Can Examining the Feet Prevent Falls in the Elderly?
FEATURE
REHAB
Donald C. DeFabio
DC, DACBSP, DACRB, DABCO
FALLS IN THE ELDERLY ARE A SIGNIFICANT HEALTH ISSUE. In fact, in 2020, falls were the leading cause of death in the elderly. The risk of falls is multifactorial, including physical limitations, balance, and psychological issues, and the Framingham Foot Study has determined that “higher odds of recurrent falls were observed in individuals with foot pain, especially severe foot pain, as well as individuals with planus foot posture, indicating that both foot pain and foot posture may play a role in increasing the risk of falls among older adults.”1
The Role of Chiropractic Footcare in Elderly Health
The treatment of foot pain and foot posture is integral to Chiropractic as part of a postural kinetic chain assessment. More specifically, Menz found a pronated foot is significantly associated with an increased likelihood of generalized foot and heel pain in men.7 In contrast, a supinated foot is protective against hindfoot pain in women. Therefore, as part of your exam, have your patients take their shoes and socks off and evaluate their feet.
Tip 1
► Inspect the patient’s shoes and foot-standing
Inspect the patients’ shoes for uneven wear in the soles, uppers, and especially the heel counter. Be sure to inspect the patient’s foot standing. If the calcaneus everts or inverts and the heel counter is broken down, then the patient needs support (an orthotic) of the entire foot because mid and forefoot alignment is directed by rearfoot positioning.
The Effects of Age on Foot Health
The foot changes in size and shape with age (it usually gets wider), which can affect the fit of shoes, leading to calluses, corns, and “hot spots,” indicating increased friction. In addition, there is a loss of elastin and collagen, thinning of the plantar fat pads, and muscular, ligament, and joint changes. Alone or in combination, the net effect on the aging foot is loss of support and joint dysfunction.
Remember that older adults have a higher incidence of comorbidities such as osteoarthritis (OA), diabetes, peripheral arterial disease, and neuropathy, which may present as foot pain. If necessaiy, refer the patient to their PCP for evaluation and co-management of these conditions. If you treat neuropathy, performing a thorough examination, including systemic evaluation, is essential.
Tip 2
► Improve adjusting skills of the foot and ankle
The aging, weakening foot with OA needs both adjustments to the selective ankle and foot articulations that are restricted and support for the weakened ligaments and muscles. CMT of the foot and ankle needs to be specific in the aging foot. There are excellent courses available to improve your adjusting skills of the foot and ankle if required, and support can be achieved with custom threearch orthotics.
Importance Of the Medial Longitudinal Arch in Diagnosis
Assessment of the foot’s medial longitudinal arch (MLA) is the hallmark of determining a pronated, “flat” foot posture. A low medial arch, calcaneal eversion, and forefoot abduction characterize it. The navicular bone is the most important bone affecting the height of the arch of the foot via its role in the talo-navicular and midtarsal joints2. Therefore, assessing dynamic navicular function gives excellent insight into the MLA’s function during gait.
A simple dynamic assessment of the MLA begins with the navicular drop test (NDT). Rest the unloaded feet on the floor with the knees and hips at 90 degrees. The height of navicular tuberosity from the floor is measured and marked on a card. Then, have the patient stand, and the navicular tuberosity height is marked again on the card, measuring the distance the navicular tuberosity lowers (drops) towards the ground in mm. A navicular drop test of 5 mm is clinically significant, and a navicular decline of 10mm or more indicates pedal orthotics are needed.
In addition to the NDT, the “too many toes” sign and Toe Raising Test indicates a flexible flat foot. Too many toes sign is simply observing the patient from behind while standing, and if the number of toes appearing towards the lateral aspect of the foot is greater than the medial, it is positive. For the Toe Raising Test while the patient is still standing, passively dorsiflex the great toes and observe if the MLA is restored, indicating a positive test.
Navicular drift is another indicator of loss of the MLA. Starting in the same position as the navicular drop test, trace the medial border of the foot on the floor. This line should be relatively straight unless hallux valgus is present. Have the patient stand and observe the navicular tuberosity (and medial foot), looking if it deviates medially past the tracing on the floor. Any medial collapse, or “drift” of the navicular, creating a curved outline of the foot on the floor, is considered a positive test, and the patient needs orthotics.
Tip 3
► Corrective measures for pronated foot
A pronated flat foot may be either rigid or flexible. These tests indicate the presence of a flexible, pronated foot that needs support and corrective exercises. Strengthening the intrinsic and extrinsic foot muscles via short foot exercises and wobble boards respectfully are indicated.
Biomechanical Subsystems in the Feet for Integral Approach
Recently, Lai (2023) has proposed three biomechanical subsystems in the feet that reinforce the Chiropractic whole-body approach in treatment. (6) First, the bones and ligaments form the foot’s three arches, creating a passive subsystem that maintains the structural foundation of the foot. Custom flexible orthotics and CMT can support these. Second, the intrinsic and extrinsic foot muscles are the active subsystem of the foot, providing the functional linkage between the arches in the feet into the ankle and leg. Our approach is lower leg exercises and balance board training. Third, the intrinsic foot muscles originate and insert on the foot, acting as local stabilizers to support the arches—short foot exercises.
The biomechanical insult that develops in the deconditioned flat foot creates pain and dysfunction in the feet and the entire kinetic chain. In the elderly, simply having painful feet increases the risk of falling by 62%. In addition, older patients with flat foot posture have a 78% increased risk for recurrent falls and impaired postural stability and balance. Therefore, elderly patients who demonstrate evidence of a loss of the MLA with or without foot pain would benefit from corrective exercises and supportive, custom flexible three-arch orthotics for the feet.
Dr. Donald DeFabio teaches Relevant Rehab, CCSP / DABCO to Rehab Diplomate seminars throughout the US. You can get his free e-book, The Six Keys to In Office Rehab, on his website (www.DeFabioDifference.com), and his protocols are available on YouTube, where he has 41k subscribers. Contact him at DeFabioChiropractic@gmail. com for queries, scheduling presentations, and workshop registration.
References:
1. Awale A, Hagedorn TJ, Dufour AB, Menz HB, Casey VA, Hannan MT. Foot Function, Foot Pain, and Falls in Older Adults: The Framingham Foot Study. Gerontology. 2017;63(4):318-324
2. Gomez Carrion, A.; de los Angeles Atm Arratibel, M.; Morales Lozano, M.R.; Martinez Sebastian, C.; de la Cruz Torres, B.; Sanchez-Gomez, R. Kinematic Effect on the Navicular Bone with the Use of Rearfoot Varus Wedge. Sensors 2022, 22, 815
3. Elsayed W, Alotaibi S, Shaheen A, Farouk M, Farrag A. The combined effect of short foot exercises and orthosis in symptomatic flexible flatfoot: a randomized controlled trial. Eur J Phys Rehabil Med. 2023 Jun;59(3):396-405
4. James K, Orkaby AR, Schwartz AW. Foot Examination for Older Adults. Am J Med. 2021 Jan;134(l):30-35.
5. Lai Z, Wang R, Zhou B, Chen J, Wang L. 2023. Difference in the recruitment of intrinsic foot muscles in the elderly under static and dynamic postural conditions. PeerJ 11 :el5719
6. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ, Hannan MT. Association of planus foot posture and pronated foot function with foot pain: the Framingham foot study. Arthritis Care Res (Hoboken). 2013 Dec;65(12):1991-9
