Pediatric Flexible Flatfoot Sep 2008 CME

or how to treat a child for this “de-formity.” Furthermore, we still donot have enough clinical trials totell if early intervention altersmidlife outcomes and reduces

Continued on page 130

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Following this article, an answer sheet and full set of instructions are provided (p. 136).—Editor

SEPTEMBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 129

Continuing

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Goals and Objectives1) As a result of reading the arti-

cle, the clinician will develop a bet-ter understanding of the following:

2) The normal and natural devel-opment of the human foot fromone year of age through seven;

3) The consequences of abnor-mal development on both theshape of the foot and the functionof the foot in children;

4) The specific origins of thepathology, especially in the case ofjuvenile arthritis, genetic anomaliesand neurological influences, can beaccounted for in the custom device.

5) The effect on the pediatricfoot of the overweight child;

6) Prescription writing for thepediatric patient;

7) The contemporary literaturedescribing the dysfunction of thepediatric flatfoot.

versy and has been debated in thelegitimate medical literature forover fifty years. The spectrum ofopinions for treatment is so diversethat there is a possibility that noone really has an answer to when

Treatment ofPediatricFlexible Flatfootwith FunctionalOrthoses

By Paul R. Scherer, D.P.M.

The non-surgical treatmentof pediatric flexible flatfootwith functional orthoses

has always been mired in contro-

Here’s a look at this muchdebated topic.

flexible flatfeet, then placed themin an UCBL-type polypropylenedevice for twenty-five months todetermine any change in the os-seous structure and position. Thestudy also investi-gated whetherthe changeachieved by thedevice would bemaintained afterthe cessation ofthe orthoses. Thechildren wereagain evaluatedt w e n t y - f i v emonths after dis-continuing thedevice. The studyd e m o n s t r a t e dthat the children, from three tonine years of age, maintained thecorrected rearfoot-to-forefoot posi-tion even after they stopped wear-ing the device.

Twenty-five years later, an Aus-tralian study2 compared the treat-ment of pediatric flexible flatfoot

with custom orthoses,prefab devices and notreatment, in a singleblinded parallel ran-domized controlledtrial. They found “noevidence to justify theuse of in-shoe orthoses”in the management ofthis deformity. The twostudies could not havehad more contradictoryresults. The later studydid not use an acceptedcasting method nor didit identify what stan-dards were used for castcorrection of the posi-tive, other than the

casts were “sent to an orthoticmanufacturing laboratory.” Wehave no idea what type of devicewas dispensed. The tragedy of thisstudy is the exceptional effort

made to structurea valid controlledtrial, flawed byusing a non-stan-dardized castingmethod and un-known fabrica-tion process.

Hopefully, wehave reached acollective profes-sional opinionaccepting thatmuch of the footpathology seen

in adults has a mechanical originand these dysfunctions must havebeen present in childhood. Thequestion we have yet to address,by clinical investigation, iswhether early and specific inter-ventions with orthoses alter themidlife outcome of pathology and

reduce theseverity offoot symp-toms.The two di-verse articlesregarding theeffectivenessof orthotictherapy in pe-diatric flatfootare only asmall sam-pling of thed i s cu s s i on .Several other

articles successfully debate the val-ues and benefits of treatment.2-4

There is an abundance of literaturethat recommends treatment for pe-diatric flatfoot that is symptomat-ic.4-8 The objective of this discus-sion will be to describe the materi-als and design that would be mosteffective for the specific individualwith flatfoot of specific pathologicorigin.

Although most children areborn with a flatter foot than willdevelop by adulthood, commonprofessional thought is that thehuman foot should evolve an archand vertical calcaneus by at leastthe age of seven years (Figures 1 A,

130 www.podiatrym.comPODIATRY MANAGEMENT • SEPTEMBER 2008

Flatfoot...

symptoms.The discussion of pediatric flex-

ible flatfoot symptoms must beginwith the assumption that rigid flat-foot caused by vertical talus andtarsal coalition, with or withoutperoneal spasm, usually requires asurgical approach and not func-tional orthoses. Significant equi-nus deformity is also a primarycause of pediatric flatfoot andwithout its primary correction, or-thotic therapy is an unsuccessfuland painful experience for thechild. Other etiologic origins of pe-diatric flatfoot must also be identi-fied and considered, especially ge-netic anomalies and upper andlower motor neuron disorders.Given these exclusions, treatmentof pediatric flexible flatfeet withfunctional devices is generally anaccepted treatment.

