One in four older adults have foot pain. Foot pain can affect walking and contribute to falling and functional disability in older adults. The aetiology of foot pain is often multifactorial. Foot pain may be caused by musculoskeletal pathologies, as well as vascular and neurological disorders, but the three major foot problems in older adults are pain, neuropathy, and deformities. The most common orthopaedic deformities in the elderly include hallux valgus, prominent metatarsal heads, and an abnormal medial arch structure. Overall, foot deformities and other foot conditions are highly prevalent in adults aged over 65 years, which is significant as these conditions are associated with frailty and decreased physical activity.
Risk factors[edit | edit source]
The following are risk factors for foot problems in older adults:
Physiological changes[edit | edit source]
Skin[edit | edit source]
Weight-bearing activities place specific demands on the skin of the foot’s plantar surface. The foot has certain features to accommodate these loads: the epidermis is thicker in the foot compared to other parts of the body; the dermis is around 3mm thick and has adipose tissue that can resist sheer forces; and the fingerprint-like pattern of the epidermis helps to generate enough friction during walking. However, all aspects of the skin change as a person ages. These changes affect not only the superficial skin, but also the local vascular response, thermoregulation, sensory perception, and injury response, and they include:
- Flattening of the dermo-epidermal junction
- Decreased contact between the dermis and epidermis, which causes the skin to separate along this interface
- Loss of elastin and collagen fibres in the dermis. The dermis becomes atrophic. There is a reduction of fibroblasts, and the collagen becomes disorganised. The remaining collagen fibres become thicker and stiffer.
- Limited ability by the dense collagen to recoil, which leads to increased compression and development of hyperkeratosis (corns and calluses)
- Hyperkeratosis is defined as increased thickness of the outer layer of the skin
- Alteration in the mechanical properties of the plantar skin, leading to increased hardness and dryness
- A reduction in density of sweat glands, which contributes to impaired thermoregulation
- Loss of subcutaneous fat and decreased dermal vascularity, leading to poor thermoregulation
- Reduced sensation to touch, pressure, and vibration due to decreased mechanoreceptors (Meissner and Pacini corpuscles)
Overall, the thickening of the exterior layer of the skin and the presence of calluses may lead to the development of plantar lesions, causing severe pain and disability. The best management strategies are custom-made orthotics, which support the medial arch and unload the metatarsal heads.
Soft Tissue[edit | edit source]
The role of the plantar soft tissue is to protect underlying blood vessels and nerves, and to reduce the shear forces that occur while walking. Ageing has a direct impact on the foot’s soft tissues, causing progressive stiffness. In particular, it affects the tissue at the big toe, first, third, and fifth metatarsal heads, and the heel. The metatarsal pad becomes slower to recover after being compressed. Similarly, the heel pad dissipates more energy when compressed, and the plantar fascia demonstrates less recoil due to stiffness. The consequences of the soft tissue ageing process are:
- Range of motion reduction (especially in ankle dorsiflexion)
- Achilles tendon complaints
- Changes in gait pattern: more pull-off vs pushing off, less propulsion
- Increased risk of falls
Range of Motion[edit | edit source]
The ageing process affects joint physiology leading to joint stiffness. Changes include:
- Reduction in the water content of the cartilage
- Reduction in the synovial fluid volume and proteoglycans
- Bonding of the collagen fibres
A decrease in ankle dorsiflexion and subtalar joint inversion-eversion range in older adults contributes to their reduced ability to perform dynamic tasks, maintain static standing balance, and perform functional activities.
Muscle Strength[edit | edit source]
Progressive changes in skeletal muscle mass (sarcopenia), metabolism and functional capacity are typical in the ageing population. Older adults experience a reduction in the size and number of muscle fibres in their foot muscles. Large, slow-twitch motor units develop and type II fibres become denervated. These changes indicate the presence of age-related atrophy, which can be exacerbated by wearing poorly fitting footwear long-term. The consequences of atrophy of the foot muscles in the elderly include:
- Decreased ankle plantar flexor strength (causes difficulty rising onto the toes)
- Weakness of the toe plantar flexors, which negatively affects the grasping function of the toes during weight-bearing activities (impaired static and dynamic balance and functional ability, increased risk of falls)
- Development of toe deformities (hallux valgus and lesser toe deformities)
- They alter weight distribution under the foot when walking 
Biomechanical Changes[edit | edit source]
Age-related changes in soft tissue, range of motion, and muscle strength lead to the following biomechanical changes:
- The lowering of the medial longitudinal arch
- Reduced midfoot and metatarsal mobility
- Flatter and more dynamically pronated feet
- Planus foot posture
- Less plantarflexed calcaneus at the toe-off phase of gait
- Less propulsive gait pattern
Physiotherapy Intervention[edit | edit source]
General Principles[edit | edit source]
- Do not focus on just the foot
- Assess the kinetic chain: look at posture, weight distribution, and centre of mass distribution
- Offer a programme which includes stretching and strengthening
- Use manual techniques to reduce tissue stiffness
- Stimulate the plantar sensors
- Assess footwear
- Be careful when choosing orthotics for medial arch support: do not make the foot stiffer
Therapeutic Interventions[edit | edit source]
Manual techniques: mobilisation of the stiff foot and stimulating of the plantar sensory receptors to increase proprioception and improve balance.
Mobilisation techniques can be one or more of the followings:
- Mobilisation with movement: application of gentle pain-free overpressure to an end-range movement
- Anterior/posterior talocrural joint mobilisation in weight-bearing and non-weight-bearing positions, which aims to for improving DF range of motion 
- Subtalar joint mobilization for eversion and inversion
- Mid-tarsal mobilisation for pronation and supination of the midfoot
Plantar-sensory treatments may include the following:
- Plantar massage
- Whole-body vibration
- Textured surface-stimulation treatment
According to Hu et al. , patient with chronic ankle instability may have better postural control after plantar-sensory treatments were applied. Plantar massage and long-term whole-body vibration were found to be the most effective.
