Custom-Molded Versus Prefabricated Orthotics for Children: Which Is Superior?

Custom-molded.

This author recommends that clinicians consider the potential deformity-specific benefits of custom devices, along with thinking about the long-term effects over one’s development.

By Nicholas Pagano, DPM, FACFAS, FACFAP

I contend that custom-molded orthotics should be the standard of care for your pediatric population when managing and preventing foot pathology. When a patient presents to your office with an issue, it is imperative that one is aware of all previous treatment options utilized, any familial history of pathology, and the patients’ (and parents’) expectations for results.

While prefabricated orthotics offer the benefits of in-office immediate dispensing and direct delivery of a care plan at the time of visit, I believe that a custom-molded orthotic provides the optimal treatment, especially in the pediatric population.

The pediatric population is a special one. If a parent takes the time to bring their child into your office, as a physician, I feel that you need to offer custom-molded orthotics as a superior option. By the time they have come to that appointment, they have already researched on the internet a litany of treatment options, perhaps stood on a kiosk in the local pharmacy, gotten “influencer” opinions from social media, and ultimately, made the decision to see you for medical intervention.

You should offer what sets podiatrists apart. That is our expertise in lower extremity pathology recognition and biomechanical awareness, treated with custom-molded orthotics.

There are multiple advantages of customization in an orthotic when compared to a prefabricated device. While I do note that the prefabricated devices available today offer excellent predetermined formats that can be helpful with a wide range of concerns, one can use a custom-molded orthotic to directly address the individual patient’s pathology.

When a pediatric patient comes in with significant pathology, a custom device is better able to directly address the patient’s needs as patients develop. Certain pathologies will improve with growth, for example: Sever’s disease presents acutely during a finite developmental period, which on average can last 2.5 years.¹ Recognition of pronatory effects, foot position, and hindfoot issues are all components one can address with the appropriate postings in the rearfoot and forefoot, as well as in the medial and lateral arches.

If a patient presents to your office with metatarsus adductus, in my experience, utilizing a gait plate modification is only enhanced with a custom device. It is important to capture the rearfoot properly with your personal casting methods (digital or direct application of molds) with the foot in a weight-bearing position to prevent the intoeing position pivoting from the lower and upper leg in the child’s gait. The rearfoot position changes with every year of a child’s life until the age of 7, when they take on their adult foot type.²

When a patient presents with a flatfoot pathology and there is a significant familial history, being able to create a unique balance of biomechanical control and guidance with the individual’s foot in the custom position could lead to avoidance of pathology. I find that the child will benefit, and that the parents will easily appreciate those benefits from their own experience, or recognize what they may have lacked in their own lifetime. (Me and my 45-year-old knees wish they had known!)

Specific Instances Suited to Custom-Molded Orthotics for Children

In my experience, various pathologies are also best addressed with a custom device. I find that cavus foot type is best addressed with a rearfoot position vertical to the ground with appropriate medial and lateral support. Also, using a metatarsal cutout can be beneficial in these cases if the pathology is more anterior based on Coleman Block Testing.³

Other pathologies requiring care like a limb length discrepancy, whether structural or functional, can benefit the developing child after appropriate physical workup and studies to create an even mechanical balance and prevent upper chain pathology. I feel that custom orthotics are a key intervention in these cases.

Juvenile bunions are a common presentation to my office. In a surgical practice, there are typically limitations in surgical intervention options due to the developing foot up until the age of 14–16 in females and up to 18 in male patients. While surgery may be in the patient’s future, to optimize prevention and to slow or stop deformity progression, a full-width UCBL-style orthotic is very often beneficial. In my experience, this can delay or even prevent the need for later surgical intervention.

In my geographic area, there is a significant presence of sports specialization at a very young age. This comes along with a very proactive and eager parental desire to optimize the child’s performance. To aid in injury prevention, biomechanical considerations need to be a part of your care. One must consider that custom orthotics can also be a part of addressing the built-in overuse injuries due to repetitious single sports.

Orthoses may also allow these children to continue to train and compete. Right or wrong, in my observation, this situation is quickly becoming the norm. When a patient presents with a sports injury, (such as apophysitis, tenosynovitis, and stress fractures), recognition of pathology, if it is not achieved through microtrauma, allows us to address any biomechanical failures leading to the injury. Thus, addressing the underlying mechanical issues with custom devices could potentially lead to better performance and prevention of injury.  

