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A 7-year-old girl with a diagnosis of Down syndrome was referred to outpatient physical therapy for an evaluation to address the child's deteriorating gait and obtain recommendations for orthotic devices. The mother reports that the child had bilateral bunionectomies (performed by a podiatrist) 6 months earlier and an improvement in her gait was noted briefly after the surgery. However, in the last 3 months her gait appears to have regressed and is now at the level that it was before the surgery. The child's previous history was gathered from the details provided by the parent and from available medical records. She was born at term (weighing 6 lb 2 oz) and had Apgar scores of 6 and 8 (at 1 and 5 minutes, respectively) and was diagnosed at birth to have Down syndrome. Subsequent genetic testing confirmed the diagnosis of Trisomy 21. No other medical complications were identified and she passed the newborn hearing screen. She was discharged with her mother 48 hours after birth. The mother describes the child's development as slower than her brother who is 18 months older. However, she sat independently at her first birthday and began taking first steps at age of 22 months. Around that time, the mother noticed that the child's knees intermittently tended to be red and slightly inflamed and she occasionally gave her ibuprofen. The mother thought these signs were related to the child transitioning from creeping to walking with support and because she sometimes let go of her support and fell on her knees. The knee swelling episodes continued intermittently for about a year. The mother took her to the pediatrician, but the problem had usually subsided by the time of the appointments. When the child was 4 years old, the pediatrician referred her for an orthopaedic evaluation. The report indicated that there were no significant findings other than usual problems consistent with the diagnosis of Down syndrome. Between the ages of 4 and 6 years, she was screened for thyroid dysfunction and the results were described as normal for age. During that period, the mother noted that her daughter seemed to be developing a slightly “shuffling” gait. She became concerned that her daughter may need orthoses because she was also developing noticeable bilateral bunions at the first metatarsal joints. Review of school records revealed that between the ages of 5 and 7 years, the child demonstrated no progress in Adaptive Physical Education (APE) so the goals written at age 5 were carried over yearly for 2 more years. To address concerns about the child's walking, the mother took the child to a podiatrist. The podiatrist recommended and scheduled bilateral bunionectomies, which were completed without complications. She received routine postsurgical care and remained hospitalized for 5 days. The mother noted that the child walked with decreased stiffness by the end of her hospital stay. This improvement continued for about 3 months when the mother noted increased stiffness again and sought out a physical therapist to explore management ...

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