Pediatric Lower Extremity Orthoses

• Patty Navarro McGee, PT, DPT, PCS prepared the content about pediatric orthoses for the lower extremity.
• The terms "orthosis," "splint," and "brace" are often used interchangeably.
• PTs often use the term "splint" because historically the fabrication and billing for "orthoses" and "braces" has been exclusive to licensed orthotists, though PTs have been allowed to work on "splints."
• Use the proper terminology when referring to specific orthoses, such as SMO or AFO
• The Foundations of Pediatric Orthoses Fact Sheet by the APTA Academy of Pediatric Physical Therapy covers UE and trunk orthoses, as well as LE orthoses.

Normal Alignment and Gait Development

• Awareness of normal alignment and gait development is needed when deciding on orthoses for a child
• Human biomechanical development through childhood may be reviewed in Canvas

Wolff's Law

• Wolff’s law states skeletal architecture adapts to its history of mechanical usage
• Bones are most cartilaginous during the first year of life which means they are able to model under strain by the forces of a brace for example
• Skeletal maturity occurs by age 7, bones of the foot ossify, which means skeletal changes are possible with early LE impairments detected in children.
• After the age of 7, there are either compensating for a fixed deformity or attempting to make soft tissue changes.
• Babies and young children model, while older children and adults can only remodel.

Deviations from Normal Alignment

• Deviations from normal alignment can occur either prenatally or postnatally.

Prenatal deviations:

• Chromosomal/genetic anomaly (e.g., idiopathic clubfoot, arthrogryposis)
• Abnormal muscle tone
• Breech positioning leads to increased forces on the LEs
• Oligohydramnios is low amniotic fluid, leading to decreased movement in utero that can cause joint restriction and contracture.
• Multiple gestation results in decreased space for movement.

Postnatal deviations:

• Influence of gravity
• Muscle imbalance/relative stiffness issues
• Weight bearing patterns change abnormal alignment based on the forces up the chain
• Prolonged maladaptive positions or movement patterns, such as "W" sitting

"W" Sitting

• W sitting is a short kneeling variation where the child places their bottom on the floor with their feet to either side vs sitting directly on top of them.
• Hips are at end-range medial rotation.
• The tibiofemoral joint position could be relatively medial or lateral rotation.

Long-term implications of "W" sitting:

• Persistent genu valgum where typically children demonstrate genu varum until 18 months, then genu valgum (peak at 3 years) until 6-7 later
• Children in-toeing may show regardless, the in-toeing is more significant with feet turned inward, so it is commonly asked if a child W sits, if they are referred for in-toeing
• Laxity of the tibiofemoral joint with feet turned outward forces it into lateral rotation relative to the femur, this give more excursion at the knee vs feet inward which makes the tibiofemoral joint in a more neutral position
• Unresolved femoral antetorsion happens as infants are born with femoral antetorsion; and extend laterally rotating the hip causes gradual de-rotation.

How to have kids sit:

• Correct to criss-cross apple sauce
• Get them off the floor and in age-appropriate seating with activities

Valmassy's Formula

• Used to determine relaxed calcaneal stance, since hypotonia and pronation are common diagnoses for orthoses
• Determines if a child under 7 has excessive calcaneal valgus in stance, i.e. "relaxed calcaneal stance."
• Normal relaxed calcaneal stance (degrees) = 7 – child’s age (years). For a 3-year-old it’s 4 degrees

Preventative Bracing

• Strengthening what's weak
• Lengthening what's short and/or stiff
• Promoting good alignment
• Educating the caregivers
• Initiate weight bearing at adjusted age, 10-12 months, as missing the window for skeletal modeling and bone mineralization will lead to having to use external support, bracing etc.

Factors to consider when deciding to brace.

• Age is critical as bracing is more effective younger.

• A child’s weight will determine necessary plastic thickness.

• Activity level determines need for sophisticated materials.

• Consider current and future motor skills, so as to not prohibit motor skill development

• Know impairment onset & duration to decide a remediation or compensation approach

• PROM and AROM measurements must also document R1 and R2 when spasticity is present.

• Strength of the "Knee Lockers" must be assessed, which has quads, glutes and soleus

• Gait analysis without software or cameras is explanatory enough

• Planes of motion affected should consider sagittal plane for toe walks, and frontal plane for pronation.

Goals of Orthotic Intervention

• Depend on ambulation status for weight bearing and non-weight bearing

Weight bearing orthoses

• Includes ambulatory & non-ambulatory children
• Stance-phase stability is needed
• Correct foot position and improve base of support.
• Adequate foot clearance on the swing limb
• Appropriate pre-positioning of the foot in terminal swing (i.e., heel strike)
• Adequate step length
• Decrease energy expenditure

Non-Weight Bearing Orthoses

• Includes infants not appropriate for standing and children unable to WB. Age-appropriate resting alignment is needed.
• Allowance for normal movement of environment is appropriate.
• Try to achieve muscle balance, stretching/inhibition of what is short/overactive, shortening of what is long/overstretched

Bracing Challenges

Common challenges when bracing: Abnormal muscle tone from spasticity, rigidity, dystonia, and hypotonia Joint contractures such as arthrogryposis multiplex congenita (AMC) and club foot. Bony deformities which cannot be remediated without surgical intervention. Examples: vertical talus deformity which manifests as severe hindfoot eversion and hypoplastic long bones. Muscle imbalances and relative stiffness issues such as "premature foot" Apraxia and impaired motor planning which gives stability and proprioception. Impaired cognition from decreased understand, so caregiver involvement is critical.