While the financial aspects related to custom-molded orthotics are a necessary discussion, the advantages outweigh the disadvantages from a financial standpoint, and parents should be made aware. The financial impact of the specialization and participation in club sports by far outweighs the cost of custom devices, I find.

In Conclusion

In the long run, the overall health of, and treatment results for, your patient may improve substantially by employing your specialty in custom-molded orthotics. As a physician and father, I can only see the clear benefits of custom-molded orthotics over prefabricated devices. While children may grow out of the orthotics rapidly, continuing to keep this child population in the best option for their care should remain our goal. The world is ever-changing and ever-growing, especially in our pediatric population. Our paradigms for care should change and grow, as well.

Dr. Pagano is in private practice at Barking Dogs Foot and Ankle Care in Plymouth Meeting, PA. He is course director of Pediatric Foot and Ankle Orthopedics at Temple University School of Podiatric Medicine in Philadelphia. He is a Fellow of the American College of Foot and Ankle Pediatrics and the American College of Foot and Ankle Surgeons. Dr. Pagano is also the On Air Personality and Consultant for Waco Shoe Company on QVC. He specializes in Pediatrics, Sports Medicine and Surgery.

References

1. Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987;7(1):34–38.
2. Tong JWK, Kong PW. Medial longitudinal arch development of children aged 7 to 9 years: longitudinal investigation. Phys Ther. 2016;96;1216–1224.
3. Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. How to manage pes cavus in children and adolescents? EFORT Open Rev. 2021;6(6):510-517.

Prefabricated.

This author feels that the key to successfully treating pediatric biomechanical issues lies in early intervention, and that prefabricated devices can have a role in this process, especially when properly manufactured with the right materials.

By Philip J. Bresnahan, DPM, FACFAS, FACFAP

Foot orthotics have been used for many years to treat a variety of lower extremity maladies. The description, manufacturing, and materials all vary among those devices considered prefabricated. By definition, an orthotic is a device or support, especially for the foot, used to relieve or correct an orthopedic problem. As long as prefabricated orthotic devices have been available, controversy continues to exist over their cost and therapeutic value.

For the purposes of this article, I will use the term “prefabricated orthotic device” to describe an insert that one adds to the inside of a shoe to be worn by the child while walking in order to alter a condition, symptomatic or asymptomatic, which is not manufactured as a result of an image or mold of that individual’s foot. Most of my discussion will refer to a fairly rigid material being used in the manufacturing of the device. One should distinguish this from a custom-fitted prescription orthotic device, which is manufactured to individual specifications based on some type of image or mold of the foot. I do feel that prefabricated devices have a place in successful treatment plans in the pediatric population.

Considering the Application of Prefabricated Orthotics for Children

The arguably greatest indication for using a prefabricated orthotic in pediatrics is to treat a flexible flatfoot deformity, or its sequelae, which occurs as a result of this overpronated foot type. In my experience, this is likely present at birth in a child as a result of some degree of a congenital calcaneovalgus deformity. As this foot takes its first step and begins to bear weight, this foot is already abducted and everted from under the subtalar and midtarsal joint axes and is unable to resupinate to an efficient propulsive mechanism on its own.

I find that these prefabricated devices can be used in any pediatric age group. I will often use them as a first treatment option in the youngest of walkers. While a normal foot changes and develops over time, I do not believe that a deformity, once identified, will “grow out” to become normal over time simply with forces of nature. If a flexible flatfoot deformity is identified early, intervention in the form of a prefabricated orthotic device can be beneficial to improve the alignment and allow for better foot function. Symptoms of foot pain in a child should not be the sole criteria of whether to treat this condition as many conditions, such as blurry vision, are not painful, yet there is no hesitation to initiate treatment early. Thus, the deformity alone, I find, is reason enough to intervene, and a prefabricated device can be a beneficial choice.

