SEPTEMBER 2012 | PODIATRY MANAGEMENT | 141www.podiatrym.com

The Responsibilityof the Pediatric Podiatrist

The goal of any practitioner, nomatter what the specialty, should beto better the lives of their patientsusing every tool available withoutbias. As podiatric physicians, we havethe unique ability to use all forms ofmedicine, including surgery, on ourpatients. A well-rounded podiatristshould be someone who recognizesthe implications of foot ailments atthe earliest of ages in order to preventadult problems.

The feet are the foundation of thebody, and from the first step a childtakes, deficiencies in the lower ex-tremity begin to create a destructivedomino effect on the rest of thehuman body. It is our job as podia-trists to make sure the feet are takencare of. Whether a child has a simpleor complicated medical history, feetshould be screened and treated likethose of anyone else. Children withthe diagnosis of Down syndrome areno exception.

“Normal” Development of thePediatric Foot

Let’s talk about what should occurwith foot maturation of any child re-gardless of other medical diagnoses.At the age of two years old, the heelbone should sit at about 4 degrees orso everted (means that when you lookfrom the back of the child, the heelbone looks like its collapsing down

and in.) From two years old until sixyears old, the “normal foot” shouldlose about one degree of the “ever-sion” per year and at the age of six,the heel should stand somewhat“straight up.” This allows an arch tobe present. The foot support is on theoutside, bringing the center of gravityto a more neutral stance. Another phe-nomenon that is “supposed to hap-pen” as we grow older until aroundseven, is that our lower leg bones start

to turn out, and we get a more erectstance. For a majority of those withDown syndrome, these two “normal”processes do not occur adequately.

The Down Syndrome PatientIn a patient diagnosed with Down

syndrome, there are a multitude ofconcerns which may be present in-volving the heart, digestive system,spine, eyes, intellect, joints and mo-bility. Individuals with Down syn-drome typically have problems withcollagen, which is the major proteinthat makes up ligaments, tendons,

cartilage, bone, and the support struc-ture of the skin. This creates signifi-cant laxity from the feet up, thus be-ginning at a young age the lifelongdestruction of the kinetic chain. “Al-most all of the conditions that affectthe bones and joints of people withDown syndrome arise from the abnor-mal collagen found in Down syn-drome.”1 The resulting effect in 88%of the Down syndrome population ishypotonia, with ligamentous laxity

and/or hyper-mobility of the joints.2

The combination of this ligamentouslaxity and low muscle tone contributeto orthopedic problems in people withDown syndrome.

Within the feet, the most commonfoot problems which can be found inthe Down syndrome patient are “digi-tal deformities, hallux abducto valgus,pes plano valgus, metatarsus primusadductus, hyper mobile 1st ray,brachymetatarsia, Haglunds’ deformi-ty, syndactaly and Tailors bunion.”2

Genu valgus and subluxation and/or

Early diagnosis and treatment can improve the lives of these patients.

Down Syndrome:A Serious Pediatric/

Podiatric Issue

BY LOUIS J. DECARO, DPM

Continued on page 142

From two years old until six years old,the “normal foot” should lose about one degree

of the “eversion” per year and at the age of six, the heelshould stand somewhat “straight up.”

www.podiatrym.com

BIOMECHANICS AND ORTHOTICS

DOWN SYNDROME

142 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

dislocation of the patella are anotherconcern due to this condition. Hipand spinal issues are often seen aswell.1

Overall laxity of the feet has beenreported in 88% of children withDown syndrome.3 This percentage isfar higher than in those without, yetoften their feet are ignored. The pri-mary medical diagnosis seems totrump the importance of good foothealth. They should not. All medicalissues should be addressed.

Specifically the FeetMany patients with Down syn-

drome have flat feet due to laxity,which will not cure itself. We need toscreen for this early. This troublingflexible flat foot can be spotted at avery young age. Unlike with manychildren though, this flat presentationdoes not go away by the age of threebut continues, causing foundationaldestruction to the rest of the body asthe years go on.

Your young Down syndrome pa-tients have an inability of the heelbone to come out of eversion. Whenthat happens, the arch, the ankle, andinevitably the rest of the body stay flatand become “dragged down” towardthe midline. This causes many kidswith DS to have trouble sustaininggood strengthwhen they standand buildinggood core mus-culature. This“collapse” willimpair normalexternal rotationof some longbones of thebody, whichleads to multiplepostural changes.When physicaltherapy is calledupon to strength-en the child, fail-ure or delay ofachieving astrong kineticchain is inevitable. You can’t build ona poor foundation! Not only will thestructure not support it, but due topoor foot alignment, the muscles dur-ing the exercises may not even fire.

