## 4 Discussion
Highlighting the scarcity of high-quality, multi-center RCTs that investigate long-term outcomes or the limited application of advanced technologies (e.g., digital foot scanning, pressure-mapping sensors) in clinical studies would not only enrich the current analysis but also provide a clear direction for future research priorities. Incorporating these deeper levels of synthesis would substantially enhance the value and applicability of the review's conclusions, providing a more robust evidence base to inform clinical practice and policy. In individuals with Down syndrome, custom-made shoes can accommodate unique foot morphology, which is often characterized by flat feet, hypermobility, and altered biomechanics. These shoes can enhance stability and improve overall gait mechanics, potentially increasing physical activity levels and reducing the risk of secondary musculoskeletal issues. However, it is essential to recognize the limitations, such as the potential cost and the need for frequent adjustments as children grow. Moreover, while custom-made shoes have shown promise in improving functionality, long-term studies are needed to validate their effectiveness in preventing orthopedic deformities and promoting long-term physical activity in this population. For patients with gout, custom-made shoes can provide critical support by redistributing pressure and reducing joint stress, particularly in the metatarsophalangeal joints, which are frequently affected in gouty arthritis. These shoes may help to alleviate pain, improve mobility, and prevent future flare-ups. However, the effectiveness of custom footwear in managing gout remains underexplored, and there are challenges, such as adherence to wearing the shoes and ensuring proper fit over time as the disease progresses. Moreover, more research is required to assess whether these interventions can significantly reduce disability or improve quality of life compared to off-the-shelf options or standard care. A more detailed investigation into the efficacy and limitations of custom-made shoes would provide clinicians with clearer guidelines on when and how to utilize this intervention, particularly for populations with specific orthopedic or biomechanical challenges. This would also help to delineate the conditions under which custom footwear is most beneficial and cost-effective. Highlight that providing footwear advice during regular check-ups could be an effective strategy for preventing foot problems, particularly in older adults and those with chronic conditions like diabetes. Recommend the integration of custom-made footwear options into healthcare plans for patients with specific needs (e.g., individuals with Down syndrome or those with chronic gout). Suggest that healthcare providers receive training on assessing shoe fit and prescribing appropriate footwear. This scoping review has several important limitations. Firstly, the number of included studies was limited to five. While the aim of a scoping review was not to generalize the findings but to determine the state of the science or what is known on a subject, the limited number of studies may still restrict the breadth of the conclusions that can be drawn. Furthermore, the methodological quality of the included studies was not critically appraised, which is a common practice in scoping reviews. This lack of critical appraisal means that the reliability of the results may vary, and caution should be exercised when interpreting the findings. Advocate for policies that facilitate access to custom-made footwear for vulnerable populations, such as insurance coverage for therapeutic shoes for diabetic patients or children with congenital conditions. Recommend government-funded programs to educate the public on proper shoe fit, emphasizing the link between footwear and long-term foot health. This could include collaborations with footwear manufacturers to develop affordable and supportive shoe options.