A classic study in 19831 by Bor-delon delineated objective x-raymeasurements in children with

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MedicalEducation

The non-surgical

treatment of pediatric

flexible flatfoot with

functional orthoses

has always been mired

in controversy.

Figure 1A and 1B: Most experts agree that it’s quite normal for a child to have a rather flat arch and an evertedcalcaneus until the age of seven years.

Figure 2: Most of the literature recommends that a cus-tom pediatric flatfoot orthosis must have at least thefollowing characteristics: A. Wide enough at the distaledge to be stable on the frontal plane; B. Deep heel cupof 18 mm. or greater; C. A medial skive that transfersground reactive forces to the medial side of the rear-foot; D. An elongated rearfoot post for stability. Continued on page 131

1A 1B


These studies point a suspiciousfinger at obesity as a contributingfactor to flatfoot.

Two other research groups triedto evaluate if overweight childrenwith high BMI had different func-tion of their feet or just lower andfatter arches. The controlled studydetermined that the children whowere overweight had lower archesbut also had much higher forefoot

pressures.15,16

UltrasoundMeasurements

Ul t r a s oundmea s u r emen t swere made in stillanother study ofthe actual struc-tures that makeup the longitudi-nal arch andcompared this in-formation withpedobarographs

of the children to deter-mine if the foot justlooked flatter inobese/overweight childrenor were actually structural-ly different. The resultsthat compared overweightto normal weight childrenshowed that there was nodifference in fat pad thick-ness but the obese chil-dren did actually have alower arch.17

The United States, aswell as some other coun-tries, has been addressingthe epidemic of over-weight children. We nowknow that this problemhas a dramatic effect on

B).9

No investigation can befound that documents whatontogenic process occurs toallow the foot to become morestable in some children and toremain flexible in others. Theauthor suspects that the pro-gressive rigidity of the mid-tarsal joint between the agesof nine and twenty-fourmonths may play a major role.Perhaps the function of or-thoses is to assist in the rigidi-ty by bracing the midtarsaljoint and changing the apparentmorphology while reducing symp-toms and future subsequent defor-mity.

Although two studies estimatethe incidence of moderate to se-vere pediatric flatfoot in thehuman population at 18% of thegeneral population, neither studyattributes this incidence to the par-ticular size or weight of the chil-dren.10,11 Severalother studieslooked at theseparameters. A1999 study evalu-ated over onethousand chil-dren four to 13years old by footprint analysisand documenteda flatfoot preva-lence of 2.7%.Only 28% ofthese childrenwere given treatment and thestudy noted that an abnormallyhigh percentage of the childrenwere overweight.12

A 2006 study evaluated overeight hundred three to six-year-oldchildren with 3D laser surfacescanners and compared the heel-to-ground position and the heightof the medial arch. Prevalence was54% at age three and 24% at agesix, and again, an increase of flat-foot was found in overweight chil-dren.13

A 2001 study used photo-po-doscope of 243 children eight to10 years old and found a preva-lence rate of flatfoot of 16% for theentire group but 24% prevalencefor the overweight children.14

Flatfoot... the increase in di-abetes and heart dis-ease but also on poorfoot structure. A 2001study on this topic unequiv-ocally demonstrated, aftertesting 377 children betweentwo and six years old, thatflatfooted children per-formed physical tasks poorlyand walked more slowly.18

This implies that the in-creased pressure, functionand structural differencemay lead to decreased activi-ty and pathological functioncarried into adulthood. We

are growing a new generation witha propensity for increased footproblems.

It is known that the prevalenceof pediatric flexible flatfoot hasbeen shown to significantly corre-late with a definite decrease instride length, cadence and veloci-ty.18 It is also known that whenfunctional orthotics are given tochildren with Down’s Syndrome, apopulation with 83% incidence offlexible flatfoot, the ankle move-ment, walking speed, heel eversionand stride length improved.19

Several studies have document-ed that, in the presence of symp-tomatic pediatric flexible flatfoot,an almost rigid polypropylene or-thosis with a deep heel cup re-lieved pain and improved gait.20,21

The specifics of exactly why theywork, from a biomechanicalprospective, is unknown. Duringthe development of orthoses in the

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Medical Education

The United States,

as well as some other

countries, has been

addressing the

epidemic of overweight

children.


