When I first met 13-month-old Master G and his parents, he was able to roll and sit up independently, but he was not yet crawling and not yet walking. Master G had been diagnosed with mild Cerebral Palsy, and his parents came to see me with the aim of helping Master G to achieve independent walking by his 2nd birthday. With regular weekly physiotherapy sessions, Master G quickly learnt to move in and out of sitting, started crawling and pulling to stand. At this point, I noticed that in standing, Master G’s ankles rolled inwards and his midfoot collapsed down so he appeared to be flatfooted. When I assessed his feet at rest, his ankles were easily corrected to midline position and his midfoot corrected into neutral position. Bones grow with the increased forces in weight bearing and in the direction of the pull of muscles and ligaments. When a child starts to pull up into standing and learn to walk, they are placing more weight on their feet and ankles, resulting in the foot bones developing and the ankle ligaments and muscles becoming stronger. If the ankles roll inwards and the midfoot collapses down, the bones will then grow abnormally and effectively change the biomechanics of the foot and ankle, which in turn affects the pull of the muscles at the knees and hips and up into their back. When the pull of the muscles on the knee joint and hip joints are changed this in turn affects the development of the bones of the knee and hip joint, and as the song goes, “my foot bone is connected to my knee bone…” Ultimately, the poor development of the foot and ankle bones will impact on their walking patterns, the bone development in their legs and their whole spine.

So I suggested to his parents that we needed to get him some good footwear to support his feet and ankles into neutral alignment, so that his muscles and ligaments can strengthen in the correct position as he starts to learn to walk and keep his ankle and foot bones in the correct position. Master G’s parents, like many children with Cerebral Palsy has been told that their child will require Ankle-Foot-Orthosis (AFO) when he starts walking. However, Master G does not have increased spasticity in his feet that causes him to pull his ankles downwards, instead he has full range of motion in his ankle allowing him the ability to move from squatting to standing, I felt that having AFOs would actually limit his ability to move easily in and out of playing on the floor into standing. I recommended instead that Master G’s parents get him a pair of good footwear with built in supports to keep his feet and ankles in neutral position so that he can learn to walk with good supports to his feet without limiting his ankle movements. These shoes have to be fitted and purchased from a specialist footwear store. Once Master G got his new shoes, he very quickly learnt to walk and by 18 months old, he achieved independent walking. His parents were thrilled at the results we have achieved with regular and intensive physiotherapy.

Master G outgrew his first pair of supportive shoes soon after, however, his ankles and feet were now in midline and neutral position when he stood up in bare feet. We had successfully prevented his ankle and foot bones from developing abnormally and his muscles and ligaments strengthened in the correct alignment to facilitate his bones to develop normally. I then recommended that Master G no longer needs to have specialized footwear, instead he can have the standard good footwear easily purchased in children’s shoe shops. In addition, Master G has not progressed to needing any AFOs as he will maintain his calf muscle length and ankle range of motion actively with squatting and standing as he plays independently each day.

The lesson to point out in Master G’s story is that not every child with Cerebral Palsy need to have Ankle-Foot-Orthosis made, especially children who do not have increased spasticity in their calf muscles. Instead, with early intervention and good supportive footwear, we can effectively mold the development of the ankle and foot bones so that we can maintain the correct alignment of the ankle muscles and ligaments to prevent the rolling in of the anklebones and flat feet that many children with Cerebral Palsy end up developing. It is crucial to ensure that your therapist can make the correct judgment on whether Orthotics or Good Footwear is appropriate for your child at the right time. I believe that the right time is when your child starts to pull to stand and before they stand to learn to walk. Once the anklebones are formed, it is usually too late to try to correct the deformity if any is present.