As parents, we constantly monitor our children's development, celebrating each milestone and watching for any signs that they might need additional support. When it comes to foot and ankle development, Supramalleolar Orthoses (SMOs) can play a vital role in helping children with various gait and stability issues. At Orthopedic Appliance Company, we've been helping families throughout Western North Carolina understand when these specialized braces might benefit their children's development and mobility.
What Are SMOs?
Understanding Supramalleolar Orthoses
Supramalleolar Orthoses, commonly known as SMOs, are custom-made braces that extend from the foot to just above the ankle (supramalleolar region). Unlike Ankle-Foot Orthoses (AFOs) which provide more rigid support and control, SMOs offer a more flexible solution that supports the foot and ankle while still allowing for natural movement and development.
SMOs are typically made from lightweight, durable plastic materials and are custom-fitted to your child's unique foot shape. They're designed to be worn inside regular shoes and provide support in key areas while allowing for proper muscle development and strengthening.
How SMOs Differ from AFOs
While both SMOs and AFOs fall under the category of lower extremity bracing, they serve different purposes and conditions:
- SMOs provide moderate support primarily below and around the ankle, allowing for more ankle movement while still supporting foot alignment.
- AFOs extend higher up the leg and offer more significant control of the ankle and foot, limiting certain movements more substantially.
For many children with mild to moderate stability or alignment issues, SMOs provide just enough support without unnecessarily restricting movement that's important for development. Read more about the differences between SMOs and AFOs in our blog.
7 Key Signs Your Child May Need SMOs
1. Delayed Walking or Standing
Most children begin walking independently between 12-18 months of age. If your child shows significant delays in standing or walking independently, it may indicate a need for additional foot and ankle support. Watch for:
- Reluctance to bear weight on feet by 15 months
- Not walking independently by 18 months
- Preference for crawling or scooting rather than walking
- Difficulty maintaining balance when attempting to stand
Remember that some variation in development timing is normal, but persistent delays warrant professional evaluation.
2. Unusual Walking Patterns
Children typically develop a mature walking pattern by age 3-4. Before this age, some variation is expected, but certain persistent patterns may indicate the need for SMOs:
- Toe walking (consistently walking on tiptoes)
- In-toeing (feet turn inward when walking)
- Out-toeing (feet turn outward when walking)
- Foot slapping or drop (foot hits the ground with audible slap)
- Waddling gait with excessive side-to-side movement
- Asymmetrical walking where one side appears different from the other
While many children go through phases of toe walking or in-toeing, persistent patterns beyond age 3 often benefit from professional assessment.
3. Excessive Tripping and Falling
All children trip and fall as they learn to walk, but excessive or persistent falling beyond the early learning stages may indicate a need for SMOs:
- Frequent tripping over flat surfaces
- Falls that seem disproportionate to environmental obstacles
- Tendency to trip over own feet
- Inability to recover balance easily after minor obstacles
- Increasing rather than decreasing frequency of falls as the child ages
- Avoidance of physical activities due to fear of falling
These patterns may indicate instability in the foot and ankle that could be supported with appropriate orthotic devices.
