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 , 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 - , including , 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 | 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 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 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

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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). It’s like every step the child takes to do the same job cases require sur - is in quick sand. Let’s quickly review as someone with gical correction.” 1 the specifics of these two common better functioning Next up the foot types. feet, drastically in - chain comes the The D Quad foot type is a moder - creasing energy ex - hip. Leshin con - ately over-pronated foot-type. This penditure. This tinues, “Five to foot-type occurs when a compensated foot-type causes a eight percent of rearfoot varus exists with a normal or lot of damage to children with DS neutral forefoot alignment. This foot- the forefoot during will develop ab - type is congenitally a partially unsta - propulsion. In ad - normalities of the ble foot and is often diagnosed in chil - dition to transverse hip. The most Figure 3: A functional UCB type orthotic, with dren as developmental flat foot. It’s a metatarsal arch re - common condi - high medial and lateral sidewall flanges, such as versal, don’t be mistake to think that this child will littleSTEPS, combined with supportive footwear, tion is dislocation “out-grow the deformity.” Just ask the surprised to see can be highly effective for the typically flexible foot of the hip, which biological parents, grandparents, and hammertoes, hal - of a young child with Down Syndrome. is also called sub - older siblings to take off their shoes lux abductovalgus luxation. In this and socks. If family members demon - deformity, functional hallux limitus, condition, the head of the thigh bone strate similar foot characteristics, and painful corns and calluses. (the femur) moves out of the socket chances are that this child is not going formed by the pelvis (the acetabu - to develop an arch. During gait, this Effects of the D & F Foot (of those lum). This dislocation may or may not foot begins to pronate at the subtalar with Down Syndrome) on the be associated with malformation of joint in contact phase, and continues Kinetic Chain the acetabulum. The dislocation ap - to pronate throughout midstance. In Let’s start with the knee. Len pears to be due to a combination of propulsion, the 1st ray will plantarflex Leshin, MD, FAAP writes, “Instability laxity of the connective tissue that to load the medial column of the foot of the patella (kneecap) has been esti - normally keeps the hip together along and allow the foot to re-supinate. mated to occur in close to 20 percent with the low muscle tone found in DS. The F Quad Foot Type is com - of people with DS. The majority of Interestingly, hip subluxation in children with Down syndrome is hard - ly ever found at birth but instead is While people with instability of the patella are able most common between the ages of three and 13 years. The most common to walk, there is often a decreased range of motion of the sign is a limp, and pain may or may not be present. Treatment often starts knee, with an accompanying change in gait. with immobilization of the hip with a cast. Many children with DS will re - quire surgical correction, however.” 1 monly referred to as a pes planoval - cases of instability present only as And finally, there’s the back. gus foot deformity because of its very kneecaps that can be moved further to Leshin adds, “Another condition asso - poor alignment to the floor. This is a the outside than the normal kneecap ciated with the spine in Down syn - true “flat foot.” The condition occurs (subluxation); however, some people drome is scoliosis, which is the curva - when a compensated rearfoot varus is can have their kneecaps completely ture of the spine to the side. While it coupled with a large flexible forefoot move out of position (dislocation), appears to be more common in peo - varus (also called forefoot supina - and some may even have a hard time ple with DS, the exact incidence isn’t tus).This foot type is the most hyper - getting it back into the right position. known….Treatment of scoliosis re - mobile or flexible of the foot-types. Mild subluxation of the kneecap is not mains the same as in other children, This hypermobility leads to great in - associated with pain, but dislocation with bracing being the initial therapy, stability throughout the foot and may be painful. While people with in - followed by surgical intervention if ankle, and can be prevalent through - stability of the patella are able to necessary.” 1 out the body. walk, there is often a decreased range Continued on page 145

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The Overall Plan Orthoses need to be specifically designed to improve coordination, balance, pain, posture, and strength, and to aid in the development of a more stable and functional gait. These orthoses should be comprised of a deep heel cup, a medial heel skive, and high medial and lateral side - wall flanges (Figure 3). Control of the subtalar joint is paramount. Often, kids are over-braced with AFOs due to lack 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 growth and maturity.