Figure 4: Pre-fabricated “kiddythotics” are producedin sizes that fit children to age seven or eight. Sizersets are used to find the select length, width and cal-caneal correction.

Figure 3: “Kiddythotics” are devices (left) that have manyof the recommended characteristics of custom orthoses(right) but are pre-fabricated.

tive force on the medial side of thesubtalar joint axis, not just raisethe arch. The orthosis must createa counterbalance that produces agreater equilibrium across the jointaxis.

Orthotic therapy for pediatricflatfoot should address this con-cept if it is to change both themorphology and function of thefoot.

Orthotic CriteriaThe orthotic therapy specific to

pediatric flexible flat-foot must meet the fol-lowing criteria (Figure2):

• It must be of suffi-cient rigidity to transfercorrective ground reac-tive forces to the footand have a realignmenteffect on the subtalarand midtarsal joint;

• It must be wideenough to exert forcesto the medial column ofthe foot;

• It must not inter-fere with the ability ofthe first ray to plantar-

flex at midstance;• It should be made

from an impressioncast of the foot thatavoids the pronatedposition or one thatallows the forefoot toinvert on the rearfoot;

• It should transfergreater ground reac-tive forces to the me-dial side of the rear-foot;

• It should be struc-tured to be stable inthe frontal planewhen in the shoe;

• It should have asufficiently deep heel

cup that increases cal-caneal contact to influ-ence the position of theheel-to-ground position.

Polypropylene Pre-fabricated Devices

The polypropylenepre-fabricated pediatricdevice is another alter-native that meets mostof the above criteria, but

is not required to be constructedfrom a cast or impression of thechild’s foot. Although the result ofusing a pre-fabricated pediatric de-vice, commonly referred to as a“kiddythotic,” is not always favor-able, the over-the-counter device

may function well enough to post-pone casting for a custom device(Figure 3).9

These pre-fabricated kiddythoticsare available in a variety of materials,designs and sizes. In order to meetthe optimal orthotic standards out-lined, the device should be madefrom rigid polypropylene and not amaterial that is flexible or affected bybody temperature. The device shouldhave a deep heel cup, sufficient me-dial flange, and a rearfoot post forstability. The addition of a 6 mm.medial skive correction in the heel isa distinct advantage (Figure 5).

Customarily, suppliers of thistype of pre-fabricated device pro-vide a sizer set that can be used tostand the patient upon to deter-mine length, width and calcanealcorrection. When the appropriatesize is identified, the correct devicecan be dispensed. The depth of theheel cup must consistently in-crease with the next larger size(Figure 4).

Custom pediatric orthoses ob-viously meet all the optimal stan-dards. Additions are added to theprescription specific to the degreeof deformity.

The specific origins of thepathology, especially in the case ofjuvenile arthritis, genetic anoma-lies and neurological influencescan be accounted for in the customdevice.

Polypropylene is most appro-priate for the shell of pediatric flat-


Flatfoot...

mid-twentieth century, theShaffer Plate and Whitman

Roberts Plate9 were designed tochange the morphology of the pe-diatric foot by raising the arch.Today, the theory of a displacedsubtalar joint axis explains whythe foot flattens and provides amore sophisticated approach to or-thoses designs.22 This concept re-quires that the orthoses be con-structed to increase ground reac-

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Polypropylene

is most appropriate

for the shell of

pediatric flatfoot

orthoses.

Figure 5: The medial skive technique is a cast modifica-tion that raises the medial side of the heel cup (leftimage) to increase ground reactive force on the medialside of the calcaneus.

Figure 6: Custom polypropylene functional orthoses areproduced either by the milling process (left) or vacuum-forming process (right). Milled is more rigid and thinnerthan vacuumed-formed.

Figure 7: A well cast and fabricated custom orthosiswill decrease the calcaneal eversion and off-weight themedial forefoot.

SEPTEMBER 2008 • PODIATRY MANAGEMENT 133

range of motion, a position thatassures a less flexible foot duringmidstance when the child wearsthe device.

Prescription EssentialsThe prescription essentials for

the device should include a deepheel cup of no less than 10 mm.for three-year-olds and no less

than 18 mm. forsix-year-olds. Theanterior edgewidth should al-ways be wide.This means thatthe anterior me-dial edge of thedevice should ex-tend to the medi-al edge of the me-dial sesamoid(Figure 7).

