Restoring Balance: Special Considerations when Treating the Geriatric Foot

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In robe and slippers, Jean, 80, was preparing her breakfast when a sudden slip sent her falling to the floor. She knew she was injured but was not in much pain. Unable to get up, with both her cell and landline phones out of reach, she spent hours lying helplessly on the floor until her daughter stopped by after work to check on her. The story is based on the actual experience of a friend of the author and illustrates the heightened risk of falls faced by the geriatric population. One in every three adults age 65 and older falls each year, according to the Centers for Disease Control and Prevention (CDC).

Fall injuries can lead to loss of independence, chronic disability, and premature death. Falling can instill a fear of repeated falls in elderly persons, limiting their mobility. Their world shrinks and their quality of life is reduced. Limiting their mobility out of fear starts a circle of further loss of strength, flexibility, and balance—increasing fall risk even more.

WHY THE ELDERLY FALL

Normal aging, with age-related decline in the body's neuromusculoskeletal and balance systems, along with weakening vision and other age-related physiological changes, lead to a higher risk of falls. Studies comparing healthy persons in their 70s with healthy persons in their 20s demonstrate a 10 to 20 percent reduction in gait velocity and stride length in the older population, according to a study by Brooke Salzman, MD, "Gait and Balance Disorders in Older Adults" (American Family Physician, July 2010). Other gait characteristics that commonly change with age include increased stance width, increased time spent in the double-support phase (both feet on the ground), bent posture, and less vigorous force development at the moment of toe-off. "These changes may represent adaptations to alterations in sensory or motor systems to produce a safer and more stable gait pattern," Salzman says.

Gait and balance disorders are leading causes of falls, whether due to normal aging deterioration or exacerbated by other medical conditions including diabetes, arthritis, and foot and ankle deformities and ailments. Obesity is another predisposing factor for falls.

An article "Biomechanical Effects of Obesity on Balance," by Hannah C. Del Porto et al. (International Journal of Exercise Science, May 2012) points out, "The existing literature provides evidence for a strong link between obesity and balance impairments" and supports the efficacy of weight loss for improving balance in obese persons including the elderly.

FREQUENTLY SEEN PATHOLOGIES

The O&P EDGE  talked with three foot and ankle specialists about what they often see in their practices. Muscle weakness or atrophy, and systemic disease issues that affect circulation to one limb and cause edema and affect flexibility are two conditions often seen by Pam Haig, CPed, founder and president-elect of the Robert M. Palmer, M.D. Institute of Biomechanics, Elwood, Indiana.

Patients often present with midfoot instability, joint instabilities, and diabetic neuropathy with loss of sensation, says Joshua A. Bailey, PT, DPT, OCS, CSCS, CPed, partner/ director of Rehab Associates of Central Virginia, headquartered in Lynchburg. With balance disorders, "Patients usually don't know they have a balance problem until they start falling," Bailey says. He would like to see screening programs in place to identify at-risk patients before serious issues develop using standardized tests such as the Berg Balance Scale. He notes that a simple test, the Unipedal Stance Test (UST), which involves the patient standing on one foot with eyes closed for 15 seconds, can reveal balance issues.

"What we're hoping to develop with our local community are accountable care organizations (ACOs), which are measured on 33 key metrics [under the Patient Protection and Affordable Care Act (Affordable Care Act)] for chronic conditions, including diabetes," Bailey says. Part of the ACO clinical package is that Medicare beneficiaries with diabetes will be able to have sensation and balance screening right away, he explains.

Michael Gross, PT, PhD, FAPTA, a professor in the Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill School of Medicine, frequently sees metatarsalgia, plantar fasciitis, and osteoarthritis (OA) of the various joints of the midfoot and of the first metatarsophalangeal (MTP) joint (hallux limitus/rigidus).

When asked about the most common problem he sees with patients' shoes, Gross echoes the experience of many foot care specialists when he says, "The shoes don't fit well." He continues, "Commonly, the shoes aren't long enough or wide enough. If they are not long enough, you can get compression on the dorsal aspect of the top of the foot. If they are not wide enough, you can get mediolateral compression of the forefoot. Look at the sole: The more reduced the sole area is, the more that is correlated with falls." In his article, "Shoe Wear Recommendations for the Older Adult" (Clinical Geriatrics, May 2010), Gross recommends having a thumb's width of space between the end of the longest toe and the end of the shoe. The clinician should be able to grasp a slight amount of the upper materials across the dorsum of the metatarsals, and the patient should be able to move his or her toes up and down freely without any shoe pressure against the dorsal aspect of the toes or nails.