In other words, the objective of an orthotic device, prefabricated or custom, is to restore the osseous alignment of the foot skeletal structure so that the muscles can function as designed for stability in stance and efficient propulsion in gait. In my experience, for a prefabricated orthotic to accomplish this in a child’s foot, it should meet certain criteria. The orthosis should be constructed of a firm material. A soft material will “cushion,” whereas a firm device should act as a brace to reshape the bony alignment to its “neutral” position. A child’s foot is typically very flexible, so it should conform to the firm material placed beneath it. I recommend a deep heel cup and high medial flange capable of limiting the pronatory force exerted on the foot as the child reaches the midstance phase of gait. I recommend an extrinsically posted rearfoot (again in neutral) as I find it provides better stability in young children.

At the risk of inducing criticism, if a neutral shell device can restore the osseous alignment and enable the muscles to maintain the foot’s integrity, one does not need to prescribe a prefabricated orthotic device made for “different foot types.” The prefab orthotic will allow the osseous structure to be stable due to improved alignment and allow the muscles to work as designed during a specific moment in time during the gait cycle to maintain an effective propulsive mechanism, enabling what I refer to as “dynamic planar dominance.” Also, I do not feel there is a benefit to a gait plate where the orthotic’s metatarsal parabola is the reverse of the foot’s natural parabola. It is too difficult for a device to alter the foot’s osseous alignment at that late stage in the gait cycle.

These prefab orthoses can often be used as an initial test to determine whether this type of mechanical alteration of foot function is the correct treatment path. Any symptomatic relief would logically indicate improved, mechanical function of the foot. This “test” would also serve to indicate that if a “simple” device helps partially, it would be reasonable to presume a “better,” doctor-prescribed custom-fitted orthotic should provide a greater benefit. In addition, lower out-of-pocket expense for an over-the-counter prefabricated device seems more reasonable, especially in a growing child’s foot.

Considering the Pitfalls of Any Orthotic Device

One must recognize that limitations of any orthotic device, including prefabricated, do exist. I advise that the patient must wear them 100% of the time when on their feet to be fully effective, which is rarely practical. Also, one aims for this device to control the osseous alignment of the foot from the outside of the body with soft tissues interposed, making it less specific to the bony structures themselves.

Finally, the goal of altering foot alignment would ideally begin at the moment of heel strike, which, in my experience, an orthotic device cannot accomplish until nearly the midstance phase of the gait cycle, which is somewhat later than desired in order to fully achieve its full effect.

Studies have shown mixed results regarding the effect of orthotics on various measures, including position and motion, muscle activity, and oxygen consumption, but these studies admit difficulty when comparing methodology.¹ Another study has shown that orthotics reduce tibial rotation, which may be the result of reduced foot pronation.² Although pediatric-specific literature is limited, recent studies suggest that in adult patients, the cost and effectiveness differential may favor prefabricated devices for pain reduction and functional improvement in heel pain in adults.³ Conversely, another study favored custom devices for pediatric flatfoot.⁴

However, one thing is clear from my point of view. Intervening for pediatric biomechanical deformities early on is key. And, prefabricated devices are a viable way to do that, especially if barriers to obtaining custom devices exist.

Final Thoughts

Despite the controversies surrounding this topic, if a pediatric flatfoot deformity is diagnosed, a prefabricated foot orthotic is a reasonable course of action. Do not “wait and see” if this condition will spontaneously resolve itself. Prefabricated devices, when properly designed and properly implemented, can indeed prove beneficial in the certain pediatric treatment plans.

Dr. Bresnahan is a Fellow of the American College of Foot and Ankle Surgeons. He is a Fellow and Past President of the American College of Foot and Ankle Pediatrics and a past Assistant Professor in the Department of Orthopedics at Temple University School of Podiatric Medicine in Philadelphia.

References

1. Landorf KB, Keenan AM. Efficacy of foot orthoses. What does the literature tell us? J Am Podiatr Med Assoc. 2000;90(3):149-58. doi: 10.7547/87507315-90-3-149. PMID: 10740997.
2. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther. 1995;21(6):305-427.
3. Tran K, Spry C. Custom-Made Foot Orthoses versus Prefabricated foot Orthoses: A Review of Clinical Effectiveness and Cost-Effectiveness [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Sep 23. PMID: 31714699.
4. Suh JH, Yoon SY. Comparing the effects of University of California Biomechanics Laboratory and custom-made semi-rigid insole on pedobarographic parameters in pediatric flexible flat foot. Prosthet Orthot Int. 2023 Dec 1;47(6):614-620.