How To Address Conditions That Affect Pediatric Gait

Guest Clinical Editor: Edwin Harris, DPM

Often, Dr. Valmassy will use serial casting for children who are ambulatory as well but he notes that patients often do not tolerate this well. He prefers using a night splint for children in whom he has initially utilized casting. When he does not choose serial casting, Dr. Valmassy uses night splint therapy.

Dr. Keen will use serial casting for mild contractures that do not respond to a stretching program and for patients who will not tolerate nearly full time splinting. For more severe contractures, she usually recommends serial casting as a first step and then nighttime splinting for maintenance.

“I have been surprised how effective this treatment plan can be,” recalls Dr. Keen. “I had one 12-year-old patient with worse than 45 degree plantarflexion contractures (therefore missing 65 degrees of normal ROM) respond to serial casting and maintain it for more than a year.”

For serial casting to be safe and successful, Dr. Harris says one must meet several criteria. He says the child must be sensate and verbal enough to express pain if something happens under the cast. The equinus contracture should not exceed -15 degrees. In addition, Dr. Harris says contracture should not be so rigid that the only way to achieve dorsiflexion would be through destructive compensation through the midfoot. Finally, the child ideally should be ambulatory, according to Dr. Harris.

Q: What are your indications for stopping orthotic therapy?
Dr. Valmassy typically looks for an improvement in the overall range of motion as well as an improvement in overall foot position and foot function before stopping orthotics. He notes that if a child can function in an asymptomatic fashion without any signs of compensation, then it would be appropriate to stop orthotic therapy.

Other rationale for stopping orthotic therapy would involve the underlying problem becoming worse. In these cases, surgical intervention may become an appropriate adjunctive therapy, says Dr. Valmassy.

In regard to stopping orthotic therapy, Dr. Keen says there is generally a weaning process of weeks to months to ensure the child maintains gains with ongoing growth. First, she will discontinue daytime splinting since it is “generally what the child wants.
“Children will usually agree to nighttime splinting if it means they can do without it during the day,” points out Dr. Kern.

For children with diplegia and hemiplegia, Dr. Harris says most are going to remain in orthoses for a very long time as they remain at risk for development of contracture at least until they achieve skeletal maturity. Due to the functional gains these children experience with bracing, he notes many of them will prefer to continue bracing since it makes walking easier.

Many children with a mild deformity will stop wearing bracing during their later teenage years but Dr. Harris tries to convince them that it is advantageous to use bracing at least at night. He says most patients “continue in some form of bracing indefinitely.”

Idiopathic toe walkers need to retrain themselves with orthoses, which also prevent contractures, says Dr. Harris. He would not consider stopping orthoses for at least six months and if possible, would try to get patients to wear orthoses for the life of the orthosis, which is probably about a year.

Q: What do you do if orthosis therapy maintains a range of motion but does not restore a heel-to-toe gait pattern?
In such cases, Dr. Valmassy evaluates the child to determine whether any compensatory changes have occurred and if there is any symptomatology. He may continue using an orthotic device as the child continues developing.

“The first thing that I would consider is that I have made a bad therapeutic decision,” says Dr. Harris.

As he points out, the existence of a functional or static hip and knee flexion deformity may explain why the child in question can maintain a range of motion with an AFO but is still walking on the toes. Although this is unlikely to occur with idiopathic toe walking syndrome, Dr. Harris notes it is extremely common in cases of spastic hemiplegia and diplegia.

If the child has a corrected gait in an orthosis but reverts to a toe-heel or toe-toe pattern without the orthosis, he or she is probably a candidate for an appropriate lengthening of the triceps mechanism, according to Dr. Harris.

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