Lack of support can be problematic for patients with ankle joint and midfoot arthritis, Gross says. "If the shoe is too flexible at the toe break and he or she has painful arthritis (hallux rigidus/limitus) in the first MTP joint, which is compressed at that point, the shoe does not provide enough protection and can cause more pain." According to an online podiatry website (www.podiatryaffiliates.com/referring-hallux.htm), 90 percent of body weight normally pushes off this joint during toe-off at the end of a gait cycle, a fact that emphasizes the importance of protection and support for patients with this pathology.

FOOTWEAR: BALANCE HELP OR HINDRANCE

Footwear plays a role in balance and stability, whether positive or negative.

"Because footwear appears to be an easily modifiable risk factor for falls, identifying the specific shoe features that might facilitate or impair balance in older people is imperative for the design of targeted fall prevention interventions and provision of evidence-based recommendations," point out Jasmine C. Menant, PhD, et al. in the article, "Optimizing Footwear for Older People at Risk of Falls" (Journal of Rehabilitation Research & Development (JRRD), volume 45, number 8, 2008).

Interestingly, a report published in the Journal of the American Geriatrics Society cited by Gross in his article notes that only 58 percent of healthcare providers including emergency department physicians, hospital discharge planners, home health agency nurses, and primary care physicians either provided intervention or made a referral for foot or footwear problems identified in their patients. Barriers to effective intervention could include patient unwillingness to comply, availability of services, financial resources, and the practitioner's knowledge.

SHOE CONSTRUCTION: ELEMENTS TO SEEK, ELEMENTS TO AVOID

Foot and ankle experts are unanimous about the negative effects on balance when wearing high-heel shoes, shoes with reduced sole surface area, and in general, rocker-sole shoes. However, the interviewees pointed out one exception to the recommendation against wearing high heels: Patients with tight triceps surae should wear shoes with enough heel lift to accommodate the tightness and avoid the risk of falling backward due to shifting the center of pressure toward their heel.

FOOTWEAR RECOMMENDATIONS

Below is a summary of footwear recommendations based on interviews and the previously mentioned articles, "Optimizing Footwear for Older People at Risk of Falls" and "Shoe Wear Recommendations for the Older Adult."

  • Avoid excessively elevated heel heights.
  • Provide heel lift in instances where the patient has very tight triceps surae soft tissues and pronounced dorsiflexion limitations.
  • Avoid very soft sole material that results in an unstable support surface.
  • Wear shoes with wide sole surface area for stability and balance.
  • Avoid shoes with rocker-bottom sole designs, except for patients with hallux rigidus. Gross adds that patients with hallux rigidus should also wear shoes with very stiff sole materials, especially at the toe break, and rigid sole plates inside the shoe, within the sole materials or added to the bottom of the patient's foot orthosis.
  • Wear shoes indoors and outside; avoid walking barefoot or in socks or slippers. Walking barefoot or wearing socks increased the risk of falls the most—up to 11 times compared with walking in athletic or canvas shoes, according to a research study.
  • To help prevent slipping in icy, snowy, or other adverse conditions, avoid shoes with very hard sole materials. Take shorter steps. Use shoes with wide, deep grooves in the sole for traction. Putting a device such as Yaktrax® on appropriate footwear can add more traction and safety to walking on dangerous ground. Gross recommends applying Yaktrax to a pair of shoes dedicated to outdoor use during the winter so that the device would not have to removed and put on as often.
  • For knee OA, Gross recommends that patients with medial compartment knee OA wear very flexible shoes with laterally wedged insoles. Patients with lateral compartment knee OA should wear very supportive shoes with medially wedged insoles. Patients with medial compartment knee OA should avoid wearing shoes with elevated heels.

"Older persons also need a wider base of support for balance and stability," Haig points out. A woman's dress shoe has a very narrow base, for example. "We not only want the heel to be wider in athletic shoes but we also want the middle of the shoe where the arch is to be wider so the wearer doesn't tilt one way or the other. Besides women's high-heel dress shoes, many other shoes have soles with narrow-based heels or [that are] narrow in the arch area," she notes. "That's very dangerous." Shoes also should not be too heavy, since that increases potential for falls, she adds.

