Some of the friendliest people I know have a special condition called Trisomy 21 or Down syndrome. In these individuals many skin, bony, muscle and joint conditions exist due to abnormal collagen development. One of the types of collagen (Type VI) is encoded by a gene on chromosome 21. The resulting effect is increased joint laxity or looseness of the ligaments that attach bone to bone or tendons that attach muscles to bone (hypotonia of muscles). The ligamentous laxity and hypotonia will then lead to multiple conditions encountered in the feet of a Down syndrome individual. These conditions are then further aggravated by the pressures of walking and the play of gravity on the feet. I would like to discuss some of the common presentations of a Down syndrome foot. Characteristic Foot Type: At birth, the foot will usually present with broad feet and short toes. Some feet may also present with a larger than normal space between the great toe and the second toe. Although these conditions are not medically problematic, shoegear and walking can aggravate these conditions and produce further problems, especially with the increasing life expectancy of these individuals over time. Conditions Encountered with Down Syndrome: Pes Planus, or flat feet, are commonly encountered with Down syndrome. In fact, this foot type will be seen in the vast majority of individuals. This condition may present with neutral gait (no excessive flattening of the arch) in mild cases or may be aggravated by the hypotonia and allow severe pronation (flattening of the feet). In both cases, an orthotic or custom insert for the shoes can support the flattening of the foot against gravity and produce a more ideal walking (gait) pattern. This will reduce fatigue and allow the individual to remain active and more involved. Another problem with Pes Planus is the poor fitting of shoes. Standard insoles in shoes will irritate the feet and may cause increased callus formation, increased fatigue to the feet and may lead to decreased activity. Orthotics again could assist with this difficulty. Metatarsus Adductus, or turning of the metatarsals (mid part of foot behind the toes) toward the inside of the foot, may be encountered especially with the first metatarsal or the metatarsal of the great toe (Metatarsus Primus Varus). Since this condition can be aggravated in the foot, a painful prominence to the inside of the 1st metatarsal (inside of great toe bone) may present as a bunion deformity. Early cases, especially if mild, can be treated with orthotics as discussed earlier. More severe cases may require surgical correction. My recommendation is to progress to surgery if the foot is painful and limiting ability to stay active and/or function in normal life. Hammertoes, or contracting of the little toes can also be present over time due to the hypotonia of the muscles. This condition can treated with padding, orthotics or surgical correction depending on the extent of the problem. The most common cause of pain from hammertoes is rubbing of the toes on the shoes. Callus formation is also commonly encountered due to some collagen changes in the skin, bony prominences from changes in the feet structure or just the gait (walking) pattern of the feet. It is recommended that care should be utilized to decrease pressure by wearing correct shoegear, adjusting insoles through orthotics and/or trimming of calluses if they become increased in thickness. Some lotions may also help, including a commonly recommended lotion in our office called Atractain. The goal of foot care in an individual of any age with Down syndrome is to optimize what they were born with and keep them active. As stated previously, this can be done by correct shoegear, custom orthotics and surgery in rare situations. The Down syndrome foot is a unique entity, but can fully function and carry the individual through a fulfilling life. Copyright (c) 2009 Mountain West Foot & Ankle Institute
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