Quality of Life Factorsfor Down SyndromePatients

According to Benoit,“when a person has limit-ed ability for movement,there is bound to be somerestriction in exposure tolearning opportunitiesand social stimulation,and this privation tendsto be reflected in de-pressed intellectual abili-ty.”4 In other words, byallowing the patient to bemore mobile, the patien-t’s overall well being willbe increased. This is criti-cal since those withDown syndrome are liv-ing twice as long as theywere 25 years ago.5

In fact, studies have shown thatthose with Down syndrome livelonger when they have developedgood self-help skills.6 What betterway to encourage self-help than toenable a patient to walk, run, and bephysically active over the course of alifetime?

It is a known fact that with Downsyndrome comes with an increasedincidence of Alzheimer’s disease.With that typically comes an increase

in proteinscalled Amyloids.Researchers atWashingtonUniversity in St.Louis found thatthere was a cor-relation betweena sedentarylifestyle and ahigher level ofamyloid deposi-tion.7 Thus, thescience is onceagain telling usthat inactivitycan lead to anearly demise.Obesity is alsocommon in

Down syndrome patients, partiallydue to inactivity. By correcting thebiomechanics, inactivity may be less-ened and quality of life may be in-creased (Figure 1).

Treating the Pediatric FootIt’s troubling that identifying

problem feet at an early age is almostnon-existent in the medical communi-ty. This is especially true in thosewith Down syndrome. Not only arethe feet typically last to be looked atbut also since there can be a plethoraof other ailments, the feet get littlenotice. A person’s foot type is theirfoot type no matter what medical con-dition they may or may not have. Un-beknownst to them, many practition-ers fall guilty of not recognizing andtreating important issues like flat feetwhen they become focused on whatthey deem “larger problems.”

Most Common Foot Typesin Down Syndrome

There are six major categories offoot types (www.whatsmyfoottype.com)in the adult population, each becom-ing apparent as early as age six orseven. When a podiatrist treats a pa-tient with Down syndrome, whetheran adult or a child, the biomechanicsof the feet and lower extremities needto be analyzed closely, and each pa-tient needs to be foot-typed. Fre-quently, patients with Down syn-drome have a D foot type with a neu-tral to mildly compensated rearfootand a neutral forefoot.

As the child matures to adult-hood, this foot type can often

Continued on page 144

Figure 1: A patient of Dr. DeCaro’s successfully completing a climbto the top of a mountain for the first time utilizing the correct footsupport. Functional orthoses can significantly increase the activelifestyle of a child diagnosed with Down syndrome.

Figure 2: Typical foot type in those with Down syn-drome pictured left to right: The D foot type (neutralforefoot with compensated rearfoot) The F foot type(rigid forefoot varus with compensated rearfoot) cour-tesy of www.whatsmyfoottype.com

www.podiatrym.com

BIOMECHANICS AND ORTHOTICS

DOWN SYNDROME

144 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

progress to an F foot type where theheel rotates even more, causing theperson to strike the heel on the in-side. This creates more collapse of thesubtalar joint, which pulls the entiremedial side of the kinetic chain down-ward, resulting in genu valgus, kneetorsion, and greater hip rotation. Thisis a very inefficient foot type causingearly fatigue and muscle pain (Figure2). It’s like every step the child takesis in quick sand. Let’s quickly reviewthe specifics of these two commonfoot types.

The D Quad foot type is a moder-ately over-pronated foot-type. Thisfoot-type occurs when a compensatedrearfoot varus exists with a normal orneutral forefoot alignment. This foot-type is congenitally a partially unsta-ble foot and is often diagnosed in chil-dren as developmental flat foot. It’s amistake to think that this child will“out-grow the deformity.” Just ask thebiological parents, grandparents, andolder siblings to take off their shoesand socks. If family members demon-strate similar foot characteristics,chances are that this child is not goingto develop an arch. During gait, thisfoot begins to pronate at the subtalarjoint in contact phase, and continuesto pronate throughout midstance. Inpropulsion, the 1st ray will plantarflexto load the medial column of the footand allow the foot to re-supinate.