A medialflange must beincluded to ex-pand the surfacearea under the

midfoot and arch. The cast fill orarch fill part of the prescriptionmust be “minimum”, which is astandard of the Root technique23 orthe UCBL technique.8 This allowsthe resulting device to closely re-semble the plantar shape of thenon-weight-bearing foot in an ef-fort to allow the orthoses to ma-nipulate the foot into a similar po-sition when weight-bearing (Figure8).

The cast work correctionshould include the medial skivetechnique.21 The severity of thistechnique, 2 mm. to 8 mm., mustcorrespond to the sever-ity of calcaneal ever-sion. The greater the ev-ersion, the greater theskive. Children seem totolerate the 8mm skivewith no adverse reac-tion, provided that theheel cup depth is ade-quate and artfully sculp-tured.

Blake TechniqueThe Blake technique

of inversion of the posi-tive cast has been re-ported as helpful incontrolling the extremesof hypermobility in se-

foot orthoses. This material is thestandard of the UCBL device.(UCBL/ Root photo) Polypropylenethat is 1/8” or 3 mm is sufficient instrength and rigidity to controland endure most children up to 50lbs. (22.7 kg). Beyond this weight,4mm or 5/32” poly is necessarythrough 90 lbs.(40.9 kg). Milledpolypropylene,rather than vacu-um-formed, ismore desirablebecause a thinnermilled poly ismore rigid thanthe same thick-ness vacuum-formed poly.Also, the millingprocess producesa spine on theplantar aspect ofthe device pro-viding a morerigid and durable device (Figure 6).

Accuracy of the Negative CastCareful attention to the accura-

cy of the negative cast is essentialfor pediatric patients. Foam im-pression casting results in a customorthotic device that usually main-tains the foot in its deformed posi-tion without altering morphology,let alone function. Negative sus-pension casting is most desirable,although not the easiest task, con-sidering the cooperation of a three-year to six-year-old child. Thisalone often makes the pre-fabricat-ed kiddythotic more popular forchildren and possibly more effec-tive than a custom device from acrush foam impression or a poorquality negative suspension cast.

The objective for negative cast-ing is to place the child’s foot in amore aligned position than itadapts to when weight-bearing.Care must be taken to assure thatthe child has not dorsi-flexed thefirst ray by contracting the tibialisanterior muscle. Counter pressureby dorsi-flexing the hallux whilethe plaster sets usually avoids thisproblem. Care must also be takento dorsi-flex the forefoot on therearfoot sufficiently to bring themidtarsal joint to the end of its

Flatfoot... vere pathology.9 This isan aggressive correctionthat was devised for athleteswho often exhibit a greater de-gree of pronation, but may havean application in treating hyper-mobile pediatric flatfoot.9

The standard amount of inver-sion for this technique is twenty-five degrees, which alters the archand inverts the heel cup of the re-sulting device. Caution should beused if both the Blake inverted andmedial skive technique are used inthe same device. This techniqueshifts the foot dynamics and maydecelerate pronation. If both tech-niques are used in the same orthot-ic, it will cause the orthotic to shiftin the shoe and become ineffec-tive.

Flat and large rearfoot posts areessential in treating pediatric flat-foot. A recent study demonstratedthat the rearfoot post not only stabi-lizes the orthoses in the shoe by in-creasing the contact surface area, butalso increases rearfoot control whencompared to the same functionaldevice without a post.24 An elongat-ed post was more effective than thestandard size post (Figure 9).

Topcovering a pediatric deviceis usually not necessary and some-times counterproductive since thematerial usually deteriorates rapid-ly in active children. EVA seems tobe the most durable. Occasionallythe provider will use a shoe with aremovable insole when pediatricflatfoot is associated with neuro-logic spasticity, ulcerations sec-ondary to spina bifida, or children

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Medical Education


The Blake technique of

inversion of the

positive cast has been

reported as helpful in

controlling the

extremes of

hypermobility in

severe pathology.