4. Visible Foot Alignment Issues
Visual cues in your child's feet and ankles can provide important information about potential structural issues:
Flat Feet (Pes Planus)
While most babies have flat feet due to fat pads that disappear over time, persistent flat feet beyond age 3-4 may indicate a problem, especially if accompanied by:
- Pain or discomfort when walking or running
- Visible collapsing of the arch when standing
- Feet that appear to roll inward excessively (overpronation)
- Inside edges of shoes wearing out quickly
Hypermobile Joints
Some children have joints that are more flexible than average. While flexibility can be beneficial, excessive joint mobility can lead to instability:
- Ankles that seem to "wobble" when walking
- Ability to move feet and ankles in extreme ranges of motion
- Frequent ankle rolling or sprains
- Poor recovery after minor ankle injuries
- Joint hyperextension in other body areas (elbows, knees)
Muscle Tone Concerns
Both high muscle tone (hypertonia) and low muscle tone (hypotonia) can affect foot and ankle stability:
- Low Tone Signs: Floppy appearance, poor endurance, preference for sedentary activities, delayed gross motor skills
- High Tone Signs: Stiffness, toe walking, difficulty with smooth movements, limited range of motion
5. Complaints of Pain or Fatigue
Children may not always articulate discomfort clearly, but these signs might indicate foot and ankle issues:
- Requesting to be carried frequently during activities other children their age can complete
- Avoiding playground equipment or physical play
- Removing shoes frequently or complaining that shoes hurt
- Rubbing feet, ankles, or legs after minimal activity
- Sitting down or stopping activities earlier than peers
- Complaining of "tired legs" or sore feet after typical childhood activities
6. Abnormal Shoe Wear Patterns
Examine your child's shoes for these telling signs:
- Uneven wear on the soles (typically more wear on the inside or outside edges)
- One shoe showing different wear patterns than the other
- Shoes that lose their shape quickly
- Excessive wear at the toes (indicating toe walking)
- Shoes that tilt to one side when placed on a flat surface
7. Developmental or Neurological Diagnoses
Certain diagnoses often benefit from SMO intervention:
- Cerebral Palsy (mild forms)
- Developmental Coordination Disorder
- Hypotonia (low muscle tone)
- Down Syndrome
- Autism Spectrum Disorder (in some cases with associated motor challenges)
- Muscular Dystrophy (early stages)
- Charcot-Marie-Tooth Disease
When to Seek Professional Evaluation
Age-Based Considerations
- Under 2 years: If your child isn't bearing weight or attempting to walk by 18 months
- Ages 2-3: Persistent toe walking, significant in-toeing or out-toeing, or excessive falling
- Ages 3-5: Continued abnormal gait patterns, complaints of pain, or avoidance of physical activity
- School-age: Difficulty keeping up with peers, fatigue after typical activities, or visible foot alignment issues
The Assessment Process
At Orthopedic Appliance Company, our pediatric assessment typically includes:
- Detailed history: We'll discuss your child's developmental milestones, any diagnoses, and your specific concerns
- Observational gait analysis: Watching how your child walks and moves
- Physical examination: Assessing range of motion, muscle strength, and joint stability
- Footprint and pressure analysis: Understanding how your child bears weight
- Functional assessment: Evaluating how your child navigates different activities and terrains
What to Expect with SMOs
If our specialists determine that SMOs would benefit your child, here's what to expect:
The Fitting Process
- Precise measurements or casting of your child's feet and ankles
- Custom fabrication of the orthoses to your child's unique specifications
- Initial fitting with adjustments as needed
- Instructions for wear schedule and care
Adjustment Period
Most children adapt to SMOs within 2-4 weeks. During this time:
- Begin with shorter wearing periods (1-2 hours), gradually increasing to full-day wear
- Monitor for any signs of discomfort, pressure points, or skin irritation
- Keep scheduled follow-up appointments for adjustments
- Follow recommended exercises or activities to complement the bracing
Expected Outcomes
With consistent use of properly fitted SMOs, many children experience:
- Improved stability and balance
- Reduced falling and tripping
- More efficient gait pattern
- Decreased fatigue during activities
- Better alignment that may prevent future complications
- Increased confidence in physical activities
Supporting Your Child's Journey with SMOs
Creating a Positive Experience
Children may initially resist wearing orthotic devices. These strategies can help:
- Involve them in choosing colorful straps or decorations for their SMOs
- Establish a consistent routine for wearing
- Provide positive reinforcement and celebrate improvements
- Read children's books about wearing braces
- Connect with other families whose children wear similar devices
- Focus on the activities the SMOs will help them enjoy
Partnering with Other Professionals
SMOs work best as part of a comprehensive approach that may include:
- Physical therapy to strengthen supporting muscles
- Appropriate footwear selection
- School accommodations if needed
- Regular reassessment as your child grows
- Coordination with other healthcare providers
Frequently Asked Questions About Pediatric SMOs
1. How do I know if my child needs SMOs or AFOs?
The decision between SMOs and AFOs depends on the level of support your child needs. SMOs are typically recommended for children with mild to moderate stability issues who have good ankle control but need foot alignment support. AFOs provide more substantial control and are often used for children with more significant weakness, instability, or neurological conditions affecting muscle tone and control. A professional evaluation from our pediatric orthotic specialists can determine which brace would best serve your child's specific needs.
2. At what age can children start wearing SMOs?
Children can begin wearing SMOs as soon as stability issues are identified, even as young as when they begin pulling to stand (around 9-12 months). Early intervention often yields better outcomes as it supports proper alignment during crucial developmental periods. For older children who develop symptoms later, SMOs can be introduced at any age when the need becomes apparent. The design and materials will be adapted based on your child's age, size, and specific requirements.