The F Quad Foot Type is com-

monly referred to as a pes planoval-gus foot deformity because of its verypoor alignment to the floor. This is atrue “flat foot.” The condition occurswhen a compensated rearfoot varus iscoupled with a large flexible forefootvarus (also called forefoot supina-tus).This foot type is the most hyper-mobile or flexible of the foot-types.This hypermobility leads to great in-stability throughout the foot andankle, and can be prevalent through-out the body.

These feet look “very flat” at anearly age and can only worsen intoadulthood. This severe instability alsomakes it difficult todevelop and main-tain core strengththroughout thelegs and trunk.Muscles need towork “overtime”to do the same jobas someone withbetter functioningfeet, drastically in-creasing energy ex-penditure. Thisfoot-type causes alot of damage tothe forefoot duringpropulsion. In ad-dition to transversemetatarsal arch re-versal, don’t besurprised to seehammertoes, hal-lux abductovalgusdeformity, functional hallux limitus,and painful corns and calluses.

Effects of the D & F Foot (of thosewith Down Syndrome) on theKinetic Chain

Let’s start with the knee. LenLeshin, MD, FAAP writes, “Instabilityof the patella (kneecap) has been esti-mated to occur in close to 20 percentof people with DS. The majority of

cases of instability present only askneecaps that can be moved further tothe outside than the normal kneecap(subluxation); however, some peoplecan have their kneecaps completelymove out of position (dislocation),and some may even have a hard timegetting it back into the right position.Mild subluxation of the kneecap is notassociated with pain, but dislocationmay be painful. While people with in-stability of the patella are able towalk, there is often a decreased range

of motion of the knee, with an accom-panying change in gait. The longerthat nothing is done for the instability,

the worse the con-dition will getover time. Or-thoses (specialbraces) may beuseful for mildcases, but severecases require sur-gical correction.”1

Next up thechain comes thehip. Leshin con-tinues, “Five toeight percent ofchildren with DSwill develop ab-normalities of thehip. The mostcommon condi-tion is dislocationof the hip, whichis also called sub-luxation. In this

condition, the head of the thigh bone(the femur) moves out of the socketformed by the pelvis (the acetabu-lum). This dislocation may or may notbe associated with malformation ofthe acetabulum. The dislocation ap-pears to be due to a combination oflaxity of the connective tissue thatnormally keeps the hip together alongwith the low muscle tone found in DS.

Interestingly, hip subluxation inchildren with Down syndrome is hard-ly ever found at birth but instead ismost common between the ages ofthree and 13 years. The most commonsign is a limp, and pain may or maynot be present. Treatment often startswith immobilization of the hip with acast. Many children with DS will re-quire surgical correction, however.”1

And finally, there’s the back.Leshin adds, “Another condition asso-ciated with the spine in Down syn-drome is scoliosis, which is the curva-ture of the spine to the side. While itappears to be more common in peo-ple with DS, the exact incidence isn’tknown….Treatment of scoliosis re-mains the same as in other children,with bracing being the initial therapy,followed by surgical intervention ifnecessary.”1

While people with instability of the patella are ableto walk, there is often a decreased range of motion of the

knee, with an accompanying change in gait.

Continued on page 145

Figure 3: A functional UCB type orthotic, withhigh medial and lateral sidewall flanges, such aslittleSTEPS, combined with supportive footwear,can be highly effective for the typically flexible footof a young child with Down Syndrome.

SEPTEMBER 2012 | PODIATRY MANAGEMENT | 145www.podiatrym.com

BIOMECHANICS AND ORTHOTICS

DOWN SYNDROME

The Overall PlanOrthoses need to be specifically designed to improve

coordination, balance, pain, posture, and strength, and toaid in the development of a more stable and functionalgait. These orthoses should be comprised of a deep heelcup, a medial heel skive, and high medial and lateral side-wall flanges (Figure 3). Control of the subtalar joint isparamount. Often, kids are over-braced with AFOs due tolack of foot control. By providing adequate foot control,SMOs and AFOs oftentimes are not necessary. Many chil-dren who are “over-braced” lack necessary joint move-ments and muscle development vital for normal growthand maturity.