Figure 8: The Root-type custom orthosis (left) and theUCBL orthosis (right) are both made from polypropy-lene. There is no research that yet demonstrates whichis more effective. The UCBL has a deeper heel cup andmore surface area as well as a medial and lateralflange.

www.podiatrym.com

2004.8 Mereday, C, Dolan,

CM, Luskin, R: Evaluationof the University of Cali-fornia Biomechanics Labo-ratory shoe insert in “flexi-ble” pes planus. ClinicalOrthopedics 82:45, 1972.

9 Valmassy, R: Lowerextremity treatmentmodalities for the pediatricpatient. Clinical Biome-chanics of the Lower Ex-tremity.

10 El, O, Akacali, O,Kosay, C, et.al: Flexibleflatfoot and related factorsin primary school children;a report of a screeningstudy. Rheumatol Interna-tional 26:1050, 2006.

11 Park, I, Song, K, Shin, S: Flatfootsurvey in 8 year old primary schoolchildren. Journal of Korean Foot andAnkle Society. 8:7, 2004.

12 Garcia-Ro-driguez A, Martin-Jimenez F, Carney-Varo M, Gomez-Garcia E, Gomez-Aracena J, Fernan-dez-Crehuet J. Flexi-ble flatfeet in chil-dren: a real prob-lem? Pediatrics,103-6, 1999.

13 Pfeiffer M,Kotz R, Ledl T,Hauser G, Sluga M:Prevalence of flat-foot in preschool-aged children. Pedi-atrics 118:634-639,2006.

14 Bordin D,DeGiorgi G, Mazzocco G, Rigon F: Flatand cavus foot, indexes of obesity andoverweight in a population of primary-school children. Minerva Pediatrics,53:7-13, 2001.

15 Dowling AM, Steel JR, Baur LA:Does obesity influence foot structureand plantar pressure patterns in pre-pubescent children? Int J Obes RelatMetab Disord 25:845-52, 2001.

16 Mickle KJ, Steele JR, Munro BJ:does excess mass affect plantar pressurein young children? Int J Pediatr Obes,1:83-8,2006.

17 Mickle KJ, Steele JR, Munro BJ:the feet of overweight and obese chil-dren: are the flat or fat? Obesity,14:1949-53,2006.

18 Lin, C, Lai, K, Kuan, T. Correlat-ing factors and clinical significance offlexible flatfoot in preschool children.Journal of Pediatric Orthopedics21:378, 2001.

19 Shelby-Silverstein, L, Hillstrom,


Flatfoot...

with rheumatoid arthritis.These cases require a topcover

to off-weight the hot spots, reducefriction, or provide a platform foradditions such as metatarsal padsor bars.

Regardless of the controversyand debate of treating pediatricflexible flatfoot, there is ample evi-dence that treatment with func-tional orthoses reduces symptomsand improves mobility. Returningthe foot to a more consistent mor-phology with custom orthosesdoes improve function and gait.Pre-fabricated poly kiddythoticsmay be an economic alternative ora preliminary treatment for reliefof symptoms. Whether this effortof intervention ultimately reducesmidlife deformity and symptomswill hopefully bedemonstrated infuture long-termclinical trials thatproduce pediatricdevelopment reg-istries. �

References1 Bordelon, R L:

Hypermobile flat-foot in children;c omp r eh en s i v e ,evaluation andtreatment. ClinicalOrthopedics andRelated Research,181:12,1983.

2 Whitford, D,Esterman, A: A Ran-domized controlled trial of two types ofin-shoe orthoses in children with flexi-ble excess pronation of the feet. Footand Ankle International 28:6, 2007.

3 Franco, A: Pes cavus and pesplanus analysis and treatment. PhysicalTherapy, 67:688, 1987.

4 Scranton, PE, Goldner, J,Leonard, LL, Staheli, LT: Managementof hypermobile flatfoot in child. Con-temporary Orthopedics. Philadelphia,W.B. Saunders 1972.

5 Sullivan, JA: Pediatric flatfootevaluation and management. Academyof Orthopedic Surgery 7:44, 1999.

6 Staheli, LT: Planovalgus foot de-formity. Current Status, Journal Ameri-can Podiatric Medical Association89:94, 1999.

7 Harris, E, Vanore, J, Thomas J, etal.: Diagnosis and treatment of pedi-atric flatfoot. Journal of Foot and AnkleSurgery 43:6 November/December

Continuing

MedicalEducation

Paul R. Scherer,D.P.M. is Profes-sor and Chair-person of theDepartment ofApplied Biome-chanics atSamuel MerrittCollege, He isboard certifiedboth by Ameri-can Board of Podiatric Surgery andAmerican Board of Podiatric Orthope-dics and Primary Podiatric Medicine.Dr. Scherer has received both public andprivate grants for his academic workand has published on a wide variety oftopics. He is CEO of ProLab Orthotics lo-cated in Napa, California.

