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Down Syndrome: a Serious Pediatric/ Podiatric Issue Down Syndrome: A Serious Pediatric/ Podiatric Issue Early diagnosis and treatment can improve the lives of these patients. BY LOUIS J. DECARO, DPM The Responsibility and in.) From two years old until six cartilage, bone, and the support struc - of the Pediatric Podiatrist years old, the “normal foot” should ture of the skin. This creates signifi - The goal of any practitioner, no lose about one degree of the “ever - cant laxity from the feet up, thus be - matter what the specialty, should be sion” per year and at the age of six, ginning at a young age the lifelong to better the lives of their patients the heel should stand somewhat destruction of the kinetic chain. “Al - using every tool available without “straight up.” This allows an arch to most all of the conditions that affect bias. As podiatric physicians, we have be present. The foot support is on the the bones and joints of people with the unique ability to use all forms of outside, bringing the center of gravity Down syndrome arise from the abnor - medicine, including surgery, on our to a more neutral stance. Another phe - mal collagen found in Down syn - patients. A well-rounded podiatrist nomenon that is “supposed to hap - drome.” 1 The resulting effect in 88% should be someone who recognizes pen” as we grow older until around of the Down syndrome population is the implications of foot ailments at seven, is that our lower leg bones start hypotonia, with ligamentous laxity the earliest of ages in order to prevent adult problems. The feet are the foundation of the body, and from the first step a child From two years old until six years old, takes, deficiencies in the lower ex - the “normal foot” should lose about one degree tremity begin to create a destructive domino effect on the rest of the of the “eversion” per year and at the age of six, the heel human body. It is our job as podia - should stand somewhat “straight up.” trists to make sure the feet are taken care of. Whether a child has a simple or complicated medical history, feet should be screened and treated like to turn out, and we get a more erect and/or hyper-mobility of the joints. 2 those of anyone else. Children with stance. For a majority of those with The combination of this ligamentous the diagnosis of Down syndrome are Down syndrome, these two “normal” laxity and low muscle tone contribute no exception. processes do not occur adequately. to orthopedic problems in people with Down syndrome. “Normal” Development of the The Down Syndrome Patient Within the feet, the most common Pediatric Foot In a patient diagnosed with Down foot problems which can be found in Let’s talk about what should occur syndrome, there are a multitude of the Down syndrome patient are “digi - with foot maturation of any child re - concerns which may be present in - tal deformities, hallux abducto valgus, gardless of other medical diagnoses. volving the heart, digestive system, pes plano valgus, metatarsus primus At the age of two years old, the heel spine, eyes, intellect, joints and mo - adductus, hyper mobile 1st ray, bone should sit at about 4 degrees or bility. Individuals with Down syn - brachymetatarsia, Haglunds’ deformi - so everted (means that when you look drome typically have problems with ty, syndactaly and Tailors bunion.” 2 from the back of the child, the heel collagen, which is the major protein Genu valgus and subluxation and/or bone looks like its collapsing down that makes up ligaments, tendons, Continued on page 142 www.podiatrym.com SEPTEMBER 2012 | PODIATRY MANAGEMENT | 141 BIOMECHANICS AND ORTHOTICS DOWN SYNDROME dislocation of the patella are another Quality of Life Factors concern due to this condition. Hip for Down Syndrome and spinal issues are often seen as Patients well. 1 According to Benoit, Overall laxity of the feet has been “when a person has limit - reported in 88% of children with ed ability for movement, Down syndrome. 3 This percentage is there is bound to be some far higher than in those without, yet restriction in exposure to often their feet are ignored. The pri - learning opportunities mary medical diagnosis seems to and social stimulation, trump the importance of good foot and this privation tends health. They should not. All medical to be reflected in de - issues should be addressed. pressed intellectual abili - ty.” 4 In other words, by Specifically the Feet allowing the patient to be Many patients with Down syn - more mobile, the patien - drome have flat feet due to laxity, t’s overall well being will which will not cure itself. We need to be increased. This is criti - Figure 1: A patient of Dr. DeCaro’s