Pedorthic Treatment of Pediatric Foot Problems
March 2014 Issue
Years ago, the use of children's orthopedic shoes was a well-established, medically accepted, and oft-prescribed solution to pediatric foot problems. Each year, pedorthists and orthotists measured for, fitted, and dispensed thousands of straight-last and outflare shoes with modifications like Thomas heels, wedges, and torque heels, as well as orthopedic contraptions like Denis Browne splints. It was big business. So...what happened?
In the 1980s and early 1990s, several journal articles were published-many by noted pediatric orthopedic surgeon, Lynn Staheli, MD-aggressively decrying the very beneficial virtues of footwear and orthotic therapy for pediatric foot conditions that the medical community had espoused for decades. One such article even went so far as to declare, "[T]he term 'corrective shoes' is a misnomer, [and] [p]hysicians should avoid and discourage the commercialization and 'media'-ization of footwear. Merchandising of the 'corrective shoe' is harmful to the child, expensive for the family, and a discredit to the medical profession."1 Other studies indicated that the majority of children would outgrow common foot disorders, such as pes planus.
The conclusions and recommendations of these studies were eagerly embraced by a great number of physicians who had previously prescribed corrective shoes for their pediatric foot patients. Conceding the idea that many children's foot problems do indeed resolve as the foot continues to develop, the fact remained that there was little to no evidence presented that one could predict which children would outgrow their conditions or deformities and which would not, and could therefore benefit from corrective footwear. In less than a decade, the niche market for children's corrective shoes in the United States virtually disappeared. Many formerly profitable and long-respected manufacturers were forced out of business as the market dried up.
This transition occurred almost simultaneously with the shift in the athletic shoe industry wherein athletic shoes ceased being viewed as sports equipment and, instead, became fashionable for everyday wear by young and old alike. Once it became popular for children to wear sneakers everywhere but to church, the stigma attached to wearing oxfords or surgical-opening shoes grew and effectively put the final nail in the coffin of the era of pediatric corrective footwear. I, for one, hope to see the pediatric corrective shoe market rise from the dead.
As a practical matter, the most common application of pediatric corrective shoes used today is seen in the recent revival of the Denis Browne bar with straight-last or outflare shoes. Traditionally, these devices were used to maintain foot and ankle alignment after surgical correction of a congenital clubfoot deformity. This method is regaining popularity as the Ponseti Method, which was developed by Ignacio V. Ponseti, MD, of the University of Iowa, Iowa City, in the 1950s and is being promoted in the United States, Europe, and Africa. In the United States and Europe it is being promoted by John Herzenberg, MD, director of pediatric orthopedics at Sinai Hospital, Baltimore, Maryland, and director of Sinai's International Center for Limb Lengthening; and in Africa by consultant orthopedic surgeon Steve Mannion, MA, Mchir, DTM&H, DMCC, FRCS (Tr & Orth) with Blackpool, Fylde and Wyre Hospitals National Health Service (NHS) Foundation Trust and with Spire Fylde Coast Hospital, based in London, England. As this trend continues to regain traction within the orthopedic community, these devices may be your proverbial foot in the door to providing traditional corrective footwear for children.
The Ponseti Method involves a series of nonoperative manipulations of the hindfoot and forefoot followed by corrective serial casting. Following the manipulation and casting phase, the feet are fitted with open-toe, straight-laced shoes attached to a Denis Browne bar (Figure 1). The affected foot is abducted to 70 degrees with the unaffected foot set at 45 degrees of abduction. The shoes are then worn 23 hours a day for three months. After that, they are worn at night and during naps for as long as three years.
The Ponseti Method of treatment is typically begun within weeks of the child's birth since the tendons and ligaments are at their most elastic and correction occurs most easily, but it has been used successfully on children up to age six.
I believe that use of other corrective shoes has not resurged in modern day pedorthics, mainly because we cannot predict which children will outgrow their foot problems and which will not. Even if, as some studies suggest, 80-85 percent of these conditions self-correct, there is still one in five that will not.
In discussing children's corrective footwear, there are several last types: regular, straight, equilateral or axial, and outflare or inflare (Figure 2). Depending on the desired outcome, the different last shapes are used to accommodate deformity and to developmentally correct deformities by repositioning the foot, redirecting weight bearing, and exerting applied forces to different parts of the foot to influence growth. The shoes themselves can be oxfords, high-tops, boots, depth shoes, or open-toe shoes.
If a child is flat-footed or walks with the forefoot abducted, then an inflare-last shoe can be used to straighten out the foot. These shoes are quite stiff and supportive, and typically incorporate a Thomas heel, a long medial counter, and may have medial heel wedges. It is believed that congenital pronation is most effectively treated between the ages of two and five years.
Conversely, if the child is pigeon-toed, a reverse-last, also called an outflare shoe with a reverse Thomas heel and a lateral wedge under the forefoot can be used to correct the foot positioning. If a shoe is designated as an outflare shoe, that means that the front of each shoe swings outward. The purpose of this swing is to hold the forefoot in abduction and turn the foot outward. When properly fitted, an outflare shoe should enable a toed-in child to walk straight-or straighter-almost immediately without painful or deforming pressure on any part of the foot.
If the in-toeing is only mild, a simple straight-last shoe with no additional wedging may be adequate. In these cases, normal children's athletic shoes, many of which have a slight inflare to the last, will do nothing to encourage the foot to correct itself, and sometimes they can actually aggravate the symptoms. In contrast, since a straight-last shoe has no inflare at all, it cannot induce in-toeing and can help minimize it. When the child's forefoot has a tendency to turn inward into varus, it will be restrained by the contour of the inner border of the straightlast shoe. When the forefoot is held in a straighter position, the child is more likely to walk straighter and with a more normal gait. Although the straight-last shoe has no outflare, its effect on a varus foot is very similar to that of a mildly outflared shoe.
The cosmetic appearance of pediatric corrective footwear has improved by leaps and bounds in recent years. The remaining manufacturers and distributors of children's corrective footwear offer many styles of inflare, outflare, and straight-last shoes that look remarkably "normal," including sneakers and Mary Janes and even lug-soled, leather hiking boots that look just like the adult versions the child's parents might wear. There are a great many pediatric foot conditions that may be treated pedorthically without the use of any "orthopedic" shoes, for instance, Sever's disease. This condition is characterized by inflammation within the apophysis of the calcaneal growth plate that is believed to be caused by repetitive microtrauma from the mechanical pull of the Achilles tendon on the apophysis. But it is not a difficult condition to treat effectively with pedorthic modalities. A well-constructed custom foot orthosis with good medial longitudinal arch support to reduce pronation, a slight heel lift to decrease the pull of the Achilles tendon, and the incorporation of a viscoelastic polymer under the heel to attenuate shock to the calcaneus on heel strike will often do the job in short order.
The same device described above for Sever's disease will also work quite well for shin splints, an inflammation in the periosteum of the tibia. The shock absorption and attenuation provided by the viscoelastic polymer under the heels significantly reduces the amount of shock translated to the tibia.
Like so much of what we do as pedorthists, orthotists, and prosthetists, treating pediatric foot problems is a very rewarding and gratifying endeavor.
Dennis Janisse, CPed, is president and CEO of National Pedorthic Services, headquartered in Milwaukee, Wisconsin. He also is a clinical assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee, adjunct professor at University of Pittsburgh, Pennsylvania, and director of scientific affairs for Orthofeet, Northvale, New Jersey.
- Staheli, L.T. 1991. Shoes for children: A review. Pediatrics 88 (2):371-5.