Insights on Pediatric Orthotic Therapy

To listen to the original podcast, click here.

Dr. Pagano discloses an industry relationship with Spenco.

Jennifer Spector...:         Welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. Today we have a special edition of our podcast focusing in on our well-known orthotics Q&A with our special guest, and my classmate, Dr. Nicholas Pagano. In this episode, he will guide us through his experiences and understanding of orthotic therapy in the pediatric population.

                                    Dr. Pagano is a fellow of the American College of Foot and Ankle Surgeons, and he's the course director of the Pediatric Foot and Ankle Orthopedics course at the Temple University School of Podiatric Medicine. He's the Vice President of the American College of Foot and Ankle pediatrics. He practices with Barking Dogs Foot and Ankle Care in Conshohocken, Pennsylvania. Welcome Dr. Pagano, and thank you so much for being with us today.

Nicholas Pagano...:        Well, thank you for having me, Dr. Spector. I'm excited to talk about pediatric orthotics. It's something that I really love to do, and I'm excited to have a good chat, good discussion with you and see how it goes.

Jennifer Spector...:         Well, we're excited as well. I think the first thing we'd like to start off with today is can you tell us a little bit about how you decide when a pediatric patient might benefit from, say, a custom orthotic, as opposed to an off-the-shelf device?

Nicholas Pagano...:        When a patient comes in to see you, usually they have either been referred to you from their pediatrician or, dependent on the age, another specialist, or they heard about you online. So they're coming in knowing that orthotics are available to you. So whenever they come in, I always like to find out exactly what their complaint is.

                                    I'm lucky enough to take care of a lot of sports medicine, so a lot of times the complaint may be acute, like a sports injury, or it could be something chronic. And example of chronic, and I don't want it to sound negative, but is if a parent notices that a child is tripping or if a parent notices that their child has flat feet or another foot deformity. So then the next thing that I need to know about is, if it is a deformity, then what is the extent of the deformity? A lot of times, the extent of the deformity will already have been diagnosed. With the advancements in medicine now, the patient is going to come in and you will know that they had a history of clubfoot that you casted, right?

Jennifer Spector...:         Right.

Nicholas Pagano...:        However, a sports injury, this is something acute. So as to whether a custom is requiring an off-the-shelf device, sometimes if it is something that just requires a temporary fix, and I know it's not an off-the-shelf orthotic, but a Tuli's heel cup, in this scenario of fevers or severs, depending on what section of the country you're from and how you pronounce it. Right? Then if you run into something like, say, a metatarsus adductus deformity, there are a lot of prefabricated devices, like a little step that has a built-in device for a gait plate. Sometimes I feel that a deformity, if it's severe enough, if they are not a candidate for surgery, then a custom-molded device is required for those severe deformities.

Jennifer Spector...:         What do you think about using an off-the-shelf device as a trial device in cases where you really think they need a custom, but it's a hard sell for the parents, based on insurance coverage, or say you're not 100% sure what the child is going to tolerate?

Nicholas Pagano...:        I think that's a really good point because, unfortunately, we are in the business of medicine. So I think anything is better than nothing. And also, if a patient with their parent is coming in to see you with a problem, they want something. They want direction, they want treatment, they want an orthotic. So dependent on what their insurance is, and I'm in Pennsylvania, so you're handcuffed a lot in regards to coverage for orthotics and a custom device, yeah, it might be out of their realm.

                                    So if you have a prefabricated device in your office, I know I certainly carry Spenco and I carry Redi-Thotics, and I carry littleSTEPS, almost like a trial. And in fact, Dr. Spector, the other thing that you can do is, back to the business of medicine, it's like, "All right, well, if this worked, how good do you think the customs are?" Because the customs are certainly the best treatment that we have.

                                    Another thing that I've noticed when a patient comes in with a chronic complaint or a familial complaint, like, "Everybody in the Smith family has flat feet, and you should see my grandmother's bunion," you want to find out what has worked before they even got to you because one thing that can be very frustrating, myself, as a parent, as you are, is when you go in and they just offer you the same thing that you're already doing.

Jennifer Spector...:         Very true. It's not always textbook. It really isn't.

