Ensuring Orthotic Efficacy For Adults And Children

Guest Clinical Editor: Joseph D'Amico, DPM

   In contrast, Dr. Jordan says it is inappropriate simply to have the child stand barefoot and then stand on the orthoses to attempt comparative RCSP. He says one should view the hip-knee-ankle-foot alignment as an expression of how well the orthosis reduces undesired compensation. Whether the pediatric patient is symptomatic with night pains, muscle spasms, dynamic toe walking or has a clinical appearance of “flat feet,” Dr. Jordan says an altered alignment of the hip-knee-foot functional coupling may be a significant reflection of the devices’ efficacy. He cites the example of positive change of the “Q-angle” in athletes as well as in children.

   Dr. Valmassy asks patients to bring the shoes they have worn three to four times with the orthotic device in place from the time of dispensing to the time of the two-week follow-up visit. He will evaluate the patient with and without the device in place to determine if the patient is achieving the anticipated result. Dr. Valmassy also looks for reduction of both abnormal pronation and abnormal supination. Finally, he assesses the patient’s overall stature and posture, noting that a functional foot orthosis would generally improve overall posture.

   Using digital camera technology and common software, Dr. Jordan says one can embed printed images into the child’s medical report for immediate and later comparison following skeletal growth. He immediately shows comparisons to parents and integrates them in a report to the pediatrician. When Dr. Jordan needs to observe reduced compensations in the more mature, walking child, he uses pocket digital video cameras. Similarly, computer aided objective gait analysis is also very effective at documenting changes in foot function after prescribing an orthosis, notes Dr. Volpe.

   Furthermore, Dr. Valmassy assesses the distal margin of the orthotic device. If there is a significant impression in the inner sole of the shoe along the distal medial margin of the orthotic device, he suspects the device is not controlling patients well and they are pronating through the device. Dr. Valmassy assesses the effect of the softness or firmness of the inner sole. If the device does not seem to be controlling the patient well, he will typically add a forefoot varus post to increase the surface area supination.


How do you determine when you need to replace an orthotic?


Replacement of the orthoses may be essential, notes Dr. Jordan, due to outgrowth where the plantar contours no longer match the contours of the child’s own foot. He notes a change in width at the navicular or base of the fifth metatarsal requires modification or adjustment, not replacement. One should assess the youngster every six to eight months regardless of the rate of skeletal growth, suggests Dr. Jordan. Even without significant growth of the foot, he says one generally needs to modify the plantar posting in association with the soft tissue and skeletal changes of a growing, maturing child.

   In regard to the pediatric patient, Dr. Valmassy informs the patient’s parents that he typically will replace the device every two to three years or every two to three shoe size changes. He notes the orthotic device is normally effective up to the point where it reaches the midshaft portion of the metatarsal. When the device becomes uncomfortable or blisters occur or where hyperkeratotic areas become more pronounced, he advises replacing the orthotic device.

   Dr. Volpe determines replacement by how the device fits. In a growing child, he says one will have to replace the device once it is too small. Dr. Volpe sees all his orthosis patients at maximum intervals of six months to make that assessment. In adults, he notes signs of wear on the device will lead to recommendations for refurbishment or replacement.

   If measurements indicate a loss of effectiveness of the device, Dr. Volpe will also recommend either a retooling or a new device. Finally, he says signs that indicate replacement include shell fatigue and any return of symptoms that were previously managed successfully with the device.

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