35 Years of the Blake Inverted Orthotic

Technique
by Richard Blake, DPM
San Francisco, California
 Thank You!!
Greg Lawrence and His Committee

OOLAB for their Sponsorship

 Goals of this Presentation
1. Introduce Inverted Orthotic Therapy
2. Brief History and Why do we Prescribe them?
3. Focus on the Importance of Lateral Column
Support
4. Manufacturing Process
 www.drblakeshealingsole.com
Dr. Blake’s blog for more information and to ask questions
 Warning about the Teacher!!

From my first presentation at

the Root Seminar in Los
Gatos, California, 35 years ago
by Dr. John Hughes,
somewhat bored in the back
row
Orthotic Therapy versus Orthotic
Devices
The Inverted Technique is a Process

May Take Several Orthoses per foot (2-3)

Typical Goal: Vertical Heel and Patient’s Feelings of Stability and Pain Relief

Treat Each Foot Different

Up to you when you are happy (100% correction, 80% correction, 50% etc. )

Great device for developing arches in children

http://synapse.koreamed.org/Synapse/Data/PDFData/1041ARM/arm-38-369.pdf
The Concept Grew Out of Runner’s Wedges

Designed to Slow Down

Pronation Produced by Running
Limb Varus
Runner’s Wedges: 1 Degree per 1.5 mm

4 degree Varus Wedge was

¼ inch for the average
sized athlete
Limited Knowledge of Inversion (1981)
At that time, only 3-4 degrees of inversion ever put into
orthotic due to shallow heel cups
Dr. Root was intentionally going away from the UCBL
deep heel cups

Shocking to Dr. Root that the Inverted Technique allowed

Heel Inverting 7-12 degrees (why was it so stable?)

But, to avoid lateral instability, there were safeguards

gradually established
Safeguards to Over Inversion
Good Maximally Pronated Midtarsal Joint in Cast

Root Lab would intentionally overfill the arch

High Lateral Heel Cups and Lateral Phalanges

No Motion in the Extrinsic Rear Foot Post

Denton Modification

Fettig Technique

Feehery Modification

Plantar Fascial Groove

High Point of Support under Nav-Ist Cunei not more Distal

What does an Inverted Cast Look Like?
Goal is typically to center the
heel under the ankle, not
invert the foot to the ground
You are Inverting the Orthotic to Do What?
Have Less Everted Position

Have Less Overall Pronation Motion

Have Less Velocity of Pronation Speed

Occasionally, Invert A Heel with High Rear Foot Varus that Pronates

***Stabilize the Lateral Column Incredibly

(pronated foot very unstable across the CC Joint)
What makes pronated feet more
Stable?
Inversion Force on Heel and Rear Foot

****Very Stable Long Plantar Ligament under CC Joint

Limiting Motion of the Subtalar Joint

Avoiding Over Correction—Slide Laterally

Allow First Metatarsal to Plantarflexion in Propulsion

No Excess 4th/5th Metatarsal Pressure (Even Push-Off)

Wide Orthotic

PF Groove

Right Amount of Material Thickness

 Stabilize Lateral Column by:
Trapping the Calc-Cub Joint against the ground or orthotic

This was a vital teaching of Dr. Root on Orthotics

How do we Invert the Foot, and not de-stabilize the

lateral column, or dorsiflex the first ray
(this is an emphasis of this lecture)
How do we stabilize the lateral column
with the Inverted Technique?
Stable impression cast with maximally pronated midtarsal
joint

No Lab Fill ever in the Calc-Cuboid area

Lateral Column that is parallel to anterior platform (not

inverted from the cuboid through 5th metatarsal)

Fettig Technique with Forefoot Valgus

Feehery Technique with Forefoot Varus or Loose Joints
Denton Modification on Over Correction Symptoms
Fettig Technique: Inverting the Heel
while maintaining Forefoot Valgus
Correction
For Forefoot Valgus Feet

Technically Challenging for Labs

Standard Inversion 25 degrees or 5
degree change at foot
If 10 degrees forefoot valgus

First nail 35 degrees inverted (first met head)

2nd nail under 5th met head to bring back to 25

degrees
 Feehery Technique: Extra Cuboid
Support Internally
Kirby Skive Process except into the Calc-cuboid area to raise the
support

Forefoot Varus Feet

Loose Feet

Where the Inversion will still not support the rear foot enough

Part of the great correction with the Fettig, Feehery, Kirby, or Blake is
in the increasing calcaneal inclination (Elvander)
Denton Modification: Lateral Support
not wedge
Typically in-office procedure
Calcaneal-Cuboid Fill or not to fill
 Lab Technique to Invert the Foot
Why?
Pes Planus and Everted Heels (children with flat feet)
Posterior Tibial Tendon Dysfunction (adults with
collapsing arches and ankles)
Sesamoid or other Medial Column Issues to shift weight
Running Limb Varus (intrinsic Runner’s Wedge)
Internal Knee Rotation and Pain Syndromes from that
 Typical Ways to Invert
Standard Vertical Orthotic and Varus Wedging

Invert Standard Orthotic

Standard Vertical Orthotic and Medial Kirby

Standard Inverted Orthotic with Medial Kirby

Standard Inverted Orthotic with Higher Arch than Normal

Blake Inverted Orthotic Technique

Biaxial and Triaxial Technique

Standard Inverted Orthotic with First Ray Cutoff

Which Way Better??

 Biomechanics is Evolving so learn
different techniques for Plan B or C
Root Focused on the Lateral Column and Metatarsal
Balancing
(narrow medial aspect to not block 1st Ray Plantar Flexion

Wernick, Langer, Dananberg focused on smooth

propulsion (Sagittal Plane Blockade)

Kirby (Skive) modified Root with more heel Control

Glasser (MASS) and Shavelson (Foot Centering) also have

wonderful ideas with more foot contact of the orthotic
device
Inverted or Medial Kirby (left side)
making more resistance to stop
pronation
Inverted vs Standard
 BIO (Blake Inverted Orthosis)
Was developed with the help of Merton Root, DPM from 1983 to 1992 and
hundreds of my patients and colleagues

What were we trying to get better from Standard orthotics in those days?

A way to invert over 3-4 degrees without creating lateral instability

Not irritating the arch

Not blocking first metatarsal plantarflexion in propulsion

The ability to go wider in shoes and not have the orthotics moving around

The ability to stabilize the long plantar ligament in pronated feet

 No Lateral Instability
Easily Felt by Patient
Want Lateral Position Shift
Not Lateral Sliding
Should Feel More Stable Laterally (counter
intuitive)
Inverted Position of Cast from the Rear
 Standard BIO RX
Measure RCSP and Invert 5 : 1
Start 25 Degrees for Moderate Pronation or Knee Internal Rotation or
Running Limb Varus
Start 35 Degrees for severe pronation or if over 7 degrees everted
High Point in Cast Correction at the Navicular First Cuneiform
Make as Wide as the Shoe for Athletics
PF Groove for Rohadur but unnecessary for Polypropylene
Deep Heel Cups (start at 21 mm)
Feehery Modification for Greater Cuboid Support
Fettig Modification to Capture FF Valgus
Denton Modification for further lateral column support
0 degrees motion placed in Rearfoot Post
Inverted Cast Correction
Inverted Cast Correction
Inverted Cast Correction
Inverted Cast Correction
Inverted Cast Correction
Inverted Cast Correction
Inverted Cast Correction
Thank You and Good Luck!!