A randomized clinical trial by McKeon and Wikstrom, found that sensory-targeted ankle rehabilitation strategies improved single-leg postural control. One treatment was sufficient for the change to occur, however it did not offer a long lasting effect.
Stretching: calf muscle stretching to reduce pressure on the forefoot.
Strengthening: toe strengthening exercises to improve the strength of the intrinsic muscles of the foot, increase the stability of the arch, improve the toe-off phase of gait and balance during ambulation.
Footwear assessment and modification: O’Rourke et al. found that older adults often wear incorrectly fitting shoes or shoes with unsafe features, like slippers. Wearing slip-on slippers means that the toe will have to grab even more to hang onto the slipper. This can contribute to the drop of the medial arch and the development of hammer toes. Proper shoes should be soft to cushion the foot and supportive to prevent the foot from collapsing.
Introduction to Orthotics: collaboration with an orthotist to make a custom-made orthosis that supports the medial arch without increasing foot stiffness. The proper orthotics should allow for increased shock absorption capacity in the foot.
- Menz HB. Biomechanics of the ageing foot and ankle: a mini-review. Gerontology. 2015;61(4):381-8.
- Zhang B, Lu Q. A current review of foot disorder and plantar pressure alternation in the elderly. Physical Activity and Health. 2020 Sep 2;4(1).
- Oh-Park M, Kirschner J, Abdelshahed D, Kim DDJ. Painful Foot Disorders in the Geriatric Population: A Narrative Review. Am J Phys Med Rehabil. 2019 Sep;98(9):811-819.
- Muchna A, Najafi B, Wendel CS, Schwenk M, Armstrong DG, Mohler J. Foot Problems in Older Adults Associations with Incident Falls, Frailty Syndrome, and Sensor-Derived Gait, Balance, and Physical Activity Measures. J Am Podiatr Med Assoc. 2018 Mar;108(2):126-139. doi: 10.7547/15-186. Epub 2017 Aug 30.
- Helfand AE. Foot problems in older patients: a focused podogeriatric assessment study in ambulatory care. J Am Podiatr Med Assoc. 2004 May-Jun;94(3):293-304.
- Simpson H. The Ageing Foot Course. Plus 2022
- Fenske NA, Lober CW. Structural and functional changes of normal ageing skin. J Am Acad Dermatol. 1986 Oct;15(4 Pt 1):571-85.
- Levine JM. Clinical aspects of ageing skin: Considerations for the wound care practitioner. Advances in skin & wound care. 2020 Jan 1;33(1):12-9.
- Smith L. Histopathologic characteristics and ultrastructure of ageing skin. Cutis. 1989 May;43(5):414-24.
- Periyasamy R, Anand S, Ammini AC. The effect of ageing on the hardness of foot sole skin: a preliminary study. Foot (Edinb). 2012 Jun;22(2):95-9.
- Farci F, Mahabal GD. Hyperkeratosis. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562206/
- Kwan RL, Zheng YP, Cheing GL. The effect of ageing on the biomechanical properties of plantar soft tissues. Clin Biomech (Bristol, Avon). 2010 Jul;25(6):601-5.
- Jha DK, Wongkaewpotong J, Chuckpaiwong B. Effect of Age and BMI on Sonographic Findings of Plantar Fascia. J Foot Ankle Surg. 2022 May 23:S1067-2516(22)00157-0
- Hernández-Guillén D, Tolsada-Velasco C, Roig-Casasús S, Costa-Moreno E, Borja-de-Fuentes I, Blasco JM. Association ankle function and balance in community-dwelling older adults. PloS one. 2021 Mar 4;16(3):e0247885.
- Shur NF, Creedon L, Skirrow S, Atherton PJ, MacDonald IA, Lund J, Greenhaff PL. Age-related changes in muscle architecture and metabolism in humans: The potential contribution of physical inactivity to age-related functional decline. Ageing Research Reviews. 2021 Jul 1;68:101344.
- Yong-Wook K, Oh-Yun K, Heon-Seock C, Jong-Hyuck W, Chung-Hwi Y, Tae-Ho K. Comparison of Toe Plantar Flexors Strength and Balancing Ability between Elderly Fallers and Non-fallers. Journal of Physical Therapy Science 2011; 23 (1): 127-132
- Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Gait, balance and plantar pressures in older people with toe deformities. Gait Posture. 2011 Jul;34(3):347-51.
- Abassi M, Whiteley R. Serial Within-Session Improvements in Ankle Dorsiflexion During Clinical Interventions Including Mobilization-With-Movement and A Novel Manipulation Intervention – A Case Series. IJSPT. 2021;16(4):1158-1168.
- Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015 Apr;45(4):265-72.
- Hu X, Liao J, Hu X, Zeng Z, Wang L. Effects of plantar-sensory treatments on postural control in chronic ankle instability: A systematic review and meta-analysis. PLoS One. 2023 Jun 27;18(6):e0287689.
- McKeon PO, Wikstrom EA. The effect of sensory-targeted ankle rehabilitation strategies on single-leg center of pressure elements in those with chronic ankle instability: A randomized clinical trial. J Sci Med Sport. 2019 Mar;22(3):288-293.
- O’Rourke B, Walsh ME, Brophy R, Vallely S, Murphy N, Conroy B, Cunningham C, Horgan NF. Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study. BMC geriatrics. 2020 Dec;20(1):1-8.
- Dr Sinha Housecall Doctors. How Aging Affects Your Feet
Available from: https://www.youtube.com/watch?v=j_819z3ILH0 [last accessed 17/09/2022]