A Closer Look At Orthotics For Pediatric Conditions

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Alona Kashanian, DPM, says children with internal femoral torsion may be clumsy with sports and running, and have a history of frequent falls. She emphasizes a thorough diagnostic exam to rule out metatarsus adductus.
When evaluating gait, if you see the knees facing internally, then at least a portion of the transverse plane deformity is attributable to either an internal femoral torsion (as seen above) or internal femoral position. (Photo courtesy of Ronald Valmassy,
Key Orthotic Considerations For Pediatric Flatfoot
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Author(s): 
Guest Clinical Editor: Eric Feit, DPM

   Modifying orthotics with a gait extension to induce out-toe can help in-toe gait from femoral or tibial torsion to some degree, according to Dr. Volpe. When extending past the MPJs laterally, the distal, lateral extension on a relatively rigid shell will alter the break in the child’s flexible shoe during propulsion and subsequently encourage more out-toe with push-off. However, Dr. Volpe agrees with Dr. Jay about the importance of tempering parents’ expectations.

    “I explain to parents that there will likely be improvement in gait that hopefully reduces instability and tripping,” says Dr. Volpe. “However, I also make sure it is clear to them that the device is primarily intended to improve function and is not a treatment of the underlying torsion.”

   For children with in-toe gait, Dr. Volpe emphasizes the importance of using orthotics to protect the foot from the abnormal pronatory compensations one frequently finds with closed-chain internal torque from the leg. Employing motion-controlling devices for these children tends to increase the amount of in-toe as a pronatory compensation and reduces the abductory component, according to Dr. Volpe. He says one can manage that condition by combining the gait extension with positive modifications to reduce pronatory compensations in contact and midstance.

   Dr. Valmassy prescribes functional foot orthotics for patients with an abnormal femoral torsion if he finds compensation within the subtalar and/or midtarsal joints. If the child has an adducted gait pattern due to a femoral torsion issue but has a fairly stable foot without compensation, he usually does not treat him or her with an orthotic device. Dr. Valmassy finds that type of gait pattern to be quite stable and says it does not precipitate any pain, discomfort or any secondary musculoskeletal problems.

   When there is foot compensation for a transverse plane deformity, Dr. Valmassy says he addresses this with a more rigid type of functional foot orthosis. As the child grows older, Dr. Valmassy may use an out-toe gait plate to improve the foot’s appearance and possibly assist with stretching some of the secondary soft tissue adaptation which occurs secondary to a femoral torsion issue.

   Children with internal femoral torsion have a history of frequent falls and are clumsy with sports and running, according to Dr. Kashanian. She emphasizes a thorough diagnostic exam to rule out a metatarsus adductus. She also assures parents that 80 percent of the deformity will correct itself. Dr. Kashanian tells patients to avoid sitting in the W position and encourages sports like roller blading or ice skating, which will force an external torsion at the hips.

   Q: How do you prescribe an orthotic for a pediatric flatfoot? Do you believe in inverting the device based on the resting calcaneal stance position? Why or why not?

   A: When prescribing an orthotic for pediatric flatfoot, Dr. Valmassy begins with a complete lower extremity musculoskeletal examination that includes a complete muscle testing examination and gait evaluation. He prescribes an orthotic that will be typically inverted to a significant degree in order to increase the heel contact control of the child’s foot.

    “Many of the children that we evaluate have resting calcaneal stance positions in excess of 8 to 10 degrees of eversion,” points out Dr. Valmassy. “Clearly, this is a more challenging type of foot to address.”

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