Complementary Solutions to Early Biomechanical Support progress typically associated with Down syndrome motor development is slow; and instead of walking by 12 to 14 months as other children do, chil - dren with Down syndrome usually learn to walk between 15 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 push off and augmenting support of the knee joint. Heel cord stretching with the heel in neutral alignment when limited passive range of motion exists. Lastly, dynamic balance activities, such as running or descending stairs, which en - courage the child to shift their weight during late swing phase rather than waiting until heel contact.” 8 These are very good recommendations. Many thera - pists are seeing that when orthotic inserts are prescribed along with physical therapy, the improvement really sticks and builds. Children in therapy have everted/flat feet and either never or too slowly build on strength, absent these orthotics. Building a better foundation helps those muscles move along faster.

Getting the Down Patient to Make an Appointment To treat a Down syndrome patient, you have to see them. That is where education is so critical. In many of our communities, we have early intervention services for babies born prematurely or with medical concerns. This can be the place where an initial referral can originate. When an EI therapist understands the importance of the feet and biomechanics in the development of any child, she/he can screen for this. With early intervention, Down syndrome patients can have a better outcome in meeting developmental milestones and lessening risks of Alzheimer’s and obesity.

Summary So what can you do to help? As podiatrists, we are in the unique position of being trusted medical professionals of 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 with the Down syndrome patients is the key to getting these Continued on page 146 www.podiatrym.com SEPTEMBER 2012 | PODIATRY MANAGEMENT | 145 BIOMECHANICS AND ORTHOTICS DOWN SYNDROME

clients proper foot care early in life in Note: The author wishes to thank 7 Head, D., Exercise Engagement as a order to allow them a better chance of Kay Brooke-Willbanks, PMA for her Moderator of the Effects of APOE Genotype long, healthy, active lives. “Treatment assistance with this article. on Amyloid Deposition, January 9, 2012. 8 of painful feet in patients with Down Selby-Silverstein, L.: The effect of foot syndrome is imperative because foot References orthoses on standing foot posture and gait of young children with Down Syndrome. pain leads to relative immobilization 1 Leshin, L. (2003). DS Musculoskele - NeuroRehabilitation 16 (2001) 183-193. tal Conditions in Down Syndrome. In Mus - and immobile retarded adults do not 9 Diamond, L.S. and Lynne, D. et al., 9 culoskeletal Disorders in Down Syndrome. remain long in the community.” Orthopedic disorders in patients with Retrieved May 25, 2012, from www.ds- Your goal as a practitioner and Down’s syndrome, The Orthopedic Clinics health.com/ortho.htm. someone who recognizes the progres - of North America 12(1) (1981), 57-71. 2 Rogers, C.: Carers Knowledge of sion of foot types is preventing pain common foot problems associated with by knowing how to deal with it be - people with Down’s Syndrome. University Louis J. DeCaro, DPM fore it happens, coupled with improv - College Northampton, 2002. specializes in ing overall biomechanical strength 3 Aprin H, Zink WP, Hall JE: Manage - with a special interest and structure. No matter what a ment of dislocation of the hip in Down in and child’s medical diagnosis, it is impor - syndrome. J Pediatr Orthop 5: 428, 1985. biomechanics. He is a vice- tant to educate parents and their chil - 4 Benoit, E.: Podiatry and mental retar - president of the American dren in what their “foot type” is, and dation: The podiatrist’s role. J.A.P.A., 55: College of Foot & Ankle what that may bring them during 434, 1965. Pediatrics and a member 5 Young, E. (March 22, 2002). New their adult years. of the surgical & medical Scientist. Down’s syndrome lifespan dou - staff at Holyoke Medical Please feel free to reference the bles. Retrieved June 5, 2012, from Center and Franklin Medical Center. He is currently websites www.whatsmyfoottype.com www.newscientist.com/article/dn2073- in private practice in West Hatfield, MA. He is and http://www.decaropodiatry.com downs-syndrome-lifespan-doubles.html. the director and founder of the Multidisciplinary for additional information regarding 6 Eyman RK, Amer J Mental Retard, Adult & Pediatric Gait Labs Biomechanics Clinic. my practice and its methodologies. PM 95(6): 603-612, 1991. His e-mail is [email protected].

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