Figure 9: A recent study demonstrated that an elongat-ed rearfoot post (left) was more effective than the stan-dard length (right) and the standard was more effec-tive than no post.

Pre-fabricated

poly kiddythotics

may be an economic

alternative or

a preliminary

treatment for relief

ofsymptoms.

H, Palisano, R. The effect of foot or-thoses on standing foot posture andgait of young children with Down syn-drome. Neurorehabilitation 16:183,2001.

20 Bleck, E, Berzins, U: Conservativemanagement of pes valgus with plan-tarflexed talus, flexible. Clinical Ortho-pedics 122:85, 1977.

21 Kirby, K, Green, D: Evaluationand non operative management of pesvalgus foot. De Valentine foot andAnkle Disorders in Children, New York,Churchill Livingstone 295: 1992.

22 Root, ML, Orien, W, Weed, JH:Normal and abnormal function of thefoot. Los Angeles, Clinical Biomechan-ics, 1971.

23 Blake, R, Ferguson, H.: Foot or-thoses for severe flatfoot in sports.Journal of the American Podiatric Med-ical Association 81:10, 1991.

24 Paton, JS, Spooner, SK.: Effect ofextrinsic rearfoot post design on thelateral-to-medial position and velocityof the center of pressure. Journal of theAmerican Podiatric Medical Associa-tion. September/October:96(5)383,2006


can be explained by which of thefollowing?:

A) The first ray becomes hy-permobile.B) The midtarsal joint be-comes rigid.C) The subtalar joint axis be-comes displaced.D) None of the above.

6) Which of the following is NOTa characteristic of an orthosis forpediatric flexible flatfoot?:

A) It should cushion the footunder the arch.B) It should have a deep heelcup.C) It should transfer groundreactive force to the medialside of the foot.D) It should be rigid.

7) The medial skive technique isdesigned to do which of the fol-lowing to an orthosis?:

A) Increase ground reactiveforce laterally to the rear foot.B) Increase ground reactiveforce medially to the rearfoot.C) Increase the strength ofthe Achilles tendon.D) Decrease the strength ofthe Achilles tendon.

8) Which of the following orthot-ic manufacturing techniqueswould make an orthosis for pedi-atric flatfoot more rigid?:

A) Vacuum formed orthosesB) Vacuum pressed orthosesC) Milled orthosesD) Foam box casting

9) When casting a child for a pe-diatric flatfoot orthosis, the firstray should be positioned in whichof the following directions?:

A) AbductedB) InvertedC) Dorsi-flexedD) Plantar-flexed

1) Which of the following is trueabout custom functional orthosesfor pediatric flatfoot according tothe medical literature?:

A) Orthoses can actually cre-ate a permanent change inosseous structure of thegrowing child.B) There is no evidence to jus-tify the use of custom or-thoses in the management ofpediatric flatfoot.C) Both answers A & B aretrue.D) Neither answers A & B aretrue.

2) Most children are born with aflat-looking foot and an evertedcalcaneus. The arch should beginto develop and the calcaneusshould become vertical by theage of:

A) One to two years.B) Two to four years.C) Four to five years.D) Six to seven years+.

3) The pediatric flatfoot occurs inwhat percentage of the humanpopulation, according to two re-cent studies?:

A) Less than 1%B) 1% to 3%C) 6% to 9%D) 18%

4) In a recent study, when cus-tom orthoses were given to chil-dren with Down’s Syndromewho had pediatric flatfoot, whichof the following occurred?:

A) The walking speeddecreased.B) The walking speedincreased.C) Stride length increased.D) Both answers B and C.

5) According to a paper in themedical literature, the biome-chanics behind pediatric flatfoot

10) A medial flange on a pedi-atric flatfoot orthosis is desir-able because of which of thefollowing reasons?:

A) It is more comfortable.B) It increases the surfacearea of the orthoses.C) It inverts the orthoses.D) It fits in the shoe better.