Nicholas Pagano...:        Yeah. Yeah. You know how pro podiatry I am, by the time they're coming to us, they've gone through your Dr. Scholl's device. I always like to take and roll them up because I just think they're a pad. They're not really offering a lot structure, which is a lot of times what these kids need.

Jennifer Spector...:         No, they really do. And the kids have very unique needs specific to orthotics, one of which being that they grow on us.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         So how do you handle that? How do you handle outgrowth plans, both from a family and patient expectation management standpoint, and just from a logistical standpoint?

Nicholas Pagano...:        Well, expectations need to be managed at your first visit. If you are going to go into the direction of orthotic therapy, you need to let the parents know, you need to let the mother know that this is something that will likely be required to be worn, not just for a short period of time. They're likely going to need to wear these devices until they reach skeletal maturity. It's known that the orthotics will help strengthen the foot and then the corrected position to help with any deformities, if you can manage that expectation.

                                    So my little secret for managing outgrowth is followup. I never discharge a child. A lot of them will discharge me after the jokes wear out, but after we have evaluated them, created a treatment plan for the sake of this, our treatment plan is orthotics, they follow up after about a three-month period of time, they're doing well, it's not, "Best of luck to you." It's, "All right. Well, I will see you in nine months." And then when we hit that, because at that point, at the three months, the nine month mark is that year.

                                    So then sometimes those office visits every year, one, they're personally rewarding because you get to see these people that you're able to help, and what I love is that kids get better. So the fact that you're able to see them on a yearly basis, it also helps if other troubles do occur. Maybe your management is not working and you need to then, like we talked about initially, now you need to go to custom because you're not addressing the deformity appropriately with your prefabricated device, or maybe the customs that you created for that patient need to be adjusted. So the way that I monitor outgrowth is, one, with followups.

                                    And our teacher, Dr. Jay, I remember him saying one to two years. And the way that I look at it is not so much one to two years, based on watching my kids grow, it's one to two shoe sizes. Then, usually, the orthotic will not be fitting appropriately. But also two other things that I like to think about is if the symptoms return, then you know that the orthotic is not providing support. The next thing, number two is if they start to have discomfort from the orthotic itself, because if they're having discomfort from the orthotic itself, whether that may be seen outwardly by blisters or calluses or internally by what the child is telling their parents, then you know that it's time to reevaluate. But I think the key to all this is followup because if they're not following up with you, Dr. Specter, they're following up with somebody else.

Jennifer Spector...:         That's so true. And by keeping that close followup, or at least inspiring the want to have that followup, you're forming a great relationship with both them and their family. So when other things happen, like heaven forbid, someone sprains an ankle or someone has a verruca, or something along those lines, they're going to choose you because you've maintained and nurtured that relationship.

Nicholas Pagano...:        Yeah. And I'm sure you've experienced it. When you see a kid, you tend to see their whole family eventually, right?

Jennifer Spector...:         You do.

Nicholas Pagano...:        It almost turns into a little bit of a joke. And the other thing, when you get to know the whole family, it is nice to ... I'm going to go off topic, but it's always nice. Sometimes the day to day can be very difficult, and in private practice, there can sometimes be that feeling of monotony. But the one thing I definitely provide preventative care to my diabetic patients, I make sure that they know that the whole point of their visit is to check their feet and not just clip their nails and trim their calluses. But what I love hearing is I love hearing Mrs. Ragusa's pasta recipe. And then, if you work it enough, maybe she'll bring some in. And then that's the real reward reward of having that followup and developing a relationship with both the patient themselves, but also your community.

Jennifer Spector...:         Very true. That's one of the things that I think is so great about podiatry in general is the opportunity to form those relationships. I used to joke around that when we're working on somebody's feet, and working with their feet, they're a captive audience.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         We have the chance to really have a back and forth conversation while we're doing range of motion or evaluating skin condition and things like that. So that really applies to the pediatric population even more so, because we are forming, to some extent, their opinions of medical professionals.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         We might be combating a fear of doctors or of medical procedures. We might be, hopefully, helping them to see medical professionals and the medical profession in a positive light.