Since each patient is unique, with his or her own foot problems, comorbidities, overall fitness status, environment, and other circumstances, many experts recommend a multidisciplinary approach, depending on the patient's health needs. Besides the correct footwear, foot orthotics, and perhaps other orthotic intervention, the patient might benefit from physical therapy and balance training. They point out that the type of footwear and foot orthotics that would help one condition, such as a balance problem, might have to be modified to adjust for another health problem that requires different footwear or biomechanical correction.

MULTIFACTORIAL CAUSES FOR GAIT, BALANCE DISORDERS

Gait and balance disorders are usually multifactorial in origin and require a comprehensive assessment to determine contributing factors and targeted interventions, according to Salzman in American Family Physician. "Most changes in gait that occur in older adults are related to underlying medical conditions, particularly as conditions increase in severity, and should not be viewed as merely an inevitable consequence of aging. Early identification of gait and balance disorders and appropriate intervention may prevent dysfunction and loss of independence."

The intervention to manage gait and balance issues "could be assistive device use, balance training, strengthening, flexibility, or postural," Bailey says. "Often it's all those things together. A pedorthist may think balance is a footwear and foot orthosis issue; a physical therapist may think balance is a training issue." Bailey advocates a multidisciplinary approach to gait and balance disorders: "Nobody can play every role."

Bailey and Gross both note that patients are more educated than in the past and often search the Internet for information. "Often patients have an opinion about what they have and often they're right," Gross says. However, he points out that sometimes patients can become confused with conflicting information. He recommends that patients go to their primary care physician who knows their conditions and histories, what resources are available in the area, and when a specialist would be the best option.

"I think working harmoniously between the different disciplines is really a key factor," Haig says. "We have to know our scope of practice and mesh the treatment plan together to truly treat the entire patient."

Taking time to educate patients about their treatment plans and building their trust and confidence is critical, Bailey says. "Twenty years ago, it was just 'do what the doctor says,' but now patients are more 'consumer-centric.' They are doing research on the Internet, talking with their friends, and wanting to validate the treatment they are receiving." He continues, "We help patients see that they will get out of their treatment what they put into it. When they feel they are controlling their care more, they are willing to follow the treatment regimen. If there isn't a 100 percent patient buy-in, you can be the best doctor in the world and not have a good outcome."

ADDING MORE "GOLD"

Research is continuing to add to the knowledge base of the healthcare professions. Growing older brings its share of health issues, including balance and gait disorders and foot deformities and pathologies. However, the expertise that foot and ankle specialists, physical therapists, and other professionals bring to older patients can put more "gold" in the golden years with better quality of life and more functional ability to enjoy what these years have to offer.

ELEVATING PEDORTHICS AS A HEALTHCARE PROFESSION

Pam Haig, CPed, would like to see higher-level academic training requirements for pedorthist certification to increase pedorthists’ knowledge base and elevate the profession in the eyes of other healthcare professionals and the public. “Our industry standards and training need to change as we move further up the healthcare platform so that we are thought of as healthcare experts in foot and ankle care instead of merely being persons selling shoes.”

Pedorthics began with shoe cobblers who then became retailers. Thus, rather than working directly with physicians, they have not become identified with healthcare, Haig says. “We need to be working with physicians in the clinic and talking with them at the same level. Pedorthists can work in the clinic, in home care, in nursing homes, with sporting teams, in orthopedic offices, and in podiatry offices, and also handle retail. But we need to let the other disciplines know we exist by being competent in biomechanics, knowing foot pathologies, and communicating what we see that may help physicians toward diagnosis and treatment to resolve the problems of patients.”

Joshua Bailey, PT, DPT, OCS, CSCS, CPed, stresses the need for patients to know treatment costs upfront with no surprises later. “A problem in healthcare is financial ambiguity,” he says. “We need to take the ambiguity out by telling them upfront how much our time costs, how much the shoes cost, how much the orthotics cost. If you have a good outcome and the patient is very happy with the treatment but then he or she receives a bill that is three times what was expected, you’re going to end up with a disgruntled patient whom you possibly have put in a financial bind.”


Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at

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