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History of the Blake Inverted Orthosis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Jun 29, 2010.


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    A few days ago at a podiatry conference, I got to chat with my colleague and former professor, Richard Blake, DPM. I had mentioned to him that it would be very helpful for him to describe his thought process and observations during his development of the Blake Inverted Orthosis in the early 1980s. Since I was one of Rich's students and helped him make his Blake Inverted Orthoses while I was a podiatry student, I have always felt that his pioneering inverted orthosis was quite instrumental in my later development of the medial heel skive technique. I am hoping that Dr. Blake has a little extra time to share his thoughts with us here on Podiatry Arena.
     
  2. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis (Part I)

    I am honored to be asked by Kevin (Dr Kirby) to address the history of the Inverted Orthotic Technique. Due to my time restraints at present, I hope I can gradually tell the story over the next week. Someone may have to help me find this thread again, as I am just beginning to use this wonderful forum. It was 1981 that I started at the Center For Sports Medicine at Saint Francis Memorial Hospital in San Francisco. I had just finished my two year residency, the 2nd year as a Fellow in Biomechanics under Dr Ronald Valmassy and Dr Chris Smith. Dr Kirby was a sophomore during my 2nd year, and I stayed on teaching at the California College of Podiatric Medicine for the next 11 years. When I started at Saint Francis Hospital, I was hired by Dr James Garrick (who is still my boss 29 years later). The sports center was an orthopedic clinic, and I was the first podiatrist. Patients can in flocking in not to see me, but to see the famous Dr James Garrick for their knee injuries. Dr Garrick had started in 1968 the first sports medicine clinic within a medical school at the University of Washington. Dr Garrick was/is tenacious about only operating after all conservative treatment was tried. He loved podiatry, and my first year was filled with knee injury after knee injury. I came to Saint Francis armed and fully trained with classic Root/Weed knowledge. I ended up spending 10 years studying under Dr John Weed, and worked closely with Dr Merton Root on my original paper the Blake Inverted Orthosis. It was my frustration with helping one particular patient in the fall of 1981, that I began experimenting with positive cast inverted positions that were then considered radical. In my next post, if you allow me, I will go from here.
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. Re: History of the Blake Inverted Orthosis (Part I)

    I donĀ“t think anyone has done this yeat but :welcome: :welcome: to Podiatry Arena Rich (its pretty informal around here most of the time), look forward to hearing more from one of the leading players of Podiatric Biomechanics, not just the history of the Blake inverted orthotic ( which I look forward to), but also other pearls of wisdom you may add to the discussions.
     
  5. Serialised Biomechanical history. :D:drinks

    Absolute Legend. Thankyou Kevin For inviting Richard and Thankyou Richard for taking the time! For me, and I suspect others, the details an mechanics of how this sort of thing develops are fascinating. Who learned what from whom etc.

    I hope that this is the first of several such serials from the leaders and innovators in Biomechanics! I move that when Richard has finished telling his story we invite somebody else to tell theirs. How did the Kirby Skive come to be? How did Kevin Kirby meet and work with Eric Fuller? When did Simon Spooner realise he was "special";).

    Great thread. Let it be the first of many.:drinks
     
  6. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis (PartII)

