When providing Chiropractic care for your adult patients, don’t forget to address their children’s needs as well. During growth, the normal development of the pelvis and the spine will suffer if there is a foot imbalance. A budding athlete’s skill level—even running at recess—can be significantly affected.1–4 Later on, foot problems from childhood can interfere with adolescent or adult spinal function, which can result in poor biomechanics and accelerated degenerative changes in the knees, hips and spine. I’ll show you how with quick screening of younger patients you can identify those who need early intervention and could benefit from custom-made functional orthotics.
Screening Exam for Custom Orthotics
This screening exam fits well into standard exam procedures, and can be performed easily on children down to ages 5 or 6. When several red flags are present, you should to discuss the findings and the probable need for orthotics with the parents.
- Observe the child’s gait. By studying a few normal, relaxed paces, several abnormal gait findings can be distinguished. This can be identified by looking at the alignment of the foot with lower leg as your patient walks. An angle that is either less than 5 degrees or greater than 15 degrees is a red flag for excessive rotational torque stresses in the knees, sacroiliac joints and spine.
- Knee to foot alignment. Look at the lower legs of the child from the front. Mentally drop a straight line down from the mid-point of each kneecap to the foot. This imaginary plumb line should strike the foot over the first two metatarsals. If the knees point out or in when the feet are straight ahead, or if there is a value angulation (knock-knees), another red flag is raised.
- Is the Achilles tendon straight? When you see a patient’s heel cord bowing inward (medially), you have a red flag that indicates probable instability of the calcaneus. When the heel does not align with the Achilles tendon, the child will develop into an overpronator, and this biomechanical fault will interfere with knee, hip and spinal function over the decades.
- Check the medial arches. If you cannot get your finger under the medial longitudinal arch, the child is not developing normal arches. While palpating the arch, take a moment to push upwards into the plantar fascia. Even a brief palpation will tell you if the connective tissue that supports the arch is intact, or is under excessive strain. If this is painful to the child, it is possibly the sign of early plantar fasciitis, which is likely to still be at a stage where conservative biomechanical treatment will be very helpful
- Perform a “toe-raise.” If there is a lack of development of the medial arch, ask the child to do a toe raise. By standing up on the toes, the plantar fascia is put under tension, creating a temporary arch in patients with a flexible flat foot. If the foot remains flat (or becomes convex) in this position, it is likely that the child has a rigid flat foot. This is due to an anatomical fixation, such as a tarsal coalition or an equinus foot.
- Check for recurring subluxations. In older children, recurring subluxation patterns can be a sign of instability beginning in the feet. Finding and correcting pelvic and spinal subluxations and fixations is the bread and butter of every practice. Finding the silent, asymptomatic fixations and subluxations of the lower extremities and feet can be a bit more challenging. Special attention must be paid to checking the range of motion of the hips, knees and feet. Muscle testing can also be used to correlate efficient function of the three arches of the feet to the associated lower extremity muscle groups. A non-grade 5 contraction of any of the iliopsoas, gluteus medius-minimus and quadriceps muscles are correlations to aberrant function of the medial, lateral longitudinal and anterior transverse arches. Custom-made orthotics that support the three arches will result in grade 5 muscle tests and provide the balanced symmetrical foundation for the pelvis and spine.
- Look at the shoes. Take a brief moment to inspect the wear pattern on the child’s shoes. Parents may need to be instructed to bring in a worn pair for better analysis. Look to see if there are asymmetrical wear patterns present, either at the heels or in the upper, softer portions of the shoes. Asymmetrical wear patterns indicate biomechanical imbalances that can result in muscular imbalances and ultimately, injuries. The long-term ramifications of structural imbalances are degenerative changes. This simple screening test can have a profound impact on long-term joint preservation.
When are Custom Orthotics Necessary?
Children do not usually need custom-made orthotics until about the age of six years old. If at that point a child is still not developing a normal arch, or if toe-in persists, orthotics may be needed. This is particularly true when the child is involved in athletics and sports activities. In these cases, custom-made support of the arches can significantly improve gait and running performance. Parents will need to be informed of the need to regularly refit the orthotics, as the child’s foot grows.
- Three-dimensional measurement of foot arch in preschool children. Chang HW, Lin CJ, Kuo LC, Tsai MJ, Chieh HF, Su FC. Biomed Eng Online. 2012 Sep 25;11:76.
- A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Evans AM, Rome K. Eur J Phys Rehabil Med. 2011 Mar;47(1):69-89.
- Prevalence of flat foot in preschool-aged children. Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Pediatrics. 2006 Aug;118(2):634-9.
- Is the foot structure of preschool children moderated by gender? Mickle KJ, Steele JR, Munro BJ. J Pediatr Orthop. 2008 Jul-Aug;28(5):593-6. doi: 10.1097/BPO.0b013e318173f782.