Prescribing foot orthoses (FOs), supramalleolar orthoses (SMOs) and ankle foot orthoses (AFOs) for pediatric clients goes beyond what one would typically imagine when they consider the process for most adults. A lot of times you will hear people say, “my feet were hurting, so my doctor recommended I buy some inserts for my shoes,” and for adults they may work as simple as that! However, our pediatric clients are changing everyday, reaching gross motor milestones, becoming functionally independent in their mobility, and keeping up socially with family and friends. So how do we consider all the accompanying components that effect each child's ability to reach these goals? The task may seem daunting to families and even PT’s that have not prescribed many orthoses in their career. This post serves as a guide to help you understand what questions a PT may ask before prescribing orthoses, a few basic types of orthoses that brace the foot and ankle, and a few misconceptions that I hope to disprove!
QUESTIONS TO ASK AS A PT WHEN PRESCRIBING ORTHOSES
What does the child’s foot and ankle positioning look like?
o We want children to grow and develop motor patterns with the most ideal postural alignment that is realistically achievable. Each joint effects the next and this can start with foot contacting the floor or wheelchair. Some items to look for during static positioning include collapse of medial longitudinal arches (flat feet), over pronation or supination of the mid foot or hind foot, and/or carried effects into knee alignment to create genu valgum/varum, hyperextension, or excessive knee flexion. Then watch how this alignment changes when they are moving. Do arches develop in the foot when they raise off their heels or does their knee collapse with each step they take forward? Each child will require evaluation in a team-based atmosphere to create a unique prescription for their functional positioning needs.
Does the child have any pain?
o Pain can be a primary reason that FOs, SMOs, and AFOs are commonly prescribed. Based on a child’s alignment some positions of their feet and ankles can be painful, especially when they are weight bearing or walking. It is important to consider whether this is a pattern of pain associated with mobility and whether or not this improves following orthotic prescription.
Is the child falling frequently and are they able to fully participate in activities with their siblings and peers?
o Children can be clumsy, especially our new walkers. Sometimes when our pediatric clients first start walking they seem like they are falling with every new surface they encounter, which is completely normal. When we ask about frequent falls in our pediatric clients we are determining if this is related to the structural abnormalities or pain. Strength and range of motion can be assessed to determine if they have enough muscular control in their foot and ankle to clear their feet and maintain knee stability when walking or running. Sometimes if a child has excessive laxity from low muscle tone, beyond what one would expect a flexible child to present, they may present with toe drag, frequent inversion or eversion rolling of the ankle, or knee collapse inward or forward. In other situations, a child may have limited mobility in their calves and may be seen walking on their toes or altering steps in other ways to compensate their limited range of motion.
Does the child have a genetic or neuromuscular diagnosis?
o Often times diagnoses associated with abnormal muscular tone, such as Down Syndrome (commonly low tone) or Cerebral Palsy (commonly high tone), may affect musculoskeletal alignment and strength therefore affecting a child’s ability to coordinate functional mobility. Orthoses may provide increased stability in these cases to perform activity. In some neurological diagnoses that cause increased muscle tone or spasticity, orthoses can be used to prevent contracture by holding joints and muscles within a desired range to continue or preserve a stretch or decrease repetitive clonus that can result from foot/ankle positioning. However, just because a child has a diagnosis like those listed above, doesn't necessarily mean that they will NEED orthoses.
Types of Orthoses
How Does it Support?
Mild collapse of the medial arch that may or may not carry into subtalar eversion. The forefoot and hind foot may be effected, but overall positioning can be adjusted by the child or other external source.
Supra Malleolar Orthoses (SMO)
The calcaneus and malleoli (ankle bones) may present with increased eversion (pronation) or inversion (supination) requiring lateral ankle stability in addition to the plantar foot support provided with FOs. In this case a child can have voluntary control in dorsiflexing or plantar flexing the foot.
This allows more dorsiflexion and knee flexion throughout functional mobility while maintaining lateral foot and ankle alignment. However, these orthoses can contain a block that prevents knee hyperextension so that a child’s knees are not excessively locked out and placing strain on muscles and other anatomical structures behind the knee.
The tibia needs more control to limit the amount of dorsiflexion range that is allowed. In this case a child needs to limit excessive ankle mobility, not only laterally but also forward and backward, to prevent knee collapse or walking without a crouched pattern. These can also be used for stronger positioning for patients utilizing a wheelchair daily to promote even foot, knee, and hip alignment and prevent contracture or pressure injury.
Note: For an deeper dive into orthosis selection within each category as well as positioning needs see the Cascade DAFO Guide referenced below.
Families can just buy inserts from the store instead of paying for prescribed orthoses.
This is not true. While some older children may be able to fit into a foot orthotic at your local store, a PT works collaboratively with an orthotist to design, structure, and fit the orthoses to the specific needs of your child. You will not find SMOs sitting on the shelves at your local store, and this ensures that your child does not receive too much or too little support to further inhibit their activity.
If a child has flat feet that means they need orthoses.
Not all children that have flat feet require orthoses. Having flat feet when children are young is expected and can be something they grow out of. Children may not form full arches in their feet until at least 10 years old. Additionally, genetics can play a role in this development. If mom and dad have flat feet, baby may just have them too without concern.
If a child is walking on their toes that means they need orthoses to walk on their heels.
Not always. If a child has been consistently walking for a few weeks/months and is frequently wanting to walk on their toes, consult your physician or local PT for advice. Sometimes early walkers may raise up on their toes to seek stability or because they are trying to reach everything in a world that is a bit too tall for them. Watch to see if they like to alternate going up on their toes in new situations, or if it's when they are walking everywhere.
If a child gets orthoses, they will regress and rely on them too much.
This is not the case. If a child needs orthoses you will see growth in their motor development skills. One research study completed by Surestep SMOs, found that after children received their orthoses the rate of pulling to stand, cruising, and walking increased significantly compared to their previous skill development and compared to peers. The goal is to attain skills they were not previously able to achieve and orthoses can provide a medium in which they do so. However, depending upon the child, diagnosis, and prognosis, a PT will help decide if it is appropriate to continue long term use of foot and ankle support or if a patient can develop enough strength over time to transition into less or no external support.
WRITTEN BY: Sarah Bailey, SPT
- Smith M. Gross Motor Skill Changes of Children with Developmental Delay, Hypotonia, and Pronation Wearing Surestep SMOs. Surestep. Accessed September 23, 2022.
- Kane K, Manns P, Lanovaz J, and Musselman K. Clinical Perspectives and Experiences in the Prescription of Ankle-Foot Orthoses of Children with Cerebral Palsy. Physiotherapy Theory and Practice. 2019;35(2):148-156.
- Choi JY, Hong WH, Suh JS, Han JH, Lee DJ, and Lee YJ. The Long-Term Structural Effect of Orthoses for Pediatric Flexible Flat Foot: A Systematic Review. Foot and Ankle Surgery.2020;26:181-188.
- Kane K. Foot Orthoses for Pediatric Flexible Flatfoot: Evidence and Current Practice Among Canadian Physical Therapists. Pediatric Physical Therapy.2015:53-59.
- The DAFO Guide to brace Selection. Cascade DAFO.https://daniz53y71u1s.cloudfront.net/documents/dafo_guide_web-v15.pdf. Accessed September 23,2022.