    As I discussed in Part I, I started at the Center For Sports Medicine armed with Root/Weed Biomechanics ready to conquer the world. My first few months in the fall of 1981 met with a few challenges, but most patients fell within the biomechanics controlled with Root Balanced Orthotic Devices. Then, Patient X was referred to me by Dr James Garrick to help control his foot pronation and hopefully delay or eliminate the need for a knee replacement. A left lateral tibial plafond fracture with collapsed lateral joint line placed his knee in marked valgus with a strong pronatory force on the foot. His whole knee was swollen, but his symptoms remained lateral joint line. As I began attempting to change his biomechanics, he was also in physio and experimenting with various ineffective knee braces. His resting calcaneal stance position was 8 deg evertd left, and 0 or vertical right. Since I had only several experiences with partially compensated rearfoot varus patients needing a 4 degree inverted pour, and Dr Root taught never to invert the cast more than 5 degrees or lateral instability would ensue, I decided to pour the casts 4 inverted left, perpendicular right. All my rearfoot posts in those days were 4 deg inverted with 4 deg pronatory motion. So, I fully expected at least 50% reduction in the pronation and symptoms.
    At dispense, the right orthotic device was very stable. I used normal widths (standard) and 4.0 Rohadur (based on his weight) and 18 mm deep medial and lateral heel cups (standard for men's athletic shoes). On the left side, watching him walk with the new orthotic, did not make sense. He was worse!! He was more stable with just his shoe. The orthotic device merely lifted him in the shoe aggravating his pronation. He did not leave the office that day with his orthotics. But, even though I had experienced my first biomechanical failure, to the nth degree, the patient loved the process, remained positive, encouraged me. What to do? Would changing the correction to 5 or 6 degrees inverted make any difference when 4 degrees was such a failure? I decided to try a 6 degree inverted correction. I remember thinking if the patient became laterally unstable with this severe degree of cant, I could narrow the width some, lower the medial heel cup, and inflare the medial post. More on left orthotic dispense Take 2 on my next post. Rich Blake
     
  7. Rich:

    Thanks for parts I & II. Looking forward to hearing about the clinical observations you made each step along the way toward developing the inverted orthosis technique.:drinks
     
  8. efuller

    efuller MVP

    Re: History of the Blake Inverted Orthosis (PartII)

    Rich,
    Welcome. I'd forgotten that Root taught about not inverting the device too much, but it rings true in my memory that John Weed did. I appreciate the history.

    Regards,

    Eric Fuller
     
  9. efuller

    efuller MVP

    Robert, Since you asked.
    My very first patient as a podiatry student was overseen by Kevin when he was a fellow and I was in the beginning of my third year as a podiatry student. The guy came in complaining of "tightness" in his lateral ankle. I don't even remember if Kevin actually called it sinus tarsi syndrome, I'll bet he did. He had us put some moleskin on the underside of the patient's running shoe sock liner to create a varus wedge. The patient noted that it felt better. The funny part about it was the school was running free screenings where we were just supposed to talk to the patient and not treat them until they decided to pay for the treatment.

    However, Kevin's most influential moment for me was later that school year when I was writing a paper for a contest sponsored by Langer Labs. The paper was supposed to be about the function of the midtarsal joint. Kevin suggested that I read the Van Laangalaan paper. That paper questioned some of the ideas that were being taught to us. That year they awarded two first prizes. I like to think they gave me a first prize because of original thought. (It wasn't that original. A lot of it came straight from Van Langalaan.) The other paper parroted the usual stuff being taught in class.

    A further influential moment came about when his palpation of the location of the STJ axis paper came out. That pushed me a lot further into thinking about the mechanics part of biomechanics.

    Cheers,

    Eric
     
  10. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis (Part III)

    Part II showed that my suspected 50% correction of the severe pronation on his left foot with a 4 degree inverted orthotic device proved to be an utter failure. But I was so indocturnated with Root/Weed biomechanics that I then attempted a 6 degree inverted cant/pour. Again, a total failure in controlling the extreme pronation caused primarily by his acquired genu valgum force. I then proceeded to make a series of orthotic devices in 2 degree increments not knowing any way of predicting how much supinatory force I was needing to apply. He would come in every week on Friday for a new and possibly improved left orthotic device (in those days I was only working Fridays at Saint Francis). I again had complete failure at 10 degrees inverted and 12 degrees inverted. At 10 degrees inverted his arch became sore as he tried to get used to it with the radical arch support as his knee drove the pronation downward collapsing the arch. The pronation was still winning, although the pronation was becoming less noticeable in gait. He was no longer worse with the orthotic device, but he was only slightly better. And his knee still hurt just as much.
    It was when he came in to get the 12 degree inverted orthotic device that he told me the 10 degree inverted device really was hurting his arch. And here I had an even higher arch to give him. Oh boy!! As I examined his foot, it was really obvious that it was the medial slip of the plantar fascia that was getting sore. I ground the orthotic device along the sore area (can not remember if I marked his foot then like we do now with a non permanent magic marker) making a nice temporary PF groove. With rohadur this weakens the plastic, so I knew it was temporary. He instantly felt so much better. For the next 10 years, until I transitioned to polypropylene, plantar fascial grooves were placed on all of my inverted orthotic devices routinely--whether the patient needed them or not. I never dispensed the initial 12 inverted device without a groove, but the next week I designed a 12 degree inverted device with a PF groove already built in. The first of thousands of inverted orthotic devices with PF grooves. I will talk about PF grooves and the continual saga of the first inverted orthotic device success in later posts. Thank you.
     
