UCBL Material Selection Varies for Pes Planovalgus
April 2021 Issue
I posed a question on the OANDP-L listserv to find out what materials other orthotists choose for UCBLs to treat pes planovalgus (PPV) and to gather thoughts about allowing dynamic movement. There was a wide range of materials selected by those who responded, many of whom specialized in pediatric care. Compliance seemed to be a decision factor, and many practitioners allow some movement while providing the maximum amount of tolerated correction. The literature does not mention rigidity of the device as important, and it seems we have ideologies from very flexible to very rigid for UCBL treatment.
There were differing ideologies regarding the rigidity of a UCBL for PPV correction—a more rigid alignment correction in the orthoses versus a more dynamic or circumferential alignment correction. Most of the respondents balanced providing the minimum stiffness orthotic device with allowing some dynamic movement while still providing maximum achievable correction.
My initial question and the responses led me to several literature links, including research findings that most pes planus should resolve itself by the age of ten, pediatric medial longitudinal arch fat pads should be absorbed around the age of three to four from walking, and calcaneal eversion should resolve around the age of eight.
Louis J. DeCaro, DPM, recommended forefoot posting by eight to ten years of age to treat PPV, and to provide a more rigid correction between the ages of five and nine. I would still go for semi-rigid correction for patients who are five to nine years old because children's genu varum or genu valgum rotational alignments are still changing at these ages.
I like the idea of going more flexible, as some commenters suggested, and more proximal for my patients who are one to four years old. Bracing at this age is more for increase proprioceptive feedback and prevention of stretch weakness or positional weakness.
I would think we should allow flexibility for the subtalar joint to rotate in accommodation to children's changing knee and hip rotation that is seen in growth. The goal is to provide enough support to allow the patient's muscles to strengthen in (a more) proper positional within the orthosis. Allowing foot and ankle movement improves balance if the patient has strength to compensate for ground forces.
From this discussion, I am more confident regarding what is appropriate alignment for a child's age range and whether a child's alignment still has a potential to improve naturally or when to discuss the need for more rigid correction.
It is good to discuss our professional ideologies and how our professional treatment selection differs to better understand the limitations to studies reflecting our profession.
It would be interesting to better assess the balance of control, correction, and compliance in preventive orthotic care. Would it be safe to say that children approaching age eight will have a limited chance for alignment improvement and to start bracing as preventive care, even for those who may be asymptomatic? Would this reduce foot injuries in teenagers and adults? This would require more insight into long-term effects of wearing orthotics versus not.
Jennifer L. Wolbach, LCPO, is a practitioner at Tri-Cities Orthotics and Prosthetics. She can be contacted at firstname.lastname@example.org.