Preventing Falls In The Elderly: Where DPMs Can Have An Impact
Expanding on these findings, Menz and co-workers developed a series of standardized tests for foot problems and then correlated the results with the risk of falling in elderly patients in a prospective study.17 This was the most important study at that time because it validated that the previously identified risk factors of reduced ankle flexibility, more severe hallux valgus deformity and reduced plantar tactile sensitivity were associated with a significantly increased risk of falling among elderly patients. Two of these foot and ankle characteristics, toe plantarflexor weakness and disabling foot pain, were significantly and independently associated with fall risk. This important study validated previous notions about the importance of adequate ankle joint range of motion and the ability to grasp with the toes to maintain balance.
A prospective study by Mickle and colleagues further validated the importance of toe flexor strength.18 This study of 312 older individuals showed that the presence of hallux valgus, lesser toe deformity and reduced plantarflexion strength of the hallux and lesser toes increases the risk of falling in older people. In particular, hallux strength and the presence of lesser toe deformities were independent predictors of falls. Furthermore, individuals with hallux valgus and lesser toe deformities had weaker flexor muscles of the associated toes. The authors suggested that interventions focusing on exercises that strengthen the toe flexor muscles may be of benefit to prevent falls in elderly patients. This led to the development of a multifaceted podiatric fall prevention program, which has been a monumental contribution to the medical community. I will discuss the study of this program later in the article (see “What One Landmark Study Showed About A Multifaceted Intervention Program To Reduce Falls” below).
Foot pain. Previous studies have shown that foot pain is associated with a risk of falling in men and women residing in a retirement village.17 Since foot pain occurs in up to 54 percent of community dwelling elderly people, the relationship between foot pain and risk of falling can be significant.19
Mickle and colleagues correlated foot pain, plantar pressure and fall risk in a prospective study of 162 community dwelling older adults.20 In this study, those who had fallen generated higher plantar pressures during gait and reported greater foot pain than those who had not fallen. The authors speculated that providing interventions for older individuals with foot pain and high plantar pressures may result in a reduced risk of falling. These interventions could include footwear with better cushioning under areas of high pressure as well as podiatric care, which includes lesion debridement or orthotic treatment.
Footwear. The role of shoes in the risk of falls is the subject of extensive study. Some of the findings have been surprising based upon our understanding of proprioception and sensory feedback from the feet to provide balance and postural control. While most would expect that the barefoot condition would provide better balance in comparison to wearing shoes, research has indicated the opposite result when looking at the frequency of falls in the elderly.
A study by Koepsell and co-workers showed that walking barefoot or simply wearing socks indoors resulted in an 11-fold increased risk of falling in comparison to wearing shoes.21 Other studies have validated this finding that slippers, in comparison to shoes, lead to an increased risk of falling.22 Not all shoes are protective for falls in the home. Menz and others have identified the following characteristics of shoes that are associated with increased risk of falling: wearing shoes with inadequate fixation (no laces, straps, or buckles); increased heel height (greater than 4.5 cm); narrow heel (less than 20 percent width of the heel); and a reduced contact area of the sole and smooth tread.23