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
Shells made of more rigid materials and/or of increased thickness are the best choices for treating children who have generalized ligamentous laxity. Other modifications such as a deep heel seat, increased calcaneal pitch to lock the oblique midtarsal joint axis and medial and lateral flanges to reduce transverse plane compensations of the midfoot will aid in control of the foot with notable laxity.
Due to the significant medial and lateral instability of children with ligamentous laxity, employing an orthotic device capable of supramalleolar control in the frontal and transverse plane is often necessary to exert adequate control over the closed-chain foot and leg complex. An ideal device with the necessary medial and lateral support is the supramalleolar orthosis (SMO), which extends above the malleoli allowing for control of the tibio-fibular segment. The relatively low height of this device often makes it more cosmetically and functionally appealing than the higher ankle-foot orthosis.
In cases in which you find the SMO is not sufficient to manage superstructural compensations of the ankle and leg, an ankle foot orthosis is the device of choice. One example is the Dynamic Control Orthosis, which consists of a custom functional foot orthosis, a hinged ankle joint and custom molded medial and lateral leg uprights to control superstructural movements. This orthosis also includes a posterior bridge connecting the medial and lateral uprights, which enhancing the proximal control of the leg. This modification is an improvement over other hinged ankle braces that are currently available.
Using thicker shells and more rigid materials are also necessary in managing the pronated foot in the obese child. Longitudinal arch fillers will help reduce the increased compression of the arch area of the shell you’ll typically see in overweight patients. Soft tissue supplementation at the foot/orthosis interface may help reduce the hard feel of such devices and increase shock absorption necessary for sports.
How To Handle Rotational And Angular Disorders
Rotational and angular disorders that produce both in-toeing and out-toeing, bowing and knock-knees may contribute to a compensatory pes valgus. The presence of femoral anteversion, internal tibial torsion, genu varum or valgum will place an abnormal force on the developing foot and will either precipitate abnormal pronation or aggravate any existing abnormal pronation. An internal femoral torsion or position and internal or low tibial torsion will generally lead to an adduction or medial deviation of the talus in the closed kinetic chain. This precipitates the onset of pronation of the subtalar joint or aggravates an already pronated or everted attitude.
Similarly, an external femoral torsion/position or an external tibial torsion also contributes to excessive pronation in the child. A medial displacement of the center of gravity results from the externally positioned leg, facilitating compensation of the subtalar joint.
Genu valgum or varum outside of physiologic ranges is detrimental to the pronated foot. Abnormal frontal plane forces placed on the rearfoot lead to compensatory pronation of the subtalar joint. For example, in the case of genu valgum, the center of gravity passing through the leg is displaced medially over the foot relative to the axis of the subtalar joint. This maintains the foot in the pronated position.
Orthoses for rotational disorders benefit from flanges and extensions such as gait plates. Orthoses for angular disorders benefit from high posting and out-flared or wide posts to stabilize the post plate in the frontal plane.