Clinical Geriatrics

Introduction
Clinical practice suggests that many older individuals have great difficulty procuring shoes that are comfortable or shoes that successfully address a clinical problem they are experiencing. Clinicians are often faced with the difficult task of recommending shoes to their patients that will address either or both of these requirements. A report published in the Journal of the American Geriatrics Society indicated that only 58% of healthcare providers either provided intervention or made a referral for foot or footwear problems identified in their patients, with providers including Emergency Department physicians, hospital discharge planners, home health agency nurses, and primary care physicians.¹ Barriers to effective intervention in these instances could include patient willingness to comply, financial resources, availability of services, and knowledge on the part of the practitioner.

The purpose of this review is to provide healthcare practitioners and the general public with information about shoe wear that might effectively address some of the common healthcare issues faced by older adults. These issues include poor balance, slipping, risk for falling, shock absorption, knee osteoarthritis, hallux rigidus, and general fit requirements. Most of the information presented in this article reflects current literature on the topics, with some suggestions arising from 30 years of clinical practice that has focused on the treatment of foot, ankle, and other lower-extremity patient problems. Summary information for each issue appears in the Table.

Poor Balance
Many shoe wear construction features have potential influence on balance, chief among these being heel lift. Menant et al² have demonstrated that older individuals who wore shoes with a 32-mm (1.3 in) heel lift (difference between sole material underneath the heel and forefoot) had more postural sway² and adopted a more conservative gait pattern, including increased double support time,³ as compared with a standard 14-mm (0.55 in) heel-lift shoe. Older women who wore shoes with elevated heels also demonstrated a reduction in forward functional reach and a reduced walking velocity.⁴ Additional support for the deleterious effects of elevated heel lift on balance comes from the work of Lord and Bashford.⁵ These results are probably explained by a forward shift in the center of pressure over the forefoot affected by shoes with elevated heels. Such a shift effectively reduces the ability of the shoe wearer to shift his/her center of mass safely in the forward direction. A women’s dress shoe may also result in a reduced base of support in the anterior-position/posterior direction since the distance between the forefoot and the heel of the shoe is shorter than a conventional low-heeled shoe (Figure 1a).

Clinical experience suggests that one caveat to the recommendation that older individuals wear shoes with reduced heel lift involves an older individual who has ankle joint equinus, or very limited dorsiflexion that borders on a plantar flexion contracture. Older individuals who have such pronounced tightness in the triceps surae muscle group probably will experience a posterior displacement of the center of pressure toward their heel, placing them at risk for falling backwards. One of my previous older patients received advice from a geriatric clinic that she should stop wearing her ruby-red high-heeled shoes for fear that she would fall if she continued to wear these favorite shoes. She complied with the clinicians’ wishes and proceeded to suffer several falls backwards.