Assessing Correction with the Inverted Orthotic Technique

This is the right foot of a patient with posterior tibial tendon dysfunction. She is trying to avoid surgery as her foot has begun the damaging process of collapse. As the arch collapses, the heel everts to the ground, and the foot gets more and more dysfunctional ("apropulsive" in the Podiatry world). Even though this foot would look better in the shoe, from the walls of the shoe holding the foot some, this is the image of a pronating right foot through the orthotic device. The right foot is still everting at the heel and sliding laterally at the heel on the orthotic device, collapsing the arch, and abducting the fore foot on the rear foot as the front of the foot moves laterally. 

In this particular patient, the RCSP was 11 degrees everted to start on the collapsing right foot, and 4 degrees everted on the left. The patient was given a 35 degree Inverted Orthotic right (7 degree change with that orthotic technique), but only responded by inverting 4 degrees. Therefore the photo above shows a 35 degree inverted orthotic device that does not have enough power now to invert the heel enough, so the pronation still wins. Therefore the patient's right heel went from 11 everted to 7 everted (a 4 degree positive change) instead of the 7 degree change I desired. Failure? No!! The mold that made this orthotic device is back in the lab for 4 major changes: 3 mm Kirby medial heel skive, slight increase in the proximal medial arch, change in plastic from 5/32 inch to 3/16 inch (this one I should have done initially), and a full length 3 mm or 1/8 inch extrinsic varus wedge. From each of these variables, I should get 1-2 degrees more extrinsic supination moment to help center that heel at vertical (the whole 11 degrees). I think it is easy to at least see by this photo how the medial Kirby will narrow the medial heel area and let the orthotic device grab the foot better. 

The Effect on the Knee and Hip with the Inverted Orthotic Device

This is one of the closest articles to date on the positive effect of the Inverted Orthotic Technique on knee and hip problems. When I lectured at the University of Virginia, 2007, this is the results they got, although I never saw their study published. Rich

https://core.ac.uk/reader/71975935?utm_source=linkout

Inverted Orthotic Technique: The Reason the Device Works Still A Mystery??

As most of you know, I inverted an orthotic device almost 40 years ago that has been very successful. It has been the only orthotic device documented to help children outgrow their flat feet for instant. Yet, it is hard for researchers to grasp why. It is meant to change motion while walking or running into less pronation. Yet, studies have had a hard time studying this. The YouTube link below and the Podiatry Arena thread following is a wonderful example of this decision. The article they are referring to was on 11 symptomatic runners who when switched from standard orthotic devices to Inverted Orthotic Devices got better. But when studied, they could not find out why. I am actually learning a ton from these discussions and have my own theories. First of all, the study was done using the outside of the heel area of the shoe to represent the heel of the foot and this can be totally off. Secondly, the Inverted Orthotic Device is made for each foot individually, with different degrees for the right and left foot. And, when the foot does not respond, a redo is done to get it as perfect as possible. This was not done with the research. All patients, both right and left feet, got the same orthotic correction. In my mind, as a research project it was a failure from the beginning. This being said, it is my life's work, and I will continue to help it along as I can. 

https://www.youtube.com/watch?v=zLSdkIdn1K4&t=51s

Utilizing Inverted Orthotic Devices for Knock Knees (Genu Valgum)

Here is the patient with knock knees or Genu Valgum and Rear Foot Valgus deformities. In an ideal world, the subtalar joint could stay in neutral where the foot and ankle lined up although everted.

If we were to measure this patient, the heels would be everted to the ground the same degrees of genu or tibial valgum. 

However, reality sets in, and one of two things happens. The subtalar joint supinates to bring the heel vertical or close to that position (as shown on the right side), or the foot collapses more medially with subtalar joint pronation getting more everted than the tibial valgus position as seen on the left side. The right foot needs an orthotic that allows for contact phase pronation and I set it to typically pronate from 6 everted to 10 everted by using the inverted orthotic device of 20 degrees or a 4 degree change and then grinding 4 degrees of motion into the rear foot post.  The left foot needs to get them close to their everted neutral position of 10 degrees everted typically with a 25 degrees inverted orthotic device. 

Podiatry Question #1: What 3 common orthotic RX would help the foot below?

This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are: 

1. Unilateral pronation placing a strain on the posterior tibial tendon
2. Some inherent weakness in the tendon 
3. A Habit of wearing poor quality non supportive shoes

When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories? 

1. An Orthotic Device with some inversion
2. A varus foot wedge external or internal to the shoe
3. A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
4. Stable shoes, stability or motion control, with some heel elevation 
5. Aircast Airlift PTTD brace
6. Posterior Tibial J Strap for Inversion Support

https://youtu.be/w3FXx4OFqec

https://youtu.be/AcSSyBfFocE

It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include: 

1. Anterior Tibial Tendon
2. Intrinsic Musculature
3. Peroneus Longus
4. Gastrocnemius and Soleus
5. Sartorius
6. Lateral Hamstrings
7. External Hip Rotators

And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation? 

1. Mueller TPD orthotic device
2. Inverted Technique with Kirby Skive
3. Modified Root with Kirby Skive
4. DC Wedge

This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.

What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are: 

1. Too much correction in the heel fat pad for the body to tolerate
2. Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
3. You modify the Kirby skive, or the medial arch, for comfort losing support in the long run

The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support. 

Inverted Orthotic Technique: 35 Years Experience

   35 Years Inverted Orthotic Technique by Richard Blake on Scribd