The role of footwear and foot characteristics in reducing falls in older people
The results section will look at the two main themes from this essay, namely foot characteristics and footwear and their role in falls, and will discuss the main themes in the literature within these two headings.
There are a number of foot characteristics associated with balance and functional ability. Ankle strength, flexibility and range of motion (inversion/eversion and dorsiflexion), hallux plantar flexion strength and plantar tactile sensitivity have been found to be significant predictors of balance and functional performance (Spink et al., 2011a; Mickle et al., 2011; Menz et al., 2005).
Disabling foot pain is one of the highest risks in elderly falls and pain in the region of the toe is the most common complaint (Mickle et al. 2010). These findings are in accord with Badlissi et al. (2005) who found that hallux valgus and other toe deformities are the most common disorders. However, in contrast they also found these were often asymptomatic and had no functional limitation (Badlissi et al. 2005). Mickle et al. (2010) found that the highest risk of falls was in elderly with higher plantar peak pressures and pressure time intervals on the MFPDI, demonstrating that those with less plantar sensitivity were at significant risk, in accord with this Mickle et al. (2010) found individuals with reduced FHFS scores had plantar fasciitis and pes cava. Disabling foot pain has been found to reduce balance, step and stride length, and walking speeds (Mickle et al. 2011).
Interventions that can reduce the risk of falls in older adults are exercises to strengthen and increase flexibility in the ankle and foot. Spink et al. (2011b) showed significant reductions in falls risk of individuals that followed a regime of foot and ankle stretches and exercise. This finding is in accord with suggestions from other authors (Mickle et al. 2011; Menz et al. 2005; Spink et al. 2011a).
Footwear is associated with fall risks, although there are many characteristics that make up a shoe and so these factors will be discussed in order of decreasing risk. Heel height is one of the most common factors in the risk of falls, heel heights of 4.5cm or greater have been found to increase risks (Menant et al. 2008; Menz et al. 2006; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 2011, Lord et al. 1999). Elevated heels cause significant sway and reduction of balance when compared to low heeled shoes (Menant et al. 2008). Other suboptimal shoe features include lack of adequate fixation (Sherrington et al. 2002), low heel-collared shoes (Menant et al. 2008; Sherrington et al. 2002; Lord et al. 1999) and excessive flexation (Sherrington et al. 2002; Menant et al. 2006). Bare feet, socks and slippers are quoted as higher risk of falls in a number of findings (Sherrington et al. 2002; Menz et al. 2006). Whilst shoe sole hardness is found to be a risk factor in some findings (Sherrington et al. 2002; Menant et al. 2008), Lord et al. (1999) found no relation between shoe hardness and risk of falls.
Orthoses have been used as interventions to reduce pain in older adults with disabling foot pain, thus countering the highest risk in foot characteristics with a footwear solution (Spink et al. 2011b). Orthoses shift the weight load of the foot to areas without pain and are moulded to the individual foot. Most findings agree that the most optimal footwear to reduce the risk of falls is low heeled shoes (less than 4.5cm) and high heel-collared shoes (Menant et al. 2008; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 20011a and 2011b, Lord et al. 1999), with hard soles or reduced shoe flexibility (Menant et al. 2008; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 20011a and 2011b,) and high contact area (Tencer et al. 2004).
The role of footwear and foot characteristics and their contribution to risk of falls in an elderly population has a multiplicity of factors and an overriding weakness in the literature is being unable to take into account other factors such as musculoskeletal problems. As risk factors can be very specific to the individual it is important to discuss the overriding risks found within the literature.
Foot pain and weakness of ankle and toe are a significant risk factor of fall, as is disabling foot pain. Footwear associated with higher risk of fall includes barefoot, slippers or high heels, as well as poor or no fixation. Footwear with the least risk of fall has been found to be low heeled (less than 4.5cm) shoes with good surface area contact. Fall risk can be reduced, especially in those with disabling foot pain, by use of orthoses and shoes with good fixation, as well as targeting weakness of foot and ankle by a regime of exercise. Risk in those with symptomatic toe deformity may require medical interventions.
Badlissi, F.; Dunn, JE.; Link, CL.; (2005) Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 53Issue: 6Pages: 1029-1033
Lord SR.; Bashford GM; Howland A.; Munroe BJ.; (1999) Effects of shoe collar height and sole hardness on balance in older women JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 47Issue: 6Pages: 681-684
Menant, Jasmine C.; Steele, Julie R.; Menz, Hylton B.; (2008) Effects of footwear features on balance and stepping in older people, GERONTOLOGY, Volume: 54Issue: 1Pages: 18-23
Menz, HB; Morris, ME; Lord, SR (2005) Foot and ankle characteristics associated with impaired balance and functional ability in older people, JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES, Volume: 60Issue: 12Pages: 1546-1552
Menz, HB; Morris, ME; Lord, SR (2006) Footwear characteristics and risk of indoor and outdoor falls in older people, GERONTOLOGY, Volume: 52Issue: 3Pages: 174-180
Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2010) Foot pain, plantar pressures, and falls in older people: A prospective study, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 58Issue: 10Pages: 1936-1940
Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2011) Cross-sectional analysis of foot function, functional ability, and health-related quality of life in older people with disabling foot pain ARTHRITIS CARE & RESEARCH, Volume: 63Issue: 11Pages: 1592-1598
Sherrington Catherine; Menz, Hylton B.; (2002) An evaluation of footwear worn at the time of fall?related hip fracture AGE AGEING, Volume: 32Issue: 3Pages: 310-314.
Spink, Martin J.; Fotoohabadi, Mohammad R.; Wee, Elin; (2011a) Foot and ankle strength, range of motion, posture, and deformity are associated with balance and functional ability in older adults ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION, Volume: 92Issue: 1Pages: 68-75
Spink, Martin J.; Menz, Hylton B.; Fotoohabadi, Mohammad R.; Wee, Elin; Landorf, Karl B.; Hill, Keith D. Lord, Stephen R.; (2011b) Effectiveness of a multifaceted podiatry intervention to prevent fall in community dwelling older people with disabling foot pain: randomised controlled trial BRITISH MEDICAL JOURNAL, Volume: 342Pages: 1-8
Tencer AF.; Koepsell TD.; Wolf ME.; Frankenfeld CL.; Buchner DM.; Kukull WA.; LaCroix AZ.; Larson EB.; Tautvydas M.; (2004) Biomechanical properties of shoes and risk of fall in older adults JOURNAL OF THE AMERICAN GERIATRICS SOCIETY; Volume: 52Issue: 11Pages: 1840- 1846