  11. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis (Part IV)

    In the initial 3 posts on the History of the Inverted Orthotic Technique, I reviewed the first patient I had that pushed the limit of Root/Weed biomechanics. I had designed a 12 degree inverted orthotic device with a PF groove to prevent arch irritation for severe acquired genu valgum and knee pain and collapsed arches. But the pronation was barely being affected. Our training said if you place a patient in a 12 degree inverted orthotic that they would function 12 degrees inverted temporarily until they sprained their ankle. This patient however had an extrinsic cause of pronation, a force I learned was much more difficult to control. I had learned that extrinsic forces were harder to treat than intrinsic forces. And I had learned that frontal plane forces were easier to treat than sagittal or transverse plane forces. But, there had never been any quantification of the correction needed. It would take me 2 years of studying these forces to determine the force correction was somewhere between 3 to 8 times greater than simple intrinsic frontal plane forces (while I waited for Dr Kirby to graduate). What a ride I was in for!! More on this to come!! But, yet I digress.

    Patient X failed at 12 degrees inversion, but I could see some gait improvement. Patient X failed at 14 degrees inversion, but at 16 degrees definite pronation stability was being changed and symptomatically the patient was feeling better. I only made 3 more left orthotics for this patient. The 20 degree inverted orthotic device with PF groove controlled the patient over 80%. The 24 degree inverted orthotic device with PF groove controlled the pronation 90-95% but was too uncomfortable to a misfitting groove. I decided to recast the patient and remark the PF and made a more comfortable 24 degree inverted orthotic device. At 20 degrees the knee stopped swelling, and at 24 degrees the knee pain was mild, and function was much better. The correction of Patient X proved to be a 3 to 1 ratio, it took 24 degree correction to change the RCSP from 8 everted to vertical. This correction was also influenced by his knee bracing and high top boots we were using. The correction was probably more 4 or 5 to 1.

    Part V will begin to explore the journey with Root Lab, the podiatry profession, Kevin's skive revelation, etc. Hope you will stay tuned.
     
  12. Asher

    Asher Well-Known Member

    Re: History of the Blake Inverted Orthosis (Part IV)

    For sure!
     
  13. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis (Part V)

    In my previous posts I explained the situation around the first inverted orthotic device of 24 degrees inverted with 4.0 Rohadur and a PF groove to prevent arch irritation. This was December of 1981. The patient's knee symptoms had improved and I was excited about the findings. It would 2 more years until I gave my first local presentation on the technique as I began to discover what patients needed more correction than typical Root/Weed biomechanics had to offer.
    During those days, I spent time almost weekly learning from Dr John Weed. He was only 45 minutes down the road from San Francisco, and was the smartest human I had ever talked to. I would bring patients routinely down to his office in the early 1980s to discuss their orthotics, whether they needed surgery, etc. But in Dec 1981, I called John and asked if I could talk to him about Patient X and my discovery. So, I drove to San Jose excited about discussing my findings. I had also had 2 or 3 other patients that I had used 12 to 16 degrees of inversion with good results, so I knew it had some merit. With sports medicine, varus wedges were routine to help runners slow pronation, but these were never more than 4 degrees or less.
    My conversation with John Weed was disheartening. He was my mentor, and was not impressed, I could tell he didn't understand how my claims were possible. He sent me over the Root Orthotic Laboratory, which was next door to his office in those days, to explain what I was doing to Jeff Root and Elaine Root (office manager ---can not remember exactly if she had married Mert by then). They immediately had Mert Root on the phone with me.
    Now, Mert Root was a god-like figure. I was in awe of him. What he had done, and what his influence on the world of biomechanics continues to do, made every one uneasy. He was on a different plain of consciousness in biomechanics. And now I was going to actually talk to him. He kindly listened to my excited recourse of the events of the first 24 degree inverted orthotic device and that I was beginning to take some of the theories learned and use on other patients. He spoken for a few minutes, but I only remember the phrase--"they will never work, and they will cripple those you give them to." I was devastated!!
    The response I got at the California College of Podiatric Medicine, Department of Biomechanics, where I taught until 1992, was of uninterest. Nothing these leaders of Biomechanics were excited about. So, I continued to make and learn and remake hundreds of these orthotic devices in 1982 and 1983 without the support of my colleagues. My students, Dr Kirby, Dr Fettig, Dr Christiansen, Dr Hannaford, Dr Denton were my friends and sounding boards. More on their influences on me later.
    It was a patient I saw with John Weed in late 1982, that began to change his mind, and then Dr Roots. Dr Merton Root became by greatest supporter by middle of 1983.
     
