The rapid growth typical of children raises concerns from parents and practitioners about the cost of custom orthotic devices. One way to address these concerns is to recommend a prefabricated orthotic.
Prefabricated devices should have features such as a deep heel seat and moderate to high medial and lateral flanges. This allows for some control of the foot when custom contouring of the shell and posting are not an option. In addition, you want to ensure that the plantar surface of the device sits flat inside the shoe and the interface between the foot and the device is made of a soft, comfortable material. The Globotec device (Langer) is an example of a prefab that meets these criteria and serves as a valuable option in patients when cost is a limiting factor.
There are also lab-sponsored insurance programs you can offer to parents who are concerned about costs. Langer’s Protect program is one example. While parents will still have to pay office fees for your services (i.e. visit, biomechanical exam, casting, etc.), which may be covered by health insurance, the Protect program, for a small fee, provides the patient with a replacement out-grow device during a two-year enrollment period. This helps to alleviate parent concerns about paying for a custom orthotic their child will quickly outgrow. These programs may also spark referrals for other pediatric patients.
A Comprehensive Review Of Pediatric Orthoses
Most orthoses made for children are motion-controlling or motion-altering, often referred to as functional foot orthoses. The presenting pathology in the child’s lower extremity often requires a device to reduce excessive motion in a foot with, for example, high ligamentous laxity and genu valgum or you may need the device to direct motion in a limb with a rotational disorder such as a femoral antetorsion and compensatory hyperpronation.
Accommodative devices are less frequently required in this age group. It is much more common in adults than in children to require accommodation of reduced joint motions, prominences and pressure points. If some accommodation is needed in a child, you can usually add it to a motion-controlling device as a soft-tissue supplement, creating a “hybrid” device.
The relatively light weight of a child means materials that are more forgiving — with increased flex in a heavier individual such as an adult — will resist collapse more readily in a child. This allows you to choose from a wide range of material properties, shell thicknesses and filler options while still achieving the desired goal of motion control.
Key Posting Considerations
Varus deformities of the rearfoot and leg should be identified at an early age. Dynamic compensations for these imbalances require posting, which effectively angles the surface the patient walks on a corresponding number of degrees to the measured deformity. This reduces or eliminates compensations in the foot and reduces the symptoms and gait changes associated with them.
The amount of control a post provides is determined by numerous factors including the number of degrees the post is angled. Other factors include the stiffness or resistance to compression of the posting material, anterior-posterior length of the post and the width of the post. A longer, wider post made of a stiffer material will offer the most control to the rearfoot and leg.
There is a reduced need for forefoot posting in children under the age of 6. The ideal orthosis for a child will limit excessive or undesired motions while still allowing normal motions that are so important for ideal development.
Be Aware Of Predisposing Risk Factors In The Pediatric Pronated Foot
A child may exhibit a weak foot structure leading to pronation, but may also have additional predisposing risk factors that may affect the foot in its overall development and function. These risk factors may modify the natural history of the pediatric pronated foot and often dictate the requirements for orthosis selection and design. These risk factors include, but are not limited to, ligamentous laxity, obesity, rotational and angular disorders and ankle equinus.