When Are Orthoses Appropriate?

Children of various medical backgrounds and history may be appropriate candidates for orthotic devices. Many varieties are available based on necessity and presentation of the child. The most common types seen with children are supramalleolar orthosis (SMO) or dynamic ankle foot orthosis (DAFO). Both are designed to fit into a shoe. The SMO comes up just over the anklebone. The DAFO may vary in design but usually comes up over the calf with a Velcro strap that wraps around the lower leg. They are not meant to “hold” the foot in a proper position but rather more flexible models use compression to enhance proprioception, engaging more ankle strategies used in balance and locomotion.  

Arches in the feet are flat in a baby and toddler.  Studies are inconclusive in comparison as to what average age the arch matures. Some report 4-5 years old, however another states 6-7 years old or even as old as 10 or 11. Arch appearance alone may not indicate if an orthosis is necessary. Poor alignment may justify orthoses. Poor alignment moves from the feet, to the ankles, to the knees, to the hips, etc.  Children may often present with clumsiness or frequent loss of balance. Physical characteristics will vary from mild to very involved.  First note the position of the ankle. The ankle may roll inward and the knees may drop in and possibly touch. The Achilles tendon should appear straight up and down, without slanting. Toes work to gain feedback for balance with intermittent gripping. Excessive or nonexistent toe gripping is not present in a normally aligned foot. In addition toes should be straight and not drift outward. Asymmetry in the feet, ankles, or legs, especially muscle girth, is also an indicator.

Orthoses can be appropriate prior to walking. One study found significant improvements in crawling, kneeling, standing, walking/running, and jumping skills. The orthoses help to create a stable base of support. For children with low muscle tone, the earlier they begin wearing orthoses, the better. For those children with high muscle tone, their functional abilities are indicative of when orthoses would be appropriate. They may have a range of motion issue and the orthoses can help promote maintaining that range. One study found just a small amount of support of the foot improved stride length and early use promoted better gait quality and skill emergence in children with Down Syndrome. Another study using a similar population found overall improvements in postural stability as well as improvement in less complex skills over a long duration.

Michelle Maynard, DPT   References:
  1. Bjornson KF, Schmale GA, Adamczyk-Foster A, McLaughlin J. The Effect of Dynamic Ankle Foot Orthoses on Function in Children with Cerebral Palsy Journal of Pediatric Orthotics 26:6 773-776 (2006)
  2. George D and Elchert L. The Influence of Foot Orthoses on the Function of a child with Developmental Delay Pediatric Physical Therapy 19:322-336 (2007).
  3. Cooper FE, Ulrich DA. The Effects of Foot Orthoses on Gait in New Walkers with Down Syndrome Pediatric Physical Therapy 18:1 96-97 (2006).
  4. Martin K. Effects of Supramalleolar Orthoses on Postural Stability in Children with Down Syndrome Developmental Medicine and Child Neurology 46:406-411 (2004).
  5. Striker RS. Arch Development in Children: When are Orthotics Necessary? www.chiroviewpresents.org/article_files/Article-1767.pdfAccessed 8/11/11.
  6. Onodera AN, Sacco K, Morioka EH, Souza PS, de Sa MR, Amadio AC. What is Best Method for Child Longitundinal  Plantar Arch Assessment and When Does Arch Maturation Occur?  Foot 2008 Sept. 18(3):142-9. Epub 2008 May 19.
  7. Interview with Robert Chacon, Anacapa Orthotics and Prosthetics. July 2011.
   

What is Normal Gait?

Many changes occur throughout the lower extremities as a child begins to develop and walk. What is the normal progression?
  • One Year of Age: Begin walking with a wide base of support, knees face forward and flexed or may be slightly externally rotated (until age 5 or 6). The hips are abducted and externally rotated. The pelvis is anteriorly tilted, feet appear flat (until age 3 to 5), and the arms are held in “high guard.”
  • 18 months of age: Reciprocal arm swing emerges and the base of support begins to narrow. A heel strike becomes more consistent.
  • Two Years of Age: The pelvic tilt decreases, as well as abduction and external rotation at the hip. Increased knee flexion is still present.
  • Three Years of Age: The base of support begins to look more mature. They continue to demonstrate increased knee flexion and anterior pelvic tilt.
Possible causes for concern:
  • Toe Walking: Occurs when a child walks on their toes and is more prevalent in boys than girls. There is often no cause for toe walking and it can resolve itself during childhood. Tight gastrocnemius muscles may be a cause, in which a stretching program is indicated. Serial casting and dynamic splints may be necessary, but surgery is rare.
  • Intoeing: Walking with the toes turned inward can be caused by various conditions including: Femoral anteverison: an internal rotation of the hip causing the feet to appear to be turned inward. Ligament laxity in the hips is often a cause as well as the tendency of a child to “W” sit. Children who prefer to “W” sit often have difficulty sitting cross-legged. Stretching the internal rotator muscles of the hips and avoiding a “W” sit position will help to decrease femoral anteversion. The condition often resolves itself between 7-9 years of age. Internal Tibial Torsion: an internal twist of the tibia. It is normal in newborns but can often be seen in children who are walking. It may resolve itself by 4-6 years old. Metarsus Adductus: a problem that occurs in the foot. It is characterized by a curve of the forefoot, or toes, inward. It may be rigid or flexible. Stretching can be used if the foot is flexible. For rigid feet, reverse last shoes, or serial casting may be used. Surgery may be necessary for rigid metatarsus adductus.
  • Outtoeing: May be caused by increased tightness of the hip external rotators, in which case the problem resolves itself. In other cases it may be due to femoral retroversion characterized by outward facing patella. It may also occur in the lower leg caused by external tibial torsion, which often resolves by 2-3 years of age.
  • Bowlegs (Genu Varus): Bowlegs is normal in a young infant and should correct itself by the age of two as increased weight bearing and walking occur. If it does not correct, surgery or bracing may be necessary.
  • Knock Knees (Genu Valgus): Common at 2-6 years of age. Should resolve by age 7 as a more mature gait pattern emerges.
Review submitted by: Michelle Maynard, DPT References:
  1. Keen, Mary MD, Early Development and Attainment of Mature Gait; American Academy of Orthotists and Prosthetists; Journal of Prosthetics and Orthotics 1993;5:35-38.
  2. Valmassy, RL, How to Recognize Pediatric Gait Abnormalities; Podiatry Today; 2002;15.
  3. www.pediatric-orthopedics.com/topics/in-out-toe/in-out-toe.html. Accessed 4/26/09.
  4. Bellett PS, The Diagnostic Approach to Symptoms and Signs in Pediatrics. Lippincott Williams & Wilkins, 2006.