Three Questions to ask when Selecting an Orthosis

• What planes of motion are involved and need to be addressed?
• What impairments in stance phase need to be addressed?
• What impairments in swing phase need to be addressed?

Ideal Weight Bearing Alignment

• Try to achieve ideal weight bearing alignment by building up the plantar surface of the orthosis in specific areas to affect the alignment during stance
• Different posting can change a child's gait pattern.

Excessive pronation in stance

• Assuming the child has normal ROM and fully correctable static alignment
• Using *Medial Hindfoot and Medial Forefoot varus posting will shift the weight towards the lateral border of the foot, thus distributing the pressure more normally during stance

Knee hyperextension PROM

• Assuming child has 5° and presents genu recurvatum during gait, and has plenty of DF PROM, while muscle tone and strength are WNL
• Heel posting can ONLY exacerbate it
• It helps increase quadriceps activation and decreases dynamic genu recurvatum, provided caution is provided

Shoes

• Shoe fitting gives good pointers on shopping
• Cascadedafo.com gives many shoe tips and links to vendors for orthoses and braces.

Education Points

• Wearing schedule should start with two hours then add two hours each day Goal-dependent:
• Infants can have alternate on/off in q3-4 hrs
• Weight bearing is daytime while to make changes Daytime/Nightime stretching with straps
• Skin Precautions: Make sure the heel is seated all the way down and it is seated all the way down in the orthosis. Check for redness over bone points, and malleoli joints etc. Darker skin means redness is not visible Redness lasting over 20 mins mean its bad.
• Orthosis Care: Low temperatures can warp, like hot sun or dish washers! Use soapy washcloths for cleaning
• Growth: If snugs, you can stretch If too short, you can move padded areas. Redness can mean a new sole is needed for new sizes.
• Refer to a Dr for new growth etc

Recommended follow-up to consider

• 0-6 months monthly
• 6-12 months every 1-2 months
• 1-2 years every 3-5 months
• 2-3 years every 4-6 months

• 3 years every 6-12 months for wear

Pressure Areas

Malleoli and bases are the main points to check. Try not to touch the padding or structures or it might get worse Add anterior strapping. ST and midfoot supports Consult a Dr if no changes

Lower Leg Orthoses styles

• Plantar Orthoses
• UCBLs
• SMOs
• Hinged/Articulating AFOs
• Ground Reaction AFOs
• Solid Ankle AFOs

Terminologies are "Static & Dynamic" vs "Hinged & Solid",

• You will be shown the planes and movements to try to aid decisions
• Be shown OTS(off shelf) vs custom decision.
• In peds, the age of the foot aid is a big factor as they will outgrow it! Some people's feet will not go well with certain foot types

Plantar Orthoses/Foot Orthoses: Planes of Control

• Frontal: Minimal subtalar joint can be focused in support, support under ST
• Sagittal: Is not controllable! Mods include footplate to toe (carbon fibre), out toe can be modified for posting
• Traverse: no control!

Plantar Orthoses: Indications are

• Mild pronations and supinations
• Hyptonias
• Toe walking if ROM WNL
• Mild intoe or toeing out

UCBLs

• University of Califronia, Berkley lab, which basically helps between P and SUPS-OS
• Covers the navicular front to give more frontal planes

UCBLs: Planes

• Frontal is heel cupping, resistance against navi in stance, so medial/inf movements.
• Sagittal: Negligible
• Traverse Minimals, moderate control if sidewalls

Indications

Mild to mdoerate supination Hypotonia, e.g downs mild in and toeing Low pro

SMOs

Supports the Mid-Lateral foot through traverse planes Moderate to low Ext toe out by supporting front

indications

Hyoptonia Low toe walking if WNL Low Moderate/Toe out Sensory and ankle modulation

AFO hinged can variably control, such as no knee joint to modeate, all depends

AFO indicaitons is free and can

• Inos cons ankle and med lat whips
• resist sever toe
• DF and Shortness of CM

Sag Pattern

True is better

GRAFO for crouch

Variable high strong control High DF Rare PF

Indication for Crouch

Hyptonia if Knee Can bend and correct df

Solid angle

• It is just a peice of AFO You can mod ify with AFO

Indication is all Sign hyptoricity, FLACCIO paralysis and Early walk Non amb and P PP

Solid ag

The knee and foot is a combo.

Solid A FOF pat

App are true

SOme AFO mods

Remove the strap or alter