Nicholas Pagano...:        Yeah. And just to pile onto that, a lot of times, when the child comes into your office, they've already formed an opinion because they were talking to their friend in school. So if a patient comes in, just because you're seeing a doctor, it doesn't mean you're getting a needle, because unfortunately. when these kids are younger, for those first couple years, every time you went to a doctor, you got a needle. So by the time they come to me, sometimes I'll even open up a visit with saying, "We're not using needles today," and it just relaxes them.

                                    But also Dr. Spector, you needed definitely, especially with orthotics and evaluating them, it's so critical to have time. A pediatric patient is nothing that you need to rush. And if you do rush them, you're absolutely going to have an unproductive visit. You're not going to get anything out of it. And sometimes the visits are unproductive with pediatric patients. Unfortunately, I would love to stand here with my chest out and tell you that I never had a kid kick and scream, right? They're kids, it happens.

Jennifer Spector...:         We all have.

Nicholas Pagano...:        Right. But if you give them the appropriate time, they'll have a good experience, and you're right, you're molding their opinion for the world of medicine. And I like to think that, especially knowing you and being around you, you and I certainly mirror our ways of making a child feel comfortable, and then you get a more productive visit.

Jennifer Spector...:         Well, speaking of making the child feel comfortable, we all know that sometimes it's a princess and the pea syndrome where different materials and different modifications of an orthotic may work really well for one person, but the person next door may not tolerate them at all. And in my experience with children, that was even more the case.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         Are there any materials in your experience that you feel that kids tolerate particularly well?

Nicholas Pagano...:        I do. I do. And the first one that I do really like is Spenco. I like Spenco top covers. You can carry it in your office. I know some of the manufacturers that we purchase from some of the supplies will actually sell it in a roll. And I have that in your office so that you can create a cut. A lot of the pre-fabricated pediatric inserts will have a similar top cover to it. But then, on the other hand, sometimes just the shell itself, if it's a soft plastic, I feel like the kids can tolerate that a lot.

                                    Another thing that can work is cork. One way of getting a kid used to orthotics, and especially since we're recording this in July, is Birkenstocks. Two things that Birkenstocks taught me, especially this summer, is that cork can be very well tolerated in kids, but also now, Birkenstock makes very similar to a Spenco one that we have, that is one-piece EVA, that thin cushion that makes running shoes so good, the texture and the material also works really well. One thing that I found can be helpful is if the child is used to wearing sneakers, which they all are, if the sneaker that you're going to per prescribe or fit them with their orthotics has and insole, just have them put the insole on top of the orthotic. That'll give you an idea of what they're going to be able to tolerate, right?

Jennifer Spector...:         No, it's very true. And then in the end, that tends to be a positive point to the family, especially for kids that, depending on their school requirements and their preferences, because they all have very distinct preferences, a device like that is going to be more versatile among multiple shoe types.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         So although the thick, cushy top covers really are very comfortable for many people, sometimes, at least I found, the bulk of that could be somewhat prohibitive.

Nicholas Pagano...:        Well, yeah. I don't know in your experience, but I think the most common complaint about orthotics is, "They don't fit in this shoe, Dr. P." It's a difficult complaint to handle because I know the answer is you've just got to go a half size up, or maybe switch to a wide. And it's a lot easier for our pediatric patients, because a lot of times their shoes are very wide anyway, and they're going to grow out of that shoe anyway. So to get a half size up is not a terrible, terrible deal. However, when you get past the children's sizes and you're still dealing with the pediatric population, stuff gets real when their shoes get to be above 70 dollars each time you need to buy a new one.

                                    So it's a matter of, I think, going back to what we talked about earlier, it's about managing expectations when you're going to provide that therapy and know you may need to purchase a new pair of shoes in order to accommodate these, and just letting them know. And I think that, like we said in the beginning, when you do have those expectations managed and it's out front there and it's not a surprise, people are like, "Oh, all right." Like, "No problem. I can do that."

