Inside Insights On Common Orthotic Dilemmas

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Author(s): 
Ronald Valmassy, DPM

   Dr. D’Amico subscribes to a basic orthopedic tenet for the correction of pediatric musculoskeletal deficiencies: the earlier one institutes treatment, the more favorable the prognosis. He says early intervention in the developmentally challenged foot leads to bony remodeling to more normal alignment or structure, according to Davis’ law of soft tissue and Wolff’s law of bone.1
Q: Have you ever discontinued orthotic treatment in a pediatric patient or are these patients “patients for life”?

   A: Before he stops orthotic therapy, Dr. D’Amico says children must meet the following criteria:

   • absence of visible pronation;
   • absence of symptomatology;
   • realignment of lower extremity osseous and soft tissue structures;
   • normal lower extremity function (i.e. first ray stability, active propulsion);
   • normal center of gravity and center of vertical force pathways;
   • normal postural complex including upper extremity skeletal alignment; and/or
   • complete skeletal growth.

   Dr. Burns cautions parents that a pronated foot may need lifelong treatment. He tells parents it is their responsibility to allow adequate control while the child is growing. Then they can decide for themselves about symptomatic treatment after bone growth is complete.

   In Dr. Burns’ experience, 10 to 15 percent of children with excessive pronation develop fairly normal foot function without midstance instability before bone growth is complete and he discontinues orthotics for those youngsters. He usually sees those patients a couple of times over the next several months to confirm that their feet remain stable.

    “It is difficult to say whether they might have developed ‘normal function’ without orthotic treatment,” notes Dr. Burns.

   Dr. Levine sometimes discontinues orthotic therapy in this patient population but not always intentionally. As he explains, if patients outgrow devices, they may be lost to follow-up. However, Dr. Levine says symptoms also may resolve, particularly if patients have growth-related issues. He adds that monitoring and follow-up can help the decision process.

Dr. Burns is the CEO of Burns Lab. He is a Fellow of the American Academy of Podiatric Sports Medicine and a Fellow of the American College of Foot and Ankle Surgeons. Dr. Burns is a Diplomate of the American Board of Podiatric Surgery.

Dr. D’Amico is a Fellow of the American Academy of Podiatric Sports Medicine. He is in private practice in New York City.

Dr. Levine is in private practice and is the the director and owner of Physician’s Footwear, an accredited pedorthic facility, and Walkright, a shoe store, in Frederick, Md. He is a Fellow of the American Academy of Podiatric Sports Medicine and a member of the American Society of Podiatric Surgeons.

Dr. Valmassy is a Past Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco.




References:

1. D’Amico JC. Developmental flatfoot. In Volpe RL (ed.): Introduction to podopediatrics. Churchill Livingstone, New York, 2001, pp. 257-73.

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