successfully completing a climb screen for this early. This troubling cal since those with to the top of a mountain for the first time utilizing the correct foot flexible flat foot can be spotted at a Down syndrome are liv - support. Functional orthoses can significantly increase the active very young age. Unlike with many ing twice as long as they lifestyle of a child diagnosed with Down syndrome. children though, this flat presentation were 25 years ago. 5 does not go away by the age of three In fact, studies have shown that Treating the Pediatric Foot but continues, causing foundational those with Down syndrome live It’s troubling that identifying destruction to the rest of the body as longer when they have developed problem feet at an early age is almost the years go on. good self-help skills. 6 What better non-existent in the medical communi - Your young Down syndrome pa - way to encourage self-help than to ty. This is especially true in those tients have an inability of the heel enable a patient to walk, run, and be with Down syndrome. Not only are bone to come out of eversion. When physically active over the course of a the feet typically last to be looked at that happens, the arch, the ankle, and lifetime? but also since there can be a plethora inevitably the rest of the body stay flat It is a known fact that with Down of other ailments, the feet get little and become “dragged down” toward syndrome comes with an increased notice. A person’s foot type is their the midline. This causes many kids incidence of Alzheimer’s disease. foot type no matter what medical con - with DS to have trouble sustaining With that typically comes an increase dition they may or may not have. Un - good strength in proteins beknownst to them, many practition - when they stand called Amyloids. ers fall guilty of not recognizing and and building Researchers at treating important issues like flat feet good core mus - Washington when they become focused on what culature. This University in St. they deem “larger problems.” “collapse” will Louis found that impair normal there was a cor - Most Common Foot Types external rotation relation between in Down Syndrome of some long a sedentary There are six major categories of bones of the lifestyle and a foot types (www.whatsmyfoottype.com) body, which higher level of in the adult population, each becom - leads to multiple amyloid deposi - ing apparent as early as age six or postural changes. tion. 7 Thus, the seven. When a podiatrist treats a pa - When physical science is once tient with Down syndrome, whether therapy is called again telling us an adult or a child, the biomechanics upon to strength - Figure 2: Typical foot type in those with Down syn - that inactivity of the feet and lower extremities need drome pictured left to right: The D foot type (neutral en the child, fail - can lead to an to be analyzed closely, and each pa - forefoot with compensated rearfoot) The F foot type ure or delay of tient needs to be foot-typed. Fre - (rigid forefoot varus with compensated rearfoot) cour - early demise. achieving a tesy of www.whatsmyfoottype.com Obesity is also quently, patients with Down syn - strong kinetic common in drome have a D foot type with a neu - chain is inevitable. You can’t build on Down syndrome patients, partially tral to mildly compensated rearfoot a poor foundation! Not only will the due to inactivity. By correcting the and a neutral forefoot. structure not support it, but due to biomechanics, inactivity may be less - As the child matures to adult - poor foot alignment, the muscles dur - ened and quality of life may be in - hood, this foot type can often ing the exercises may not even fire. creased (Figure 1). Continued on page 144 142 | SEPTEMBER 2012 | PODIATRY MANAGEMENT www.podiatrym.com BIOMECHANICS AND ORTHOTICS DOWN SYNDROME progress to an F foot type where the These feet look “very flat” at an of motion of the knee, with an accom - heel rotates even more, causing the early age and can only worsen into panying change in gait. The longer person to strike the heel on the in - adulthood. This severe instability also that nothing is done for the instability, side. This creates more collapse of the makes it difficult to the worse the con - subtalar joint, which pulls the entire develop and main - dition will get medial side of the kinetic chain down - tain core strength over time. Or - ward, resulting in genu valgus, knee throughout the thoses (special torsion, and greater hip rotation. This legs and trunk. braces) may be is a very inefficient foot type causing Muscles need to useful for mild early fatigue and muscle pain (Figure work “overtime” cases, but severe 2).
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