Children with Down syndrome showed several orthopaedic anomalies including bony deformity of the forefoot (90%), flat foot (60%), isolated calcaneal valgus (24%), knee valgus (22%) - knock knees and pronated - flat foot (16%). These abnormalities were responsible for postural alterations as confirmed by foot pressure examination.

CONCLUSION: The data demonstrated a greater incidence of minor orthopaedic alterations and suggest the necessity of regular podiatric examinations in the follow-up of this syndrome.

And from personal experience the most common defining foot and gait/walking features of Down Syndrome Patients include:  
• smaller and/or shorter limbs, fingers, hands, toes and feet
• low muscle tone and loose ligaments
• Broad feet with a deep plantar crease
• Flat 'pronated' feet
• Decreased ankle range of motion
• Abducted and wider base of gait/support
• Excessive external hip rotation (feet pointed outwards)
• Inadequate heel contact during gait (tendency to walk on toes)
• poor foot clearance during swing phase (tendency to scuff the foot and trip)
 
The combination of ligamentous laxity (loose ligaments) and low muscle tone contribute to orthopaedic problems in people with Down Syndrome. Often these characteristics become evident when children learn to walk, as specific physiological differences may be compounded by gravity. This is largely where Podiatrist's can play a role in aiding Down Syndrome lower-limb development and coordination.
 
The most common foot and leg conditions include:
 
1. Hallux Abducto-Valgus (bunions)
2. Plantar fasciitis (pain in the arch)
3. Anterior knee pain related to 'pronated' flat feet
4. Clawing of the toes
5. Calluses and corns and associated ingrown toenails
6. Shoe irritation (generally from footwear with insufficient width)

The importance of comprehensive podiatric evaluation in patients with Down syndrome for the early diagnosis and treatment of minor orthopaedic problems is crucial.
 
Treatment
 
Treatment is directed towards the cause and is generally painless.
 
1. Foot Orthotics

If flat feet are implicated in the development of symptoms this can be addressed with soft rubberised, highly contoured foot orthotics to assist in maintaining good foot and ankle alignment. Hard plastic orthotics should be avoided due to pressure they apply to the arch in isolation, whereas soft full length orthotics can support the foot from heel to toe.
 
2. General Footcare

Hard skin and thickened toenails can be treated painlessly with skillful removal by a podiatrist. This may need to be performed periodically to maintain comfort, although alignment of the feet with orthotics generally assists in this are too.
 
3. Wide and Supportive Footwear

It can often be a challenge to find footwear that both fits well and provides adequate support, whilst still being socially acceptable. Custom made footwear is expensive and rarely required, as brands such as New Balance offer width fitting up to 6E and there are a number of shoe shops that stock wide fitting shoes.

An extract from Acta Paediatr. 2006 Jan;95(1):17-20

Department of Paediatrics, University Magna Graecia, Catanzaro, Italy. dconcolino@unicz.it

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