Jennifer Spector...:         Well, I think that having the right shoe for the right orthotic is sometimes half the battle, and yeah, unfortunately, we have a bit of a war on our hands sometimes when we're talking about youth sports and footwear.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         So how do you handle those challenges when we're talking about things like cleats, things like dance shoe gear, where they're not going to fit a standard custom orthotic?

Nicholas Pagano...:        I think one thing that is important, if you're dealing with sports and you're dealing with custom-made orthotics, to have a good lab. A lot of times your lab will have a program where you could send a sports shoe cleat or whatnot that the child is going to wear, and they can fit it to them with the way that they construct the orthotic themselves. And that's honestly, Dr. Spector, that is the perfect scenario, but not a scenario that is available to all of your patients.

                                    One of the things is that you know in sports, the orthotic is really focused on controlling the rear foot. So you may need to make a consideration if, let's take track, for example, and it's a sprinter. If it's a sprinter, and if you ever see a Nike sprint cleat, there's nothing on the back at all. It's just a rounded heel and the spikes are at the very end. So for handling cut the molded or prefabricated orthotics, for something like that, you have to know what the function of the orthotics is going to do. Long distance runner, soccer player, basketball, sports that are going to are going to require heel strike, now you can get cooking, right? You and I before talked about dancers. You had a really good point about outside of the world of sports. And you had mentioned to me that you try to control outside of sports, which I thought was brilliant.

Jennifer Spector...:         I found that, in many cases, it was just physically impossible to have a truly biomechanically sound, insert orthotic in something like a floor ballet slipper, or a point shoe or a jazz boot or things along those lines. So a lot of times what we would do is we would focus on proper biomechanical control of that patient's needs outside of the dance studio in their everyday shoes, school shoes, sneakers, things like that, to control whatever the biomechanical issue is. A lot of times posterior tib tendon dysfunction. Then what we would do in the dance shoes is we would add individual features to control whatever we could at the time. That was many times an arch cookie, that could have been a metatarsal pad, that could have been something to offload a digital neuroma, something along those lines.

                                    Again, like you said, exactly, taking the sport and the function into consideration. And among dancers, there's so many different considerations depending on the division of dance and where the stresses lie. Certain dances do have a lot more heel strike involved. Other ones, it's all forefoot weight bearing. So it all goes across the board, I think, for all athletes to understand the mechanics of that sport and what we can do for them during that sport.

Nicholas Pagano...:        One real unique scenario that I was in once was Irish dancing.

Jennifer Spector...:         Really?

Nicholas Pagano...:        And I am 50% Irish, so I'm very proud of it, but I am not a dancer at all. But the uniqueness and the beauty of the Irish dancing is that they stay very straight, and it's primarily just hammering away at their feet. And the only thing that I could make work was metatarsal padding, because the way those shoes are specially made. Another thing that I'd been able to do is with my soccer players, just utilizing ... And the soccer cleats now have actually almost an anklet boot, like a Lycra ankle boot, so you can get away. You can accommodate a lot of things there. If it's too thin, you can add padding, like you had mentioned, long arch pads, metatarsal pads or whatnot. But I also have been able to get a very slim three quarter length orthotic without any top cover. And if you think about in a soccer cleat, in regards to needing a top cover, you are just running on a cleat when you're in a soccer boot.

                                    Another thing that I've noticed was in hockey, I had a referee that was working with kids sports, and he told me about a thing called Shock Doctor, and it's a prefabricated, specially for hockey. So then building on that, I had to go to one of the soccer stores in Burwin, which is around, Dr. Spector and I. People are well aware of the purpose of orthotics because in there I saw, and I took a picture, prefabricated orthotics for soccer cleats, to which I think to myself, "Why didn't I not come up with this?" Right? This is your shark tank moment.

                                    But another one that can be helpful, I am usually not a proponent of the dress-style orthotics, just because I feel like they're not controlling you biomechanically, and I'm not trying to split a room or open up a can of worms. I'm just saying from my own experience, but a Cobra design, with that, that's a really flexible, functional low-profile orthotic. And I have found that has been helpful with my athletes.

Jennifer Spector...:         I think it goes back to the same thing you mentioned earlier in our talk, was something's better than nothing.

Nicholas Pagano...:        Yeah.

