Debating Current Issues In Orthotic Management

   Evans also reviews three of the most important evidence-based articles on pediatric flatfoot with which Dr. Scherer says every podiatrist should be familiar. Lastly, he notes Evans’ recommendation that if one uses orthoses for hypermobile flatfoot in children, prefabricated devices are the most appropriate choice.

   When deciding whether to treat flatfoot in a pediatric patient, Dr. Williams takes the patient’s pain level and the biomechanical evaluation into account. He says a child who is experiencing foot pain needs relief via treatment. When a child does not have pain but does have some degree of biomechanical abnormality, he or she may or may not be treated according to the individual evaluation, notes Dr. Williams.

   Evans’ article points out the need for evaluation of the child’s family history of flatfoot and other factors, according to Dr. Williams. Ultimately, he says the decision to treat conservatively, via orthoses and/or shoe gear, should be the primary route for patients without pain.

   Dr. Kirby says low cost options for asymptomatic flatfoot include prefabricated pediatric orthoses or the addition of varus heel and medial arch wedging to the child’s shoes with adhesive felt. He notes these options can be effective alternatives for parents who want their children to be treated but cannot afford the cost of custom foot orthoses.

   Q: Given the article by Davis and co-workers in JAPMA, what are the advantages and disadvantages of “semi-custom” foot orthoses?2

   A: Dr. Scherer notes the Davis study provides some insight into the differences between custom orthoses and prefabricated orthoses that the author called semi-custom because several contours of each shoe size were available. As he explains, the study authors found that during running, the custom orthotic device reduced the excursion of rearfoot eversion more than the semi-custom device.

   As Dr. Kirby points out, in the study, each patient received two pair of orthoses: a typical casted custom orthosis with no special anti-pronation modifications, and a semi-custom orthosis chosen from a library of pre-made orthoses to fit the plantar cast of the foot. Although the two orthoses showed little difference in their kinematic function, one-third of patients preferred the comfort of the custom foot orthosis to the semi-custom orthosis.

    “In my mind, it is unethical and fraudulent for either an orthosis lab or a podiatrist to provide a patient with a pre-made library orthosis without first informing the podiatrist or the patient that they are not receiving a true ‘custom orthosis,’ but are receiving a pre-made orthosis,” asserts Dr. Kirby. “These distinctions in orthosis construction techniques must be understood by all podiatrists so they can make the best informed decisions regarding the quality of foot orthosis therapy for their patients.”

   As Dr. Williams says, the primary advantages for semi-custom devices are cost and the immediacy of usage. However, Dr. Williams notes they generally will not hold up as long or as well in the general treatment population in comparison to custom orthoses. In his experience, custom devices usually offer better fit, more comfort and last longer.

   Dr. Williams notes that the study authors assessed patients without foot discomfort. He would prefer to see a similar study on a population of patients who actually need treatment.

Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College in Oakland, Ca. He is in private practice in Sacramento, Ca.

Dr. Mutschler is in private practice at Advanced Footcare in Miami. He is a member of the American Academy of Podiatric Sports Medicine and is board certified by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. Dr. Mutschler is the team podiatrist for St. Thomas University in Miami.

Dr. Scherer is the Chairperson of the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is also the CEO of ProLab Orthotics/USA.

Dr. Williams is a Diplomate of the American Board of Podiatric Surgery. He is a Fellow and the current President of the American Academy of Podiatric Sports Medicine. Dr. Williams practices in Merrillville, Ind.

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