Editors note: Since 1984, Patricia

Winders has worked with babies and

children with DS as a physical therapist at
Kennedy Krieger Institute (Maryland) and
its Down Syndrome Clinic and now at the
Sie Center for Down Syndrome, The
Childrens Hospital, Aurora, CO. Winders
is the author of Gross Motor Skills in
Children with Down Syndrome: A
Guide for Parents and Professionals
(Woodbine House); a member
of the NDSC Professional Advisory
Council and will present a workshop
at the NDSC Convention in Sacramento.
WHAT CAUSES FLAT FEET
IN CHILDREN WITH DS?
Individuals with DS are at risk for
foot problems due to hypotonia and
ligamentous laxity. Both
characteristics contribute to joint
hypermobility. This means the foot
bones (see photo 1) are not properly
stabilized and aligned for standing
and walking. Without taut
ligamentous support, the heel
(calcaneus) tilts inward and the
surrounding bones (talus and
navicular) follow. When the inside
borders of the feet collapse to the
ground, it gives the appearance of
no arch (see photo 2). The degree
of at footedness varies from person
to person. If it persists without
treatment, the child may have
further ankle and joint deformity.
Long-term use of this standing and
walking pattern may lead to pain.
WHY IS FLAT FOOTEDNESS
A PROBLEM?
When the child walks with this
posture, she bears her weight on the
inside borders of her feet, walking
with a wider base and turning her
knees and feet outward (see photo
3). This inefcient walking pattern
forces her to take shorter steps and
walk more slowly. She doesnt learn
to rotate her pelvis on her trunk and
the muscles have to work harder
because the bones are not optimally
aligned. The child must use more
energy to walk and fatigues more
quickly. She tends to use a heavy-
footed pattern and sometimes slaps
her feet. As the child grows, the
increased weight on the ligaments
stretches them even further. If the
foot posture collapses more, causing
malalignment in the knees and
other joints, it alters body mechanics
and compromises how the child
runs, jumps and balances.
WHAT CAN BE DONE
ABOUT IT?
There are many possible treatment
strategies for exible at feet,
depending upon the individuals age
and needs. The treatment goal is to
provide the right support to
facilitate an efcient walking pattern
with optimal alignment in the legs
and feet (see photo 4). This
achievement gives the foundation
for the child to participate in
physical activities he chooses. Any
foot management strategy needs to
consider both the type of shoe and
How to Treat Flat Feet
By Fatricia C. Winders, FT, Denver, CO
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the type of support in the shoe. In
addition, practicing gross motor
skills develops strength in the
desired movements since the child
needs to dynamically use the foot
support to fully benet from it.
Running, walking on uneven
surfaces and up and down inclines,
kicking a ball, rising up on tiptoes,
jumping, climbing stairs, stepping
up curbs and working on balance
skills are all good activities to
promote.
The shoes the child uses for physical
activity need to have soles that are
very exible in the toe box area so
minimal force is needed to use toe
push off (see photo 5). The child
will not push against stiff soles to
break them in, so movement is
limited. The shoes also need to have
rm medial and heel counters,
which vertically support the foot in
the shoe. With a imsy heel or
medial support, the shoe will
probably tilt inward to take the
shape of the childs foot posture.
Lace-up shoes are best to hold the
foot over the support since its
difcult to tightly close Velcro and
the foot tends to tilt.
WHAT TYPES OF SUPPORTS
ARE AVAILABLE?
There are many types of supports
including a variety of orthotics
(plastic foot supports), shoe inserts
and arch supports. The foot support
team can include the PT, orthotist,
pediatrician, orthopedist, child and
parents. The products need to be
tested with each child for
effectiveness and modied until the
desired results are achieved.
In my experience, children generally
tolerate exible supports better than
rigid ones. The type of support
needs to be decided on a case-by-
case basis considering 1) the degree
of ankle and knee deformity and
how it impairs walking; 2) the
individuals size and weight; and
3) what is appropriate for age and
activity level. These are all
important factors; however, the most
important factor is whether the
individual will tolerate the support
because the support wont help if
the individual wont wear it.
If the child is a new walker and able
to walk independently on level
surfaces, the most direct way to
optimally support the foot is to
stabilize the heel in the midline
toward the vertical position. This
lifts the collapsed bones to create a
mild arch to the foot. However, the
heel support needs to allow it to
move within a mild range in and
out of the midline. This is best
achieved with the Sure Step
Dynamic Stabilizing system (see
photo 6) (www.surestep.net). This
system stabilizes the foot and ankle
by compressing the foot into
alignment by using an extremely
lightweight, thin and exible plastic
(unique patented design). It allows
for more natural foot and ankle
movement while still maintaining
proper alignment when standing,
walking and running. This system
has specic trimlines (patented
design) so the toes are free for
squatting, jumping and running. In
my experience, children tolerate
these orthotics well since they do
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not feel restricted. Children learn to
ex the plastic (to do gross motor
skills) while benetting from the
optimal alignment and stability
provided. Over time, the child
learns to use an efcient walking
pattern with toe push off and the
childs endurance improves.
There are many varieties of inserts
or arch supports that can be used if
the child needs less support.
Orthotists can custom make a
support or t an off-the shelf model.
Other types of supports can be
purchased in shoe stores or drug
stores. Inserts (for example, Cascade
dafo Hot Dog insert (see photo 7)
www.dafo.com) usually have a heel
cup (a concave space for the heel) to
support the heels center in a specic
space. This allows the shoe to
vertically support the heel. There is
a medial longitudinal arch (some
are lled with dense foam) which is
long and wide to fully support the
length and width of the arch. For
individuals with DS, a exible toe
lever (support from the ball of
the foot to the toes) is preferred.
Supportive shoes provide the full
benet of the insert.
For some children and adults, the
arch supports that already come
in the shoes (like good supportive
walking and running shoes) are
adequate and comfortable for
physical activity.
WHEN DO I CHECK TO SEE IF
FOOT SUPPORT IS NEEDED?
After the child learns to walk, the
foot posture and foot support should
be assessed yearly to determine the
individuals needs. The foot
management plan must be sensitive
to the childs weight, size and
activity preferences, as well as the
foot and leg posture while standing
and walking. With the correct foot
support, the childs walking pattern
will improve and the activity level
will increase.
Some children need foot support
prior to walking independently, but
this needs careful evaluation,
customized to the childs general
means of mobility and frequency
of use.
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