3. How long will my child need to wear SMOs?
The duration of SMO use varies significantly depending on the underlying condition and your child's response to treatment. Some children may need SMOs for 6-12 months to correct a specific issue, while others with ongoing developmental or neurological conditions may benefit from them for several years. Regular reassessment is essential, as children's needs change as they grow. Our team works with families to establish clear goals and regularly evaluate progress to determine the appropriate duration of use.
4. Will SMOs delay my child's development or weaken their muscles?
This is a common concern, but properly prescribed SMOs actually support normal development by enabling better alignment and more efficient movement patterns. Rather than replacing natural muscle function, SMOs provide the stability needed for children to use their muscles more effectively. In many cases, children become more active with SMOs because movement becomes easier and less tiring. Your orthotist and physical therapist may recommend specific exercises to ensure continued muscle development while wearing SMOs.
5. How often will my child need new SMOs?
Growing children typically need new SMOs every 12-18 months, though this varies based on growth rate and wear patterns. Signs that replacement may be needed include:
- Redness or pressure marks on the skin
- Complaints of discomfort
- Visible outgrowing of the device
- Deterioration of the materials
- Changes in your child's gait or function
Regular follow-up appointments allow us to monitor fit and function and plan for replacements before problems develop.
6. Will insurance cover SMOs for my child?
Many insurance plans, including Medicaid, cover pediatric orthotic devices when medically necessary. Coverage typically requires a prescription from a physician and documentation of medical necessity. Our office staff at Orthopedic Appliance Company specializes in navigating insurance requirements and can help verify your coverage, obtain necessary authorizations, and explain any potential out-of-pocket costs before proceeding with fabrication.
7. Can my child wear regular shoes with SMOs?
Yes, most children can wear regular shoes with SMOs, though you may need to select shoes with certain features:
- Adequate depth to accommodate the brace
- Removable insoles to create extra space
- Shoes that open widely for easy entry
- Firm heel counter for stability
- Flexible sole in the forefoot
- Secure closure (velcro or laces)
We typically recommend buying shoes a half to full size larger than your child's foot measurement, with a wide width if available. We can provide specific shoe recommendations based on your child's unique SMO design.
8. How do I clean and maintain my child's SMOs?
SMOs should be cleaned regularly with mild soap and water, then thoroughly dried before wearing. Avoid soaking the braces or using harsh chemicals, as these can damage the materials. Check regularly for cracks, rough edges, or loose parts that might need repair. Straps and padding may need replacement more frequently than the plastic shell. We provide detailed care instructions specific to the materials used in your child's devices.
9. Can my child participate in sports and physical activities with SMOs?
Absolutely! One of the main goals of SMO treatment is to enable children to participate fully in age-appropriate activities. Most children can engage in regular physical education, sports, and recreational activities while wearing their SMOs. For water activities, check with your orthotist about whether your child's specific SMOs are waterproof or if temporary removal is recommended. For some competitive sports, sport-specific adaptations to the SMOs may be beneficial.
10. What's the difference between custom and off-the-shelf SMOs?
Custom SMOs are fabricated based on precise measurements or molds of your child's feet and ankles, ensuring an exact fit that addresses their specific alignment issues. Off-the-shelf (prefabricated) SMOs come in standardized sizes and may be appropriate for mild, symmetrical issues or as a temporary solution while custom devices are being made.
While prefabricated options are less expensive, custom devices typically provide better outcomes for children with moderate to significant alignment challenges or asymmetrical issues. Our team can recommend the most appropriate option based on your child's needs and practical considerations.
Contact Us for a Pediatric Orthotic Evaluation
If you've noticed any of these signs in your child, the experienced pediatric orthotic team at Orthopedic Appliance Company is here to help. With locations in Asheville, Fletcher, Hickory, Spruce Pine, Rutherfordton, Murphy, Morganton, and Bryant, AR, we provide comprehensive evaluations and custom SMO solutions tailored to your child's unique needs.
Call us at (828) 254-6305 to schedule a pediatric assessment and learn how SMOs might help your child move more confidently and comfortably.
Orthopedic Appliance Company - Supporting children's mobility with expert orthotic care since 1960.