Jennifer Spector...:         And managing expectations, it all goes back to that. You may have to say, "Listen, this is not the most ideal situation, but if it is absolutely not possible to have shoe gear that will accommodate what is needed, then what can we do to get you some level of intervention?" So I think the flexibility that we can show and the adaptation that we are capable of is something, I think, really unique to our profession as well. That's something we're used to maneuvering.

Nicholas Pagano...:        Yeah. The maneuvering is the appropriate word for that. You really do have to maneuver around, and if you have the patience for it, it is so incredibly rewarding. With my pediatric patients, I'm like, "All right, I'll read about you in the papers tomorrow," and then I pause and I go, "I'm referring to something that's called a newspaper. It's not on your iPad."

Jennifer Spector...:         They probably have no idea what you're referring to.

Nicholas Pagano...:        They have no idea what I'm talking about.

Jennifer Spector...:         So although we could talk about this forever, and we'll just have to bring you back for another episode to dive more deeply into some of these issues, before we part with the audience today, are there any particular tips or pearls that you really want to drive home for docs that create orthotics for younger patients?

Nicholas Pagano...:        I think one thing that is important, and we spoke about it earlier, is following up, establishing your rapport with the patient, solidifying expectations, making them know what the plan is, and then following up with them because it is a dynamic population that is going to continue to grow. And I would rather establish that relationship, be aware of the patient and their complaints, and follow them the whole way until they reach age 18 and they don't need us anymore, or they start to take on other issues.

                                    The other thing that I think is important is recognition of what a pediatric foot should look like at what age. I mean, that is completely out of the full scope of this talk because if you wanted, I can line up one of my lectures from school and we can do this for two hours, and we could probably fall asleep, but I'm a big fan of Dr. Val Mathey, God rest his soul, but his rule of sevens and being aware of the position of the heel and being able, if you are going to do a custom-molded orthotic, being able to calculate that into your actual orthotic for any posting that you're going to do, also be aware that a pediatric foot should be flat and floppy until they're seven. So that is something to always have in the back of your head.

                                    And then the most important thing in regards to creating orthotics for kids is parents. When they talk about real estate and the number one thing in real estate is location, location, location. I do feel in treating pediatric patients, Doctor, that it is parents, parents, parents, because you absolutely need to ... The parent absolutely needs to participate in the care of this patient, especially in the younger ages, whether it is the home exercise program to stretch so that the orthotics function properly, or reinforcing the need to wear the orthotics because if you lose that parent, you've definitely lost the child and the ability to treat.

                                    I have found that there are definitely certain situations where you can be the dominant, right? The doctor is the master, but those are usually for acute things where it's like, "There's a fracture. We need to go in and fixate it." There's not really room for any discussion. But something like an orthotic program is going to be a huge investment in your time, and you need a huge investment from the parents. So education of the parents is just as critical as education of the child patient.

                                    And then another thing that can be very helpful is, as a proud member of the American College of Foot and Ankle Pediatrics, going to our seventh international meeting, which is going to be located in Rapid City, South Dakota, September 15th through 17th. I've been privileged to go to a lot of these meetings. And if you are into caring for pediatric patients, imagine just getting to go away for a weekend and hanging out with other podiatrists, orthopedic surgeons, and international people, and international physicians that come to the meeting. And it's fun, and you get to see the national parks, and you can hang out with Louis DeCaro and the whole crew. And I guess this really goes into my [inaudible 00:28:23] tip, Dr. Spector, you've got to go back to the well and constantly be learning because much like that newspaper that I referenced a little earlier, things are changing, and you've got to keep up with it for sure.

Jennifer Spector...:         Definitely. And when you're looking at ways to learn about these specialties, the specialty organizations tend to have conferences, I've found, where the faculty and the attendees are just so enthusiastic and really love what they do. So it's contagious, and that's the great thing is you can definitely come away with a lot of great information that you can apply in your practice the next day.

                                    Thank you so much to both Dr. Pagano, and for our listeners for joining us today. Don't forget to check out other episodes of Podiatry Today Podcast, both past and future, on podiatrytoday.com, Streaker, iHeart Radio, Apple Podcast, and more.