11) Minimum fill cast correc-tion technique is used in pedi-atric flatfoot orthoses becauseof which of the following?:

A) It makes the shoe fiteasier.B) It is less painful to thechild.C) It mimics the Shafferplate.D) It provides better con-trol of the orthoses.

12) The UCBL device was de-signed to treat which of thefollowing conditions?:

A) Pediatric plantar fasciitisB) Pediatric antetorsionC) Pediatric FlatfootD) Knock-knee deformity

13) A rearfoot post on or-thoses used for pediatric flat-foot is intended to accomplishwhich of the following?:

A) Stabilize the orthoses inthe shoes.B) Compensate for equinusdeformity.C) Invert the orthoses.D) Bring the calcaneusmore perpendicular.

14) Research has demonstrat-ed that a rearfoot post worksbetter when which of the fol-lowing characteristics occur?:

A) The post is varus.B) The post is shorter.C) The post is longer.D) The post is soft.

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E X A M I N A T I O N

See answer sheet on page 137.


136 PODIATRY MANAGEMENT

15) Which of the following topcovers are themost durable when used to modify a pediatricflatfoot orthosis?:

A) EVAB) PlastazoteC) PoronD) Aluminum foil

16) Topcovers are essential when treating chil-dren who have pediatric flatfoot in combina-tion with and which of the following?:

A) Spina BifidaB) Cerebral PalsyC) Muscular DystrophyD) All of the above

17) A 6 mm. medial skive technique would beused for a child with which of the followingheel positions after age seven years?:

A) Vertical heelB) 6 degrees invertedC) 8 degrees invertedD) 2 degrees inverted

18) Which of the following would be an appro-priate heel cup depth for an orthosis used totreat a child with hypermobile flatfoot?:

A) 5 mm.B) 10 mm.C) 18 mm.D) No heel cup

19) Several authors have suggested that a pre-fabricated “Kiddythotic” may be the most effi-cient and effective way to treat pediatric flat-foot at which age?:

A) Below three years of ageB) Over seven years of ageC) Only over 10 years of ageD) Should never be used

20) Which of the following pediatric patholo-gies are not appropriate to treat with orthosesand should not be attempted under any cir-cumstances?:

A) Hypermobile flatfootB) Downs Syndrome flatfootC) Cerebral Palsy flatfootD) Congenital vertical talus

E X A M I N A T I O N

(cont’d)

See answer sheet on page 137.

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You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.

PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2006,your enrollment is valid through August 31, 2007.

If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Man-agement can be found on the Internet athttp://www.podiatrym.com/cme. Each lessonis approved for 1.5 hours continuing education con-tact hours. Please read the testing, grading and pay-ment instructions to decide which method of partici-pation is best for you.

Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may beearned during any 12-month period. You may se-lect any 10 in a 24-month period.

The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instruction-al media are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.

www.podiatrym.com

Home Study CME credits nowaccepted in Pennsylvania

Over, please

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________State_______________________Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card is the only method of payment. Checks are no longer accepted.

Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________

State License(s)___________________________Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be chargedto your credit card.)

______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each examsubmitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individualexam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must completeall info. on the front and back of this page and mail with yourcredit card information to: Podiatry Management, P.O. Box490, East Islip, NY 11730.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or

higher on any examination will receive an official computer formstating the number of CE credits earned. This form should be safe-guarded andmay be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will benotified and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.

(4) Complete all other information on the front and back ofthis page.

(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information

and mail with your credit card information to:Podiatry Management

P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already

enrolled in the annual exam CPME program, and we receive this

ENROL LMENT FORM & ANSWER SH E E T

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137

Continuing

Medical Education

exam during your current enrollment period. If you are not en-rolled, please send $20.00 per exam, or $139 to cover all 10 exams(thus saving $61* over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and

fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free ser-

vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mondaythrough Friday. Your CPME certificate will be dated the same dayyou call and mailed within 48 hours. There is a $2.50 charge forthis service if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment peri-od), and this fee can be charged to your Visa, Mastercard, Ameri-can Express, or Discover. If you are not currently enrolled, the feeis $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

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ENROL LMENT FORM & ANSWER SH E E T (cont’d)Continuing

MedicalEducation

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #7/08Treatment of Pediatric Flexible Flatfoot

with Functional Orthoses(Scherer)

Documents

Pediatric Flexible Flatfoot Sep 2008 CME