  14. Rich Blake

    Rich Blake Active Member

    Re: History of the Blake Inverted Orthosis Part VI

    It was a patient I saw with John Weed in 1982 that convinced John that I was up to something. John had a 12 year old boy in the office one day that I was visiting. The boy had had some type of severe foot pain that John had alleviated with Root Balanced Orthotic Devices made of 4.0 Rohadur and Oxford Shoes. I was actually in John's office when I heard him crying and asked John later what the story was with this young man. He explained that he could only control the pronation forces with the orthotic and shoe combination, and the boy cried since he was being told by John that he could not wear tennis shoes at all. He had to wear his Oxfords in PE, etc. I told John that an Inverted Orthotic Device would stabilize him more and should allow him to wear less supportive shoes. The athletic shoes in those days were not as stable as they are today. John told me his biomechanics and I designed a pair of inverted orthotic devices (I was making them with the help of my sister in law Kathy in my sub basement). I do not remember the correction, but I believe they were 25 degree or more. The young man did well and John finally saw the inverted technique in action. Within 6 months, I was training Jeff Root and Kathy Perkins (sp?), later married, on making the device. Root Lab made me orthotic devices exclusively from 1983 to 1988. From the spring of 1983 to early 1984, around the time Root Lab moved from San Jose to Auburn, California, I spent many a weekend with Mert Root writing the 20 page paper on the Inverted Orthotic Technique. Mert Root opened his arms, never seeing the technique used, but hearing from John Weed that it had potential as a good advancement of solid biomechanical principles.
    For the year that I traveled monthly to Root Labs, spending some Saturday nights in their guest house, so Mert and I could work through every word, every sentence for clarity. My rough draft I brought initially of 5 pages entitled the Inverted Orthotic Technique, became 20 pages entitled the Blake Orthotic Technique. Mert turned it into a masterpiece and insisted I call it the Blake Inverted Orthotic Technique. We discussed its effect on every joint in the foot and lower extremity. I saw Mert's genius in action, and was so honored by his respect. In February 1984, I was given 8 hours at the Root Lab seminar to present my paper. Being nervous, I asked our local podiatry chapter if I could present my technique to them. It was January 1984, 2 plus years since my patient with the collapsed left knee, that I presented the Blake Inverted Orthotic to the San Francisco/San Mateo Podiatry Society monthly meeting. It was only an hour, but prepared me for my Root Lab full day talk. More to come?? Mert I know wanted others to use the technique as we finished the paper so he could get their feedback on the technique in general and specific problems the lab may have in manufacturing. I always spent part of every weekend I had with Mert in the lab helping them understand the technique nuiances better. Plus, I was learning the nuiances of the lab work from their angle.
     
  15. Freeman

    Freeman Active Member

    Thanks to you all for this very educational and historic summary of a major development in foot orthoses.

    Freeman Churchill, Certified Pedorthist (Canada)
     
  16. zhangyu

    zhangyu Welcome New Poster

    Very exiciting experience!
     
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    Craig Payne Moderator

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