pronation and supination tendencies. They pronate mainly at contact, but due to chronic ankle instability, love to misstep and supinate at times (typically also at contact). For the pronation, you estimate they need a 30 degree inverted correction. For the supination tendency, they have a forefoot valgus/plantar flexed first ray we can use. So, you order a Fettig. You can also typically add a high lateral heel cup and lateral phalange, a Denton modification, and a full topcover to a forefoot valgus extension under the 4th and 5th metatarsal heads. 
     Let us say that you suspect initially, or you see at dispense, that the patient is not as controlled laterally as you would like. Your next orthotic device will be a lateral Kirby skive to the above cast, a Feehery cuboid skive, or both. And you  can also add more height to the lateral heel cup, and more height to the lateral phalange, along with a bigger forefoot valgus forefoot extension. The possibilities are endless. Please ask other questions. Rich

PS I use the Denton routinely (almost daily) and the Fettig modification 1-2 times per year. I probably use the Feehery once every other month. I relie a lot on stable shoes, lateral phalanges, forefoot valgus extensions.

     

Inverted Orthotic Technique Patent Request for the Kinetic Blake!!

After designing an orthotic device in 1981, it is fun now seeing it being used in various designs, etc. Here is a patent design for a product called the "Kinetic Blake"!!!

http://www.google.com/patents/EP2723280A1?cl=en

Inverted Orthotic Technique for Severe Pronation: A Study Attempting to Document what it Actually Does

In 1981 I designed the Inverted Orthotic Technique, also called the Blake Inverted Orthosis. It is well accepted in the world for helping patients, as this study states, but what does it actually do to the running mechanics is hard. I wish I was around the design of these studies to individualize the amount of correction and the modifications necessary based on Strike patterns. But, I am happy it helps patients every day around the world.

https://www.researchgate.net/publication/8077946_Effect_of_foot_orthotics_on_rearfoot_and_tibia_joint_coupling_patterns_and_variability?ev=prf_pub

Correcting Children with Flatfeet with Orthotic Devices

Custom Made Orthotic Devices with Blake Design Improves Arch Structure in Developing Children

http://synapse.koreamed.org/Synapse/Data/PDFData/1041ARM/arm-38-369.pdf

·        39 Flat Foot Children studied by x-ray evaluation over 6 years old (average age 10.3, range 6 to 14 years old) for a 2 year period to see if the arch developed with Blake Inverted Orthotic Design

·        Blake Inverted Orthotic Design is recognized worldwide as providing the most medial arch support

Orthotic Device cross section standard heel cup (right) and Inverted Technique (left)

Orthotic devices resting under Inverted molds (typically one foot more inverted than the other

Standard right arch and Inverted left arch

·        One study showed that if children were to spontaneously reduce their flat feet (grow out of it) it would be before 6 years old. Dr Ron Valmassy says it is predictable at any age, but 8 years old is the gold standard of knowing if they will grow out of it.

·        4 radiological angles (which measure arch collapse in the sagittal and transverse planes) and one standing angle (measuring frontal plane) were measured at the start of the study, 12-18 months into the study, and at 24 months.

·        Subjects were required to wear orthotic devices for 8 hours per day minimal

·        Exact Rx writing was used to individualize the custom orthotic devices based on the RCSP (Resting Calcaneal Stance Position).

This measurement, called the resting calcaneal stance position, changed from 8.0 everted to 1.9 everted with orthotic wear over the 2 years, and measures the frontal or coronal plane component. The ideal is 0 degrees or heel vertical measured exactly with a goniometer.





Here the exact angle is being measured with a goniometer.

·        2 of the 5 angles showed significant improvement, 2 of the angles showed improvement, and one was unchanged (the least predictive one generally)

·        Background Info: Blake Inverted Orthotic developed here at Center for Sports Medicine throughout the 1980’s. Dr Blake has lectured nationally and internationally about the technique. At one point, 17% of all custom made orthotic devices in Australia were this technique.

·        More Background: Bias of Pediatricians and Orthopedic Surgeons is that all children with flat feet will outgrow this, or at least there is no predictability in selecting children for orthotic devices. Dr Ron Valmassy developed the criteria in the late 1970s for predicting which children will not outgrow their flatfeet and also has lectured extensively.

·        Flatfeet: flexible and rigid. Flexible is the hardest to correct in adults and these were the ones chosen for the study (typically more ligamentous laxity than a rigid flatfoot). Flexible flat foot is much more common to see however in children, and can develop into rigid flat feet after the age of 22 when the adult ligament and bone structure is fully developed.

AP TCA is decreased as the arch gets better and the foot less splayed out (Angle 1)

Lateral TCA should get less as the arch improves (Angle 2)

Lateral TMA should get less as the arch improves (Angle 3)

CP should get greater as the arch improves (Angle 4)

·        RCSP changes  8.0 to 2.6 to 1.9  (less is good)

AP View TC Angle 38.4 to 38.1 to 29.6 (less is good) Angle 1 above

Lateral View TC Angle 47.3 to 49.8 to 47.3 (less is good) Angle 2 above

Lateral TM Angle 17.7 to 18.2 to 10.3 (less is good) Angle 3 above

CP Angle 11.6 to 14.7 to 16.0  (more is good)  Angle 4 above

Dr Blake’s comments:

·        Article used the Blake Design to customize the orthotic prescription typically not seen in foot orthotic studies (allowing the 5 to 1 rule of cast correction to heel eversion to create an equal and opposite force to control pronation)

·        The calcaneus is the best guide since it can be accurately measured in the sagittal and transverse planes (by the calcaneal pitch) and the frontal plane (by the RCSP) since it is trapped against the ground. The talus is notoriously a poor guide since it is influenced by the foot and ankle (and ankle positioning is not standard with these x-rays).