Expert Insights On Prescribing Pediatric Orthotics
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. For patients with Sever’s disease, Dr. Kashanian prescribes a polypropylene device with a deep heel cup and a wide width, which allows more surface area to cup the heel. She recommends a biateral heel lift, which one should grind down gradually over a four- to five-week period. Dr. Kashanian also recommends using a topcover such as 1/8 nylene (Spenco-like material) with a 1/8 poron heel cushion. The rearfoot post should be out of EVA or Birkocork to allow maximum shock absorption at heel strike, according to Dr. Kashanian. She also emphasizes the need for a stable shoe along with the appropriate orthotic. Q: What type of orthotic do you prescribe for a flexible metatarsus adductus foot type? What if the patient is less than 8 years old? What if the patient is a teenager? A: If a metatarsus adductus is flexible and reducible, Dr. Volpe says one can treat this with an orthosis designed around a rectus positive model. If the adductus is reduced in the positive model, he recommends incorporating a shell with a high and long medial flange — extending at least to the first metatarsal head, sometimes further to the hallux — pressed to the positive model. He says this will produce a device that holds the foot out of adductus. With these patients, Dr. Volpe says it is important to accommodate for a potentially prominent styloid process in the negative casting and shell design/accommodations for the orthoses. Dr. Volpe says one may take this approach regardless of age as long as the deformity is flexible and the device can reduce the deformity.