Treating Lower Extremity Conditions Of Special Olympics Athletes

Author(s): 
David W. Jenkins, DPM, FAAPSM

One of the most rewarding aspects of my 34-year career in podiatric medicine has been my involvement in Special Olympics. Besides the joy of working and interacting with these amazing athletes, we are able to provide a valuable service via foot screening exams (Fit Feet) that have been instrumental in the prevention of lower extremity problems, and helpful in improving comfort and performance.

   Likewise, in working with the intellectually disabled athlete, I encounter some very unusual podiatric conditions, some of which I had never seen in many years of practice. Sharing these clinical experiences with my students has been a wonderful spinoff of working with Special Olympics athletes.

   I hope that having a greater awareness of the podiatric challenges these athletes face will encourage practitioners to get involved in screenings of Special Olympics athletes (Fit Feet) and provide definitive treatment if required.

   Special Olympics provides year-round sports training and athletic competition in a variety of Olympic-type sports for over 3.7 million children and adults with intellectual disabilities.1

   The Healthy Athletes Initiative developed in 1997 in part because people with intellectual disabilities may experience a higher rate of numerous medical conditions in comparison to the general population and many of these affect the lower extremities.2-4

   The purpose of this initiative is providing health screenings to participating athletes.1 The screenings educate athletes on healthy lifestyle choices and identify problems that may need additional follow-up. Healthy Athletes offers health screenings in seven areas: Fit Feet (podiatry), FUNfitness (physical therapy), Health Promotion (better health and well-being), Healthy Hearing (audiology), MedFest (sports physical exam), Opening Eyes (vision) and Special Smiles (dentistry).

   Fit Feet is one of the newest additions to the Healthy Athletes initiative. It entails a screening of the feet, ankles and gait of Special Olympics athletes at competitions. Additionally, we check athletes for proper shoes and socks, and provide them with community referrals as needed. Lastly, we educate the athletes, their families and coaches on preventative foot care.

Pertinent Insights On Common Lower Extremity Conditions Associated With Intellectual Disabilities

There are many medical conditions with associated intellectual disability. The following overview is in no way complete but attempts to focus on the most typical ones I see in Special Olympics athletes with an emphasis on those with lower extremity manifestations. It is noteworthy that the top three conditions are responsible for one-third of all intellectual disabilities.5

1. Down syndrome
2. Fragile X syndrome
3. Fetal alcohol syndrome
4. Prader-Willi syndrome
5. Phenylketonuria
6. Apert syndrome (acrocephalosyndactyly)
7. Birth injury/cerebral palsy
8. Ectrodactyly
9. Malnutrition
10. Klinefelter syndrome
11. Neurofibromatosis
12. Congenital hypothyroidism (cretinism)

   Down syndrome. Many of the findings below are attributable to the significant hyperflexibility that occurs in Down syndrome. Indeed, many of the pedal deformities are related to joint laxity with excessive pronation in gait and stance.6-10

   Down syndrome lower extremity findings include short lower extremities, external hip position/abducted gait, metatarsus adductus, brachymetatarsia, patellar instability, genu valgum, hypermobile pes valgus/pes planus, metatarsus primus varus, hallux abducto valgus/varus, clinodactyly, syndactyly and hip dislocation.

   Fragile X syndrome. Like Down syndrome, Fragile X syndrome is characterized by joint laxity. The associated hyperextensible joints frequently result in findings of excessive pronation and pes planus.11

   Fetal alcohol syndrome. Besides intellectual disability, people with this condition may have a number of abnormal clinical findings, many of which are related to joint structure.12 Fetal alcohol syndrome lower extremity findings may include camptodactyly (fixed flexion deformity of the interphalangeal joints of the digit), clinodactyly (medial curvature of the digits, usually the fifth metatarsal), scoliosis and poor coordination/motor skills.

   Prader-Willi syndrome. Similar to Down and Fragile X syndromes, ligamentous laxity and related structural changes occur with Prader-Willi syndrome.13 Prader-Willi syndrome lower extremity findings include hypotonia, short stature, small hands and feet, scoliosis, ligamentous laxity, hip dysplasia, genu varum and pes planus.

   Apert syndrome. Although Apert syndrome (acrocephalosyndactyly) is primarily characterized by faciocraniosynostosis, it also presents with varying degrees of severe syndactylism as well as brachymetatarsia.14-16

   Cerebral palsy. There are varied degrees of intellectual disability with cerebral palsy, depending upon where the injury to the brain occurs. Likewise, structural manifestations are reflective of brain injury locus but in most cases will present as contractures with characteristic gait patterns.17-18

   Hip contractures manifest in the hip (adductors, flexors and internal rotators), knee (flexors) and ankle (plantarflexors). The gait of patients with cerebral palsy can be clumsy or awkward. Patients can have scissors (crossover) gait or walk on the toes. Typically, they have an arm swing to counter the hip adduction.

   Ectrodactyly. Ectodermal clefting syndrome (lobster foot) is quite rare. The foot presents as clefted due to the absence of central rays. There may be associated hallux abducto valgus with metatarsus primus varus and a wide splayed forefoot.19

In Summary

One of the major goals of this article is to educate the clinicians who evaluate and treat foot pathology about the podiatric conditions that occur in the population of athletes with intellectual disabilities.10,20 This enhanced knowledge of podiatric findings that we encounter in people with intellectual disabilities will hopefully result in more effective identification, management and prevention of such disorders, including a referral when appropriate.

   I also hope to encourage clinicians to become involved in screening programs (Fit Feet) in their local communities and/or be a referral resource for those athletes in need of definitive care. The opportunity to encounter and/or manage conditions that many of us have only read about in our training is both educationally and professionally rewarding.

   Dr. Jenkins is a Professor at the Arizona School of Podiatric Medicine at Midwestern University in Glendale, Az. He is a Fellow and Vice President of the American Academy of Podiatric Sports Medicine. Dr. Jenkins is also the Clinical Director for the Special Olympics Arizona Fit Feet Program and a Podiatric Consultant for the Los Angeles Dodgers.

References
1. Available at www.specialolympics.org .
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20. Jenkins DW, Cooper K, O’Connor R, Watanabe L. Foot-to-shoe mismatch and rates of referral in Special Olympics athletes. J Am Podiatr Med Assoc. 2012; 102(3):187-197.

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