While shoewear can make orthotic prescriptions challenging for adults, shoes are rarely an issue when prescribing pediatric foot orthoses. Whether children are at school or at their leisure, they usually wear sneakers. Sneakers are frequently ideal environments for motion-controlling orthoses. The deep, firm counter and midsole, wide shank, roomy toe box and removable insole found in most sneakers make fitting controlling devices easy, eliminating one of the most troublesome problems when prescribing orthoses.
However, children who wear “school shoes,” often part of a required uniform, may benefit from a low-profile orthosis design. In these cases, modifications — such as extrinsic forefoot posts, full-length top covers and longitudinal arch fillers — that increase the bulk of the devices should be avoided whenever possible.
Children who participate in organized sports will often require devices selected for the demands of sport. The shell material should be more flexible and forgiving for the athlete’s foot. A Langer All-Sport device is an excellent choice for cross-training or children who are involved in a variety of sports. When your patient is dedicated to a particular sport, you should consider modifications and soft-tissue supplements designed for the needs of that sport.
An example of this is the Langer Soccer Sporthotic. This device, made of a thin, highly controlling composite shell, offers several key benefits:
• an intrinsic rearfoot post to improve fit in shallow-counter cleats;
• a cushioned heel insert for increased shock absorption; and
• a sulcus forefoot post with a first ray cutout to encourage plantarflexion of the first ray.
Using such a device can help manage forefoot deformities in a sport in which heavy forefoot demands are intrinsic to the way the game is played.
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.