Complementary Solutions to Early BiomechanicalSupport

Physical therapy progress typically associated withDown syndrome motor development is slow; and insteadof walking by 12 to 14 months as other children do, chil-dren with Down syndrome usually learn to walk between15 to 36 months. Specific physical therapy recommenda-tions to consider, along with inserts/orthotics/SMOs, in-clude: “Strengthening of lower extremity musculature(hips, knees, ankles, and feet) aimed at improving pushoff and augmenting support of the knee joint. Heel cordstretching with the heel in neutral alignment when limitedpassive range of motion exists. Lastly, dynamic balanceactivities, such as running or descending stairs, which en-courage the child to shift their weight during late swingphase rather than waiting until heel contact.”8

These are very good recommendations. Many thera-pists are seeing that when orthotic inserts are prescribedalong with physical therapy, the improvement really sticksand builds. Children in therapy have everted/flat feet andeither never or too slowly build on strength, absent theseorthotics. Building a better foundation helps those musclesmove along faster.

Getting the Down Patient to Make an AppointmentTo treat a Down syndrome patient, you have to see

them. That is where education is so critical. In many ofour communities, we have early intervention services forbabies born prematurely or with medical concerns. Thiscan be the place where an initial referral can originate.When an EI therapist understands the importance of thefeet and biomechanics in the development of any child,she/he can screen for this. With early intervention, Downsyndrome patients can have a better outcome in meetingdevelopmental milestones and lessening risks ofAlzheimer’s and obesity.

SummarySo what can you do to help? As podiatrists, we are in

the unique position of being trusted medical professionalsof the lower extremity and its effects on the kinetic chain.This gives us the ability to get out and educate, educate, ed-ucate. Preparing the community of people who work withthe Down syndrome patients is the key to getting these

Continued on page 146

www.podiatrym.com

BIOMECHANICS AND ORTHOTICS

DOWN SYNDROME

146 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

clients proper foot care early in life inorder to allow them a better chance oflong, healthy, active lives. “Treatmentof painful feet in patients with Downsyndrome is imperative because footpain leads to relative immobilizationand immobile retarded adults do notremain long in the community.”9

Your goal as a practitioner andsomeone who recognizes the progres-sion of foot types is preventing painby knowing how to deal with it be-fore it happens, coupled with improv-ing overall biomechanical strengthand structure. No matter what achild’s medical diagnosis, it is impor-tant to educate parents and their chil-dren in what their “foot type” is, andwhat that may bring them duringtheir adult years.

Please feel free to reference thewebsites www.whatsmyfoottype.comand http://www.decaropodiatry.comfor additional information regardingmy practice and its methodologies. PM

Note: The author wishes to thankKay Brooke-Willbanks, PMA for herassistance with this article.

References1 Leshin, L. (2003). DS Musculoskele-

tal Conditions in Down Syndrome. In Mus-culoskeletal Disorders in Down Syndrome.Retrieved May 25, 2012, from www.ds-health.com/ortho.htm.

2 Rogers, C.: Carers Knowledge ofcommon foot problems associated withpeople with Down’s Syndrome. UniversityCollege Northampton, 2002.

3 Aprin H, Zink WP, Hall JE: Manage-ment of dislocation of the hip in Downsyndrome. J Pediatr Orthop 5: 428, 1985.

4 Benoit, E.: Podiatry and mental retar-dation: The podiatrist’s role. J.A.P.A., 55:434, 1965.

5 Young, E. (March 22, 2002). NewScientist. Down’s syndrome lifespan dou-bles. Retrieved June 5, 2012, fromwww.newscientist.com/article/dn2073-downs-syndrome-lifespan-doubles.html.

6 Eyman RK, Amer J Mental Retard,95(6): 603-612, 1991.

7 Head, D., Exercise Engagement as aModerator of the Effects of APOE Genotypeon Amyloid Deposition, January 9, 2012.

8 Selby-Silverstein, L.: The effect of footorthoses on standing foot posture and gaitof young children with Down Syndrome.NeuroRehabilitation 16 (2001) 183-193.

9 Diamond, L.S. and Lynne, D. et al.,Orthopedic disorders in patients withDown’s syndrome, The Orthopedic Clinicsof North America 12(1) (1981), 57-71.

Louis J. DeCaro, DPMspecializes in pediatricswith a special interestin sports medicine andbiomechanics. He is a vice-president of the AmericanCollege of Foot & AnklePediatrics and a memberof the surgical & medicalstaff at Holyoke Medical

Center and FranklinMedical Center. He is currentlyin private practice in West Hatfield, MA. He isthe director and founder of the MultidisciplinaryAdult & Pediatric Gait Labs Biomechanics Clinic.His e-mail is louisdecaro@decaropodiatry.com.