Editor’s 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

Children’s 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 flat 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 inefficient walking pattern

forces her to take shorter steps and

walk more slowly. She doesn’t 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 flexible flat feet,

depending upon the individual’s age

and needs. The treatment goal is to

provide the right support to

facilitate an efficient 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

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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 benefit 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 flexible 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

firm medial and heel counters,

which vertically support the foot in

the shoe. With a flimsy heel or

medial support, the shoe will

probably tilt inward to take the

shape of the child’s foot posture.

Lace-up shoes are best to hold the

foot over the support since it’s

difficult 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 modified until the

desired results are achieved.

In my experience, children generally

tolerate flexible 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

individual’s 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 won’t help if

the individual won’t 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 flexible 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 specific 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

flex the plastic (to do gross motor

skills) while benefitting from the

optimal alignment and stability

provided. Over time, the child

learns to use an efficient walking

pattern with toe push off and the

child’s 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 fit 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 heel’s center in a specific

space. This allows the shoe to

vertically support the heel. There is

a medial longitudinal arch (some

are filled with dense foam) which is

long and wide to fully support the

length and width of the arch. For

individuals with DS, a flexible toe

lever (support from the ball of

the foot to the toes) is preferred.

Supportive shoes provide the full

benefit 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

individual’s needs. The foot

management plan must be sensitive

to the child’s weight, size and

activity preferences, as well as the

foot and leg posture while standing

and walking. With the correct foot

support, the child’s 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 child’s general

means of mobility and frequency

of use.

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