Health Matters

Lower extremity key in fall risk

Conway McLean, DPM, Journal columnist

Once again, Fall Prevention Month, occurring every September, has come and gone. Little mention was made of the event in the popular media this year, not indicative of its importance, which is reflected in the statistics. Roughly 36 million falls are reported each year among older adults. About 50 billion dollars are spent annually on the costs of caring for these falls, with 32,000 deaths occurring every year.

Why do so many falls lead to morbidity and mortality? The reasons are multifactorial and cannot be summed up in a one-word answer. Numerous physical, medical, and societal issues come into play, some fairly obvious (inner ear problems!) and others less so (a painful callus under the foot). Many of them are amenable to improvement.

Most senior citizens in our culture have been prescribed medications, often multiple, summarized in the term “polypharmacy.” Well-recognized are the drug interactions resulting, some of which are difficult to predict. And various meds are known to interfere with balance and stability, making the individual more prone to “losing their balance.” The prescribing physician needs to be aware of the potential for disturbing this important faculty.

When sensations coming to and from the feet are disturbed, as in the case of many types of neuropathy, fall risk is greatly increased. Compounding the situation is the sufferer often has no idea they have a neurologic problem and are lacking in this critical feedback system, the provision of information about foot positioning, body weight distribution, limb rotation, joint motion, from the extremity to the brain.

Pain comes in many forms, experienced as various sensations, originating from numerous body parts. Orthopedic issues frequently lead to an increase in fall risk. The mind doesn’t like to experience pain, naturally, and will go so far as to prevent weight bearing on a painful extremity. The individual will simply say their leg “gave out” and wouldn’t bear weight. They don’t experience any pain with these events since the limb never assumes any weight. They had no pain, but merely fell to the ground.

There are other orthopedic conditions that can increase someone’s risk for a fall. Certain foot types, obviously determined by genetic factors, are less stable, especially that of the higher arch type. This pedal architecture places the body higher off the ground, also shifting weight to the outside. Alternatively, a tight Achilles tendon (a very common finding) can have a similar effect, resulting in a less stable lower extremity.

At this point a pertinent question centers on the subject of evaluation; how to measure an individual’s risk for accidentally going to the ground? Although we are unable to precisely determine this likelihood physiologically (we can’t easily gauge inner ear function), we can appraise various components of gait and stability, making it an indirect but helpful measurement. Numerous functional tests have been developed for this, such as the T.U.G. test, the “Timed Up and Go.” An additional one is the 30 Second Chair Stand Test.

Varying strategies have been tested and recommended for an individual at higher risk. As should seem reasonable, treating painful conditions of the foot, ankle, and lower extremity can lead to a reduced risk since pain is such a common cause of falls. Depending on the specific structure, podiatric intervention can be of great benefit. The simple debridement (a technical term for trimming) of a painful callus on the bottom of the foot can help to keep a senior upright and ambulatory.

Shoes can also contribute to falls. A shoe long past its prime will likely have ‘broken down’, providing inadequate support to the wearer. The stability offered by a shoe can serve to make the downward forces on the bones better aligned and, consequently, more stable. Even an evaluation of someone’s slippers can be informative since many have insufficient traction potentially leading to a slip and fall.

Because of the above-mentioned issues, in-shoe supports of some type can help with this skeletal alignment. Numerous options are available, falling into one of two categories: off-the-shelf or custom, (i.e. made from a [perfect??] copy of each foot). The latter requires an intimate knowledge and understanding of lower extremity biomechanics for their success. When properly prescribed, custom foot orthotics can serve multiple functions, removing force from a prominent bone, or supporting a falling arch.

Other strategies include a physical therapy program dedicated to working and strengthening the structures (muscles) involved in standing and staying upright. Any medications which are causing balance issues should be reduced or discontinued, perhaps changing to a different med. Many seniors are prescribed a supportive but lightweight foot-ankle support. Also, evaluating the home for trip hazards is also recommended.

Despite the fact that for a senior citizen, a fall can be a deadly event, too often the warning signs are ignored or trivialized. Frequently heard is the refrain “I’ve always been able to catch myself”. Personally, the typical response is “what about next time?” A better approach, borne out by the data, is that of prevention. Abundant research demonstrates the benefits of a preventative pathway, utilizing some or all of the methods outlined herein.

We know certain therapies and recommendations can lessen the number of these often damaging events. When a physician is tuned in to the presence of these heightened risks, they can reduce the likelihood of many potentially debilitating consequences of the (next) fall. This is an area in which podiatry can excel: evaluating gait and stance are skills essential to a podiatric physician providing treatment for the myriad issues originating in faulty biomechanics.

The consequences of a fall for a senior citizen can be devastating. The immobility sometimes required for treatment of a simple broken leg can set in motion a downward spiral of events, from pneumonia to bed sores. A concussion can cause lasting changes in memory and cognition, while a broken hip may lead to permanent confinement to a wheelchair. But we know the factors increasing these risks: we need only raise awareness of the breadth of the problem and the many methods of mitigating the risks.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.


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