Expert Insights On Prescribing Pediatric Orthotics

Guest Clinical Editor: Eric Feit, DPM
Valmassy says applying a soft topcoat to the devices often makes the orthotic more comfortable.    Initially, Dr. Kashanian always uses a prefabricated polypropylene orthotic for children. She notes many labs carry a range of low profile pediatric prefabricated orthotics that are not bulky. Prefabricated orthotics allow children to adjust to a device in their shoes and Dr. Kashanian says the devices can be delivered in two or three days. She advises parents to encourage gradual wear initially and a slow break-in period for the orthotic.    If the orthotics are well constructed, Dr. Jay says children should be able to tolerate them. However, he notes that sometimes orthotics may cause discomfort if they are too long in the plantar aspect and extend distally under the metatarsal heads. If the orthotic extends to the metatarsal head region just proximally, children should not have a problem, according to Dr. Jay.    Children also may experience irritation on the medial or lateral side of the foot if there is a deep seated heel cup or if the orthotic has deep medial or lateral phalanges. However, Dr. Jay suggests remedying those problems by grinding down the phalanges.    Likewise, Dr. Volpe also has experienced few problems with compliance or tolerance. He says kids usually have good toleratation to orthotics that are prescribed to control motion in high motion, flexible feet. When a carefully prescribed device is made by a quality lab from a well-executed negative impression, Dr. Volpe says there is usually few problems.    Dr. Kashanian says a little humor doesn’t hurt when prescribing pediatric orthotics.     “I tell my pediatric patients that the orthotics will make them as fast as Superman or as quick as Michael Jordan,” says Dr. Kashanian.    However, Dr. Volpe tells parents to downplay the presence of the orthotic in the shoe. He finds children do not like being asked how the devices feel too frequently so he suggests that parents not ask about the orthotic as children are likely to relay any problems. Dr. Volpe also instructs parents to check children’s feet for irritation to identify problems during the break-in period.    Q: What type of orthotic do you prescribe for a juvenile bunion? Does it make a difference to you if the foot is skeletally mature or not?    A: Although more outcomes evidence is needed on the subject, Dr. Volpe says the existing evidence suggests starting an orthotic very early in the pathogenesis of a condition will provide the greatest likelihood of a device improving foot malalignments and decreasing hallux abducto valgus progression. He often prescribes an orthotic for a teenager with a skeletally mature foot. In such a case, Dr. Volpe says the role of the device shifts to stabilizing the foot and abnormal motions of the first ray rather than to trying to slow down the progression of the deformity.    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.

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