Book Review - The Inverted Orthotic Technique: A Process of Foot Stabilization for Pronated Feet by Richard Blake, DPM, MS
Anyone that knows anything about biomechanics of the lower extremity, especially in regard to those concepts relating to and affecting the foot implicitly, understands that the inverted calcaneus provides the superstructure a more stable base of support and a more efficient, rigid lever arm for propulsion rather than the inappropriate and excessive mobility that accompanies an everted calcaneus. With this thought in mind, and recognizing the fact that there are a number of individuals from the pediatric through geriatric age groups with pathologically pronated feet that are unable to be controlled with conventional orthoses, the Blake Inverted Orthotic Technique offers a unique methodology that may be effectively utilized to neutralize all abnormal pronation. While reducing pain and encouraging normal development in the child, the technique will improve, and at the very least, restore normal alignment and function in the adult.
It is interesting to note that the original Whitman cast technique was a supinated, off weightbearing cast taken with the foot resting on the thigh of the opposite limb in order to insure that as much control as possible of the “hindfoot” complex would be achieved. The Blake Inverted Cast Technique always reminded me of a conceptually and technologically advanced, ultra modern, tolerable and improved version of what Royal Whitman, MD intuitively intended but never fully achieved.
Presented in a practical and educational workbook style format by its originator Richard L Blake DPM, MS, The Inverted Orthotic Technique discusses pertinent biomechanical principles and concepts including the role of static and dynamic examination, prescription writing, modifications and variables, as well as the influence of equinus, limb length discrepancy and frontal as well as transverse plane disorders on intended outcomes. It is an invaluable guide for any practitioner dealing with pathomechanically induced lower extremity pain or dysfunction especially in those instances that are precipitated, perpetuated or aggravated by excessive pedal pronation. It is a worthy addition to the library of all individuals interested in lower extremity biomechanics, an indispensable manual for any private or commercial orthotic laboratory, and required reading for students. As such I have been compelled to add Dr Blake’s book to the 2020 NYCPM Division of Orthopedic Sciences list of required texts.
One final point: It is interesting to note that iconic experts in podiatric biomechanics such as Richard O Schuster, DPM and Merton Root, DPM as well as others never had the need to prescribe an AFO since through their expertise and methodology they were able to obtain the degree of correction necessary to control an otherwise seemingly uncontrollable foot and ankle. The Blake Inverted Orthotic Technique when correctly prescribed and properly constructed allows today’s average practitioner to be able to consistently control this excessively pronated, progressively debilitating, pathologic foot type thereby negating the need to prescribe an AFO while at the same time lessening the urgency or obviating the necessity for surgical intervention.
Comments
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I developed the Richie Brace, which is an AFO, after failing to control certain patients with foot orthoses alone, using the Blake Inverted Technique. I know Rich Blake personally and he also can verify that his inverted orthosis will not control Stage II and III Adult Acquired Flatfoot in all cases. Certainly the inverted technique is a significant augmentation to foot orthotic therapy, but is not the cure-all to correct the severely pronated foot.
Doug, First of all, the world of Podiatry can not thank you enough for the incredible work you do in helping patients. The book on the Inverted Orthotic Technique clearly explains the utilization of the device, from patient selection, expectations, adjustments, and limitations. Yes, the inverted orthotic technique is a way of corrected the foot which fits 98% of my pronating patients. 2% of my patients typically require surgical correction for their advanced PTTD first before I can control them in the Inverted Technique (but Stage 2 and 3 PTTD are perfect candidates to attempt control with the Inverted prior to surgery). And yes, some of these 2% (and I can name them all since they become your friends along the way), are not surgical candidates and you accept less correction and more disability. I am hopeful my book helps to demystify the technique. I use it 25% of the time in my practice when I want moderate to severe pronation control, and the other 75% use Root balancing orthoses for forefoot issues, or Hannaford running orthotic devices for shock absorption or fat pad atrophy or hyper-sensitivity, or various forms of hybrid orthotic devices for the patient's unique needs. Rich
I would echo the comments by Dr. Richie. While it may be interesting to note that Drs. Root/Schuster never prescribed an AFO, it is dubious at best to claim that foot orthoses are a panacea for foot and ankle deformity. In those situations where the entire foot is grossly laterally deviated to the weightbearing axis of the tibia, or when the deltoid ligament is attenuated, even the most aggressive correction achieved by a foot orthosis will not be adequate and an AFO should be considered.
Benjamin, thanks for your comment. Yes, in my practice, I may start getting that patient comfortable with an Inverted Orthotic to begin the pronatory unwinding of the foot from lateral towards medial. Typically, it takes the patient 3-9 months to decide on their surgeon of choice, and I help direct them. I have been blessed to work with Dr. Remy Ardizzone in my practice who does great flat foot correction. And, once the surgery is done, and weight bearing begins, the need for good orthotic support is crucial as the foot is re-strengthened. So, when the patient first walks into my practice, to when they are technically finished, 2 years may of passed. I am responsible for the orthotic part of this process, changing corrections as I need to. And there are the patients who are not surgical candidates, even in California, that I will have to manage as long as I practice. This is why we become good friends. Rich Blake