346 Menz Lord

Journal of the American Podiatric Medical Association Falls are common occurrences in the older population and account for considerable morbidity and mortality in this age group. Community-based studies suggest that approximately one-third of people over the age of 65 years will experience a fall within any given year.1-3 In many cases, the injuries sustained from these falls have a significant detrimental impact on physical functioning and increase the risk of admission to a nursing home.4, 5 The prevention of falls, therefore, is a major focus of medical research. Because the foot provides the only source of direct contact with the ground during walking, it is reasonable to expect that any modification to the interface between the sole of the foot and the ground may affect postural stability and therefore the risk of falling. The most obvious modification of this interface is that provided by footwear, as shoes not only constitute a barrier between the foot and the supporting surface but also directly alter the alignment of the joints of the foot, most notably in the case of high heels. It is plausible that wearing footwear may alter postural stability by a combination of mechanical and neurophysiologic alterations. Evidence to support the suggestion that shoes may influence postural stability can be derived from epidemiologic investigations regarding falls in older people. Barbieri6 conducted interviews with older people who had fallen while hospitalized, and found that poorly fitting shoes played a role in 51% of the cases. In a prospective study of 100 older subjects, Gabell et al7 reported that 45% of the subjects who fell were wearing “unhelpful” footwear at the time, including Wellington boots with cutaway heels, heavy boots, slip-on shoes worn during a country walk, slippers with worn soles, and slippers with an excessively slip-resistant sole. The authors also found that the best predictor of multiple falls was a previous history of wearing high heels. Finlay8 evaluated footwear in 274 patients admitted to a geriatric unit and outpatient hospital, and reported that only 53% were wearing adequate footwear. A number of potentially detrimental footwear features were observed, including high heels (25%), narrow heels (20%), and heel slippage (50%). In addition, of the 28% of subjects who wore slippers, half had a history of falling. The author concluded that mobility and independence in older people may be hindered by bad footwear, and stressed the need for appropriate footwear education to prevent accidents. More recently, Hourihan et al (unpublished data, 1997) reported that 33% of 147 subjects hospitalized for fall-related hip fracture were wearing slippers when they fell. In addition, the heel counter was found to be soft and easily deformable in the footwear in 44% of cases. When questioned as to their reasons for their choice of footwear, most subjects (73%) reported that comfort, not safety, was the primary concern. Although these investigations provide some preFootwear and Postural Stability in Older People