Expert Insights On Prescribing Pediatric Orthotics

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In his experience, Ronald Valmassy, DPM, notes that once children have worn an orthotic for a brief period of time, they discover they actually like wearing it.
Here one can see a motion controlling device with a deep heel made of polypropylene. This type of shell will reduce biomechanical compensations and the deep heel seat will increase natural cushioning of the heel by maintaining the fat pad under the calcan
Guest Clinical Editor: Eric Feit, DPM

   In Dr. Kashanian’s experience, a child who has a juvenile bunion usually has a hypermobile forefoot. She accordingly uses an aggressive device to limit the medial column forces on the first ray. If the child’s foot is not skeletally mature, she will prescribe a polypropylene device with a deep heel cup, extra wide arch and minimal arch cast fill. Dr. Kashanian also incorporates a medial heel skive and inverts the positive cast, depending on the resting calcaneal position. She says the rearfoot post should be ground with 4/4 motion.

   However, if the foot is skeletally mature, she uses the same type of orthotic but incorporates a standard arch fill. In addition to the orthotic prescription, Dr. Kashanian discusses with the patient’s parents the appropriate shoes needed for this very flexible foot type.

   Dr. Jay agrees with the approach of choosing an orthotic that will control the foot type that is causing the juvenile bunion. For example, when there is an accompanying flatfoot deformity, he prescribes an extra depth heel seat with a phalange both medially and laterally that contour to the foot and limit the amount of pronatory changes. He finds a rearfoot varus post to be sufficient in most cases.

    “I do not feel that skeletal maturity has anything to do with this,” says Dr. Jay. “If the orthotic is contoured properly to the foot, there is usually minimal complaint from the child.”

   Dr. Valmassy also tries to determine both the etiology of the abnormal foot function and the extent of abnormal pronation. Accordingly, Dr. Valmassy always prescribes orthotic devices that fully address abnormal foot function.

   He does not feel the skeletal maturity of the child’s foot is an issue. Dr. Valmassy uses an orthotic device that is functional in nature once the child develops a heel toe propulsive type of gait pattern, which typically occurs at the age of 3 or 4. An important adjunct to treating juvenile bunion problems in adolescents is initiating exercises that strengthen the abductor hallucis brevis muscle. Dr. Valmassy says doing so complements the overall use of the orthotic device.

   Q: What type of orthotic do you prescribe for Sever’s disease (calcaneal apophysitis)?

   A: The main complaint of children with calcaneal apophysitis is usually pain upon ambulation because the tendo Achilles is too tight and there is compression at the closing growth plate, according to Dr. Jay. If symptoms are mild to moderate, he usually prescribes a temporary heel rise to the insert. He prefers not to go any higher than 1/4 to 1/2 inch and usually recommends placing the rise into a high-heeled sneaker.

   Dr. Volpe prefers using a device with a deep heel seat to cup and hold the plantar fat pad under the calcaneus. While the material should be relatively non-compressible to limit abnormal motions and contain the fat pad, Dr. Volpe says it should not be too rigid as this may increase irritation to the apophysis. He notes other options include incorporating a heel cushion on the dorsal surface of the shell and adding heel lifts for equinus influences when appropriate.

   When it comes to Sever’s disease, Dr. Valmassy will make specific modifications such as fully addressing the extent of abnormal pronation and asking for a deeper heel cup. He often utilizes a combination of materials (PPT, Spenco or EVA) in the heel portion of the orthotic to provide increased shock absorbtion.

   Often, Dr. Valmassy asks the laboratory to create a “sweet spot,” an aperture built into the body of the orthotic device, which will then be lined with PPT and covered with another softer material. Utilizing heel lifts, Korex or other suitable materials often helps in such cases, according to Dr. Valmassy. He adds there is a correlation of this process with tight posterior musculature. When children experience tightness of the posterior musculature, Dr. Valmassy says regular stretching exercises, night splints and possible referral to a physical therapist may be important adjuncts.

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