A Closer Look At Orthotics For Pediatric Conditions
While one must take special considerations into account while prescribing orthotics for children, different pediatric conditions also warrant special care. Following up on the previous discussion of pediatric orthotics (see “Expert Insights On Prescribing Pediatric Orthotics,” page 24, February issue), our expert panelists discuss key orthotic pearls in treating metatarsus adductus, abnormal femoral torsion and flatfoot in the pediatric population. Q: Are orthotics helpful for a rigid metatarsus adductus foot type? A: Richard Jay, DPM, Alona Kashanian, DPM, and Ronald Valmassy, DPM, agree that orthotics can be useful in treating patients with rigid metatarsus adductus. Dr. Kashanian says an orthotic can reduce stress on the lateral column when one utilizes a rearfoot post that is extended laterally but is not beveled laterally. She adds that a forefoot varus post helps support a structurally elevated first ray. While Dr. Jay believes that orthotics are indicated in patients with rigid deformities, he notes that children may complain of discomfort at the base of the fifth metatarsal laterally. Accordingly, he says it is imperative to use an insert that does not have any high phalange against the fifth metatarsal base. Dr. Jay notes it is usually indicated to cut out the lateral area to allow exposure of the styloid process of the fifth metatarsal. When patients have rigid metatarsus adductus, Dr. Valmassy says correcting the abnormal foot function with orthotics will reduce secondary symptoms often associated with the deformity. For many children who have a metatarsus adductus with a forefoot valgus deformity, he notes correcting the valgus deformity will not only cause the foot to function in a more stable manner but may also reduce the overall adducted appearance of the foot in gait. However, Russell Volpe, DPM, says orthotics will not help a rigid metatarsus adductus. He says these children “will have a great deal of difficulty tolerating attempted correction with orthoses.” For these patients, Dr. Volpe says one would use orthotics more to accommodate prominences and deal with issues of symptoms on ambulation. Q: Do you prescribe orthotics for patients with abnormal femoral torsion? Why and what type of device should one use? A: Dr. Jay has found orthotics to be helpful for abnormal femoral torsion. Whenever there is femoral or tibial torsion in the axial segment, there will be a resulting internal torque through the foot, according to Dr. Jay. He says this creates a pronatory drive through the ankle joint into the talus. When these patients plant the foot firmly on the ground, Dr. Jay says the foot is abducted underneath the adducted talus. When using an orthotic for these patients, Dr. Jay says the goal is to prevent any abnormally excessive amount of pronation. If you are using the insert alone to reduce pronatory change, Dr. Jay advises cautioning parents that although their children can expect an increase in the in-toe deformity, the treatment will prevent the foot from becoming permanently fixed and flattened. 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.