Taking care of your feet to prevent falls

For most of our adult lives, we take it pretty much for granted that once we're upright and on our feet, we'll stay that way. But starting around our mid-60s, remaining perpendicular is not such a sure thing. Each year, about one in every three older Americans takes a tumble, and the chance of falling increases as we age.

Everything from slippery throw rugs to poor lighting to side effects from multiple medications has been implicated as a risk factor for falling. Foot problems and pain get mentioned sometimes, but frequently as an afterthought.

Yet, when you walk, the force on the heel when it hits the ground is up to 1.5 times your body weight. As the foot rolls forward, the pressure shifts to the outside edge and then, as you start to push off, to the ball of the foot and toes. Young, spry feet can repeat this thousands of times a day and feel no pain. But older feet may not be so lucky. Muscle tissue thins with age. The nerves to our feet don't send electrical messages as efficiently, so there may be some loss of sensation.

Age also tends to bring on structural changes. Arches falter and tend to flatten out. Older toes can start curling into "claw toes" because of muscle imbalance. And older people -- especially women -- are prone to developing bunions, a misalignment of the bones in the big toe.

Bunions and claw toes can create "hot spots" of extra pressure that can be painful. Surveys show that about 30 percent of older people experience foot pain from these and other problems.

However, Marian T. Hannan, co-director of musculoskeletal research at the Institute for Aging Research, says it's a little misleading to blame aging for foot woes. Rather, it's the injuries and chronic diseases (diabetes, especially) that can make it a rough time for feet.

Over the past several years, there's been a surge of research connecting falls to foot pain and perhaps also to problems like bunions and clawed toes. Investigators at the Institute for Aging Research, a research group based at Harvard-affiliated Hebrew SeniorLife, a long-term-care facility in Boston, found that foot pain seems to be a bigger factor in indoor falls than in outdoor falls. Other researchers have linked foot pain to a slow gait and poor balance.

But until recently, only a few studies have investigated a more direct connection between foot pain and falls, according to Karen Mickle, one of a group of Australian researchers that has conducted many of the more important studies in this area. The studies that have been done focused on high-risk groups, not the general "community-

dwelling" population of older people.

In 2010, Mickle and her colleagues started to bridge that gap with a study published in the Journal of the American Geriatrics Society. They recruited about 300 adults, ages 60 and older, from the Sydney area, identified those with and without foot pain, and followed them for a year. By a sizable margin, the people who fell were more likely to have been bothered by foot pain than the people who didn't fall.

In 2011, another Australian group reported findings in the British medical journal BMJ from the first-ever randomized clinical trial to determine whether a foot-care program would prevent falls. The study included several hundred older people (average age, 74) with foot pain. The program consisted of exercises, orthotics and footwear advice. The result? Over a year's time, the program reduced the number of falls by 36 percent.

But there's reason to be a little cautious about making pronouncements about what works to prevent falls. In 2010, a major review of the fall-prevention research surprised quite a few doctors and researchers by concluding that it was "unclear" whether the kind of fall risk assessment and management programs favored by groups like the American Geriatrics Society, in fact, do work to prevent falls. The reviewers identified vitamin D pills and exercise programs as the only interventions supported by results from clinical trials. But these kinds of reviews have their limitations. Some interventions, like vitamin D pills, are much easier to test in a clinical trial than others.

And there's certainly enough experience, evidence and common sense available to offer a few suggestions about feet and fall prevention.

Choose your shoes wisely -- and wear them. People assume they know their correct shoe size, but a study published in 2011 by doctors at the New York University Hospital for Joint Diseases showed that 35 percent of people are off by at least half a size. The percentage was even higher among people with diabetes.

Be especially careful about width. Even if you don't have a full-fledged bunion, the base of the big toe may bulge out somewhat with age, so the front of your foot needs more room than it used to. This is also true for clawed toes, or the beginning of them, to avoid developing calluses on the knuckles of your toes from shoe friction.

However, Harvard researchers conducted a study that showed that choice of footwear really didn't have much of an effect on falls -- that is, there was no difference between athletic shoes and other types. They did find, though, that people who wore shoes indoors were less likely to suffer a serious injury from a fall than those who padded around in slippers or socks or went barefoot.

Lose weight. Studies have linked being overweight or obese to foot pain and other foot problems.

Try prefabricated orthotics first. Hylton Menz, the lead author on many of the Australian foot-and-fall studies and a podiatrist, says orthotics do seem to prevent some falls by stabilizing the feet.

There's a lot of debate about which kind of orthotic is best -- and not just for fall prevention but for a whole variety of foot and leg problems. Custom-made orthotics, made from an impression of the foot, cost at least several hundred dollars. The prefabricated ones cost about $50. The orthotics used in the study that showed that a foot-care program could prevent falls were prefabricated. And prefabricated and custom-made orthotics have produced similar results when they've been tested in several clinical trials as a treatment for plantar fasciitis and foot pain from rheumatoid arthritis. So, based on these data and on the cost difference, Menz, a Fulbright Visiting Scholar in 2011 at the Institute for Aging Research, says it makes sense to try prefabricated orthotics before investing in the expensive custom-made ones, unless you have a major foot deformity that clearly needs custom treatment.

Give your feet a little workout. Exercises for the feet and ankles can help offset the muscle loss and stiffness that naturally set in with age. Menz and his colleagues say home exercises were probably the main reason the foot-care program they tested was successful in preventing falls. (Three of the exercises used in the study are illustrated here.)

Some of the exercises may seem a little goofy, but they serve a purpose. For example, picking up marbles or small stones with your toes helps strengthen muscles that may counteract the tendency of toes to curl. But foot exercises aren't the only kind of activity that benefits the feet. Menz gave yoga as an example of exercise that may prevent foot problems.