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Shoe stories.

Yesterday, the last patient of the morning's routing sheet listed "needs orthotics" as the chief complaint. This meant that I would probably be seeing one of my physically challenged patients who had been wearing orthotics to achieve some reasonable facsimile of ambulation. They had either outgrown or lost the inserts, and now my reapproval and signature was needed so a third party payor might cover at least some of the cost.

Or, the patient may have had flat feet and although not having any pain someone had told his parents, "'My brother's feet look like that and the doctor prescribed orthotics." While I have found that orthotics can be helpful for some children with severe flat feet, usually good supportive shoes are sufficient. If the child is actively growing (most are), I encourage parents to go with over-the-counter orthotics to avoid the cost of custom made inserts that will be outgrown in 6 months.

This 8-year-old's mother told me that she was concerned because her son's shoes were wearing unevenly. And, she had heard that this might point to a problem that could be managed with orthotics. She had also heard that these untreated asymmetries might lead to hip, knee, or ankle problems later in life.

As I began my exam, the child was sitting on the table in shorts. The most striking finding was the appearance of his legs. Each was covered with a mosaic of dirt and grass stains, bug bites, and bruises of various shapes and sizes. When I had him stand down on the floor, he had the mildest pronation I had seen all day. I could easily get a finger tip under each arch. His gait and hopping were confident and athletic.

His shoes were well made by a prominent athletic footwear manufacturer. They had a good solid heel counter that extended well forward on the medial side. However, the soles were worn down three layers in some places and at least two all over. The wear was slightly more prominent on the lateral aspect of both heels. These shoes had not spent much time sitting idly on some mud room floor.

As I shared my findings with his mother, I told her that seeing her son's legs and shoes was a refreshing oasis in my day of looking at underutilized bodies. I told her not to be embarrassed by the grass and dirt stains but to exhibit them with pride. I told her that her son had an insignificant amount of pronation and that she had chosen his shoes wisely. The condition of his shoes was a tribute to the active lifestyle that her parenting style had fostered. He child didn't need orthotics. He just needed a new pair of the good shoes he had worn out.

This encounter triggered a flashback to my medical school days when I interviewed the mother of a 6-year-old who was 6 months past a congenital cardiac defect repair. She tearfully told me how that week was the first time she had ever had to buy her daughter shoes because the old ones had been worn out. Prior to that, the child had been too weak to be active.

Maybe it's because my uncle owned a shoe store, but I always include at least a glance at the patient's footwear as part of my exam. It may just give me an "ice breaker" opportunity, such as, "Those are cool fire truck sneakers." But, sometimes what the child is wearing on his feet can tell me something about his family and how he spends his day.

Sadly, the most common finding is that while the uppers may be stained with a collection of soda and ice cream drippings, the soles are scarcely worn. Shoes can last forever ff you spend your days on the couch.


Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@
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Author:Wilkoff, William G.
Publication:Pediatric News
Date:Jan 1, 2013
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