A Closer Look At Orthotics For Pediatric Conditions

Guest Clinical Editor: Eric Feit, DPM
Valmassy says one may need to consider surgical intervention.    Physicians frequently ask Dr. Kashanian how much to skive and/or invert the pediatric flexible flatfoot. As she explains, the pediatric flexible flatfoot demonstrates a calcaneal resting position of 2 to 10 degrees of eversion and the forefoot is abducted to the rearfoot during gait.     “The appropriate prescription for this foot type is a polypropylene device with a deep heel cup and an extra wide arch,” says Dr. Kashanian. “Both of the above dimensions allow more surface area for the orthotic to exert on the hypermobile flatfoot.”    She highly recommends using a minimal plaster cast arch fill, which allows maximum control on the medial column and prevents the midtarsal joint from unlocking and pronating. One would utilize the medial heel skive and inversion of the positive cast together to control the everted calcaneus and pronated subtalar joint, according to Dr. Kashanian. As far as the amount of medial heel skive and positive cast inversion to use, see “Key Orthotic Considerations For Pediatric Flatfoot” above.    When it comes to young children, whether they are infants, adolescents or young teenagers, Dr. Jay feels one should maintain inserts in an approximately 5-degree rearfoot varus posting alone without forefoot posting. He says the talus will go through a valgus ontogeny or, in other words, will rotate inward and down to bring the first ray down in more of a plantarflexed position and eliminate any forefoot varus.     “Placing forefoot varus posts will create an abutment or a brace to prevent the downward ontogeny of the talus and a rigid forefoot varus may result,” says Dr. Jay.    When treating these children, Dr. Jay typically prescribes an inverted heel seat as seen on the Langer Dynamic Innersole System. He also may use a deep-seated heel orthotic with a rearfoot varus post of 5 degrees.    Dr. Volpe advises taking a quality impression in subtalar neutral with a rectus forefoot and dorsiflexion of the hallux to increase the arch. One should limit plaster additions to the positive cast as they tend to reduce arch height. He also suggests using non-compressible shells and incorporating deeper heel seats and flanges when appropriate.    To improve weight transfer through the foot consistent with the tissue stress model, Dr. Volpe recommends adding plaster positive modifications such as medial skives, slight inversion of the cast and calcaneal pitch.    Inverting the cast to treat more severe deformities with higher calcaneal eversions can be effective in increasing arch height and improving weight transfer in the more severely pronated foot, according to Dr. Volpe. Dr. Feit is a Fellow of the American College of Foot and Ankle Surgeons, and practices privately in San Pedro and Torrance, Calif. He is the Past President of the Los Angeles chapter of the American Diabetes Association. Dr. Jay is a Fellow of the American College of Foot and Ankle Surgeons. He is a Professor of Foot and Ankle Orthopedics at the Temple University School of Podiatric Medicine and is board-certified in foot and ankle surgery. Dr. Jay practices at Cumberland Orthopedics in Vineland, N.J. He is the author of “Pediatric Foot and Ankle Surgery,” which is published by Saunders/Elsevier. Dr. Kashanian is a Diplomate of the American Board of Primary Medicine and Podiatric Orthopedics, and is a consultant for ProLab Educational Institute. She is also in private practice in Northridge, Calif. Dr. Valmassy is a Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco. Dr. Volpe is a Professor in the Departments of Pediatrics and Orthopedics, and is the Chairman of the Department of Pediatrics at the New York College of Podiatric Medicine. He has a pediatric foot and ankle specialty private practice in Farmingdale and New York, N.Y. Editor’s Note: For other articles and columns on orthotics, check out the archives at www.podiatrytoday.com.

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