Foot instability in Down syndrome linked to hallux valgus, narrow shoes

Regular foot checks may curb problems.

A recent study published in the Journal of Foot and Ankle Research found that hallux valgus and too-narrow footwear contribute to foot-specific disability in children with Down syndrome. Interestingly, the study found foot posture wasn’t associated with foot-specific disability in the same children.


Completly Kids. Richmond, VA

By Erin Boutwell, Lower Extremity Review November 2015

The investigators, from La Trobe University in Australia, were particularly interested in determining the influence of footwear and foot structure on patient function and well-being.

“We have to always remember that quality of life extends beyond the absence of pathology; it extends to enabling participation,” said Nikolaos Nikolopoulos BPod (Hons) MBusSys LLM, a lecturer at the university and co-author of the February 2015 study.

Prior to the La Trobe study, the precise foot posture and footwear factors associated with foot-specific disability—and consequently, lack of participation—had not been determined. The La Trobe researchers performed a cross-sectional study of 50 children with Down syndrome (aged 5-18 years) to address this question. They measured foot posture, presence of forefoot deformities, and footwear fit (length and width) and determined the children’s foot-specific disability using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C). More than one third (38%) of participants wore foot orthoses.

Other factors in children with Down syndrome that may contribute to foot-specific disability include hypotonia and ligamentous laxity.

The study authors found that 76% of the children presented with flat feet (mean footprint-based arch index, .29), while 10% had hallux valgus.

Lower extremity experts not affiliated with the study noted the potential clinical relevance of the findings.

“Walking on a flat foot, or an overly pronated foot, is a little bit like driving your car with the front end out of alignment. You can still get from point A to point B, but you’re going to have some abnormal wear on your tires,” said Kathy Martin PT DHS, a professor and assistant program director of the Doctor of Physical Therapy Program at the University of Indianapolis.

Curt Bertram CPO FAAOP, national orthotic specialist for Hanger Clinic who works at Children’s Hospital of Wisconsin in Milwaukee, used a similar metaphor to describe the importance of properly fitted footwear.

“I often relate shoes to tires on a car. You can have a new car with bad tires, and it will not drive well,” Bertram said.

Ten percent of children in the study wore shoes that were too short for their feet, though shoe length was not correlated with changes in foot-specific disability. The children’s shoes were 9 mm longer than their feet, on average, with a range from 14.3 mm shorter to 23.3 mm longer.

More than 58% of the children were wearing shoes that were too narrow for their foot (mean average, 4.5 mm too narrow; range, 26.5 mm too narrow-13.6 mm too wide). One possible conclusion is that children with Down syndrome may need wider shoes, but may not be communicating this information to their parents.

“Children with Down syndrome may not have both the cognitive and the language skills to appropriately convey to their parents that they don’t like their shoes or that they’re uncomfortable,” Martin said.

Hallux valgus and narrow shoes were significantly associated with foot-related disability, but only accounted for 10% to 14% of the variance in OxAFQ-C scores. Also, somewhat surprising to the researchers, was that foot posture was not associated with foot-related disability.

The authors noted that limitations of the parent-completed OxAFQ-C for providing a true representation of foot-related disability may have influenced the findings. But the assessment does have its benefits, Nikolopoulos said.

“You’ve got to choose a questionnaire which is pointed, a questionnaire which is relevant, and a questionnaire that is ‘easy’ to complete,” he said.

Martin and Bertram pointed out other factors that may contribute to foot-specific disability, including hypotonia and ligamentous laxity.

“The ligaments of children with Down syndrome are lax; the ability of the musculature to stabilize the joint is also impaired. So it’s the entire kinetic chain that’s affected,” Martin said.

Additionally, the prevalence of ill-fitting footwear in these children may indicate a need to check for foot issues on a regular basis.

“There has to be an increased vigilance in terms of checking the feet for anything ranging from lesions, corns, and calluses, to orthopedic foot changes such as hallux valgus and joint positional changes, to infections,” Nikolopolous said.

But vigilance alone may not be enough to prevent orthopedic deformity in adulthood, Bertram said.

“Properly fitting shoes are one tool that may be used to help mitigate the development of adulthood deformities but, as the severity of the deformities increases, prescription orthoses may be required in combination with the shoe,” he said.

Erin Boutwell is a freelance writer based in Chapel Hill, NC

Source Lower Extremity Review



The association of foot structure and footwear fit with disability in children and adolescents with Down syndrome, Lim PQ, Shields N, Nikolopoulos N, Barrett JT, Evans AM, Taylor NF, Munteanu SE. J Foot Ankle Res. 2015 Feb 12;8:4. doi: 10.1186/s13047-015-0062-0. eCollection 2015.

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