Emerging Insights On Orthotic Prescriptions And Modifications
Our expert panelists discuss current approaches to orthotic management of pediatric flatfoot, whether functional orthoses can have an impact for hallux abducto valgus and when to employ orthotic modifications in rigid and semi-rigid devices.
Given some of the most recent literature concerning pediatric flatfoot, what is your opinion about using prefabricated or custom orthoses for patients under the age of 10?
As Cherri Choate, DPM, notes, there is ongoing controversy over the approach to flatfoot in this patient population. As the incidence of pediatric obesity rises, she says studies are exploring the incidence of flat feet and other pediatric lower extremity problems in both overweight and obese children. Two different studies found that children with flatter feet have increased plantar pressure and poor performance in physical task completion.1,2
Dr. Choate says the concern is that these early clinical findings may lead to more severe physical pathology as the children become adults. She notes a paucity of studies showing that orthotics, whether prefabricated or custom, have any negative effect on the growing foot.
When treating the pre-adolescent patient, Alona Kashanian, DPM, always evaluates the pathology of the flatfoot deformity along with the symptomatic pathology and parental concern. She recommends a prefabricated orthosis for a patient with a calcaneal eversion of less than 5 degrees and mild abduction of the forefoot to rearfoot relationship during stance. If the parents relate infrequent falling, stumbling and fatigue, Dr. Kashanian considers a prefabricated orthosis. In addition, she “highly recommends” custom orthoses for pre-adolescent patients who have calcaneal eversion of 10 degrees or higher, and a moderate to severe forefoot to rearfoot abduction with soft tissue adaptation.
Dr. Choate prescribes prefabricated orthotics with a deep heel cup and wide plate for children up to the age of 14 to 16 as long as their clinical findings are mild to moderate. Once the child stops growing, she would likely have a custom device fabricated. She says one may also employ custom orthotics when the child’s foot does not fit a prefabricated device, or if he or she is involved in a specific sport that has unique demands for shoe fit or performance.
Daisy Sundstrom, DPM, uses Kiddythotics (ProLab Orthotics) for quite a few patients up to age 4. She says these devices have several advantages including rigidity and width, a deep heel cup and flat posting for better control. At age 4, when children begin to develop a heel to toe gait, Dr. Sundstrom will use the Kiddythotic or a custom device. She notes that both her daughters have pediatric flatfoot with excessive subtalar joint (STJ) pronation and both have benefited from using Kiddythotics, starting at the age of 2.
For symptomatic children with a mild to moderate deformity, Dr. Sundstrom first tries using a Kiddythotic or prefabricated device. She checks the fit while the patient is non-weightbearing and then checks the amount of correction at the STJ, metatarsal joints and the medial longitudinal arch with patients standing. If prefab devices do not fit properly or do not obtain enough correction, Dr. Sundstrom prescribes a custom orthotic with more aggressive pronation control for a more severe deformity.