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The Aged Foot

Original Editors - Scott Buxton

Top Contributors - Scott Buxton, Lucinda hampton, Kim Jackson, Jonathan Wong, 127.0.0.1, Lauren Lopez, Khloud Shreif, Mahbubur Rahman and Alexandra Stead

Introduction

Human feet

Foot problems are commonplace in older adults.[1][2] With age, feet widen and flatten, with the fat padding on the soles experiencing increased stiffness, dissipating more energy upon compression, and are slower to recover upon load removal.[3] Foot impairment contributes to impaired balance and foot function,[4] and can significantly exacerbate falls risk.[5]

The average moderately active person takes around 7,500 steps/day. If you maintain that daily average and live until 80 years of age, you'll have walked about 216,262,500 steps in your lifetime. According to these statsistics, the average person (with average stride) living until 80 will walk a distance of around 177,028 km or 110,000 miles.[6]

An estimated 24% of older adults experience painful foot conditions, which contribute to the picture of impaired foot function.[7] The management of the aged foot is then typically aimed at achieving comfort through pain reduction as well as increasing mobility. Both ultimately preserve function, prevent dependence, and reduce the need and demand for other services. Thankfully most common issues can be treated successfully by Podiatrists as well as Physiotherapists. The aim of this article is to highlight the common issues as well as basic methods of management.

Epidemiology

It is estimated that around 80% of older people have foot problems.[8] Despite this figure, only a small proportion of older people with foot problems seek medical attention.[9]

Age-related foot disorders include musculoskeletal foot disorders, such as hallux valgus, lesser digit deformities, pes planus, or cavus, and reduced plantar tactile sensitivity.[10][11] [12] Most of these issues derive from poorly fitting shoes, foot weakness, obesity and chronic conditions such as diabetes, cardiovascular disease or osteoporosis.[8][13]

Common Problems

The problems listed below are not all physiotherapy amenable however it is important that physiotherapists are aware of them and how they can affect an older person. In particular all of these issues can contribute to a multifactorial picture of falls.

Toenail Issues

Toenail issues arise because of many issues but the largest contributor is likely the fact that cutting is difficult. See Toenail Issues in Older Persons

Bunion

Feet Bunions

Foot width and length often increases with age in addition to peripheral swelling which often occurs throughout the day.[3][14] This change in shape can lead to misshapen joints, resulting in pressure changes in the skin and culminating in bunions. A bunion is a bony deformity of the joint at the base of the big toe. The main sign is the big toe pointing towards the other toes on the same foot causing a swollen bumpy lump on the medial aspect of the foot, at the first metatarsophalangeal joint. This causes a painful callus to form which could potentially develop into a sore.[15]

Symptoms include: a swollen, bony bump on the outside edge of your foot; pain and swelling over your big toe joint that's made worse by pressure from wearing shoes; hard, callused and red skin caused by your big toe and second toe overlapping; sore skin over the top of the bunion.

Hallux Valgus

Hallux Valgus

Hallux Valgus is the most common foot deformity, involving the big toe laterally deviating and the 1st metatarsal deviating medially to create a valgus angle at the 1st metatarsal-phalangeal joint (MTP). A bunion is thus typically observed, reflecting the medial eminence of the first metatarsal and the overlying adventitious bursa. It is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected and is often accompanied by significant functional disability and foot pain and reduced quality of life.[16][17]

Hallux valgus is usually more prevalent among older women than in men,[18] and wearing high-heels is a risk factor for feet deformity in women, implicating footwear as a cause of this condition.[19]

Corn / Callus

As well as being caused by bunions, ill-fitting shoes and the deterioration of fat pads can lead to pressure areas. This is called a corn or callus. They are circular masses of tissue which form on the outside of the toes, usually the outer ones, which is painful on direct pressure. They are usually caused by ill-fitting shoes and deterioration of fats pads.

Ankle Osteoarthritis

Ankle OA: Compared with knee and hip, there is a substantially lower rate of primary ankle OA.

Gout

Tophaceous gout

Gout is a crystal-induced arthritis, in which monosodium urate (MSU) crystals precipitate within joints and soft tissues and elicit a highly inflammatory but localised response. Gout is often described as a burning pain and can be extremely severe in nature with an attack lasting upwards of a week. During this period of immobility an elderly person can lose a significant amount of independence and may require help to function.

In many elderly people, who are living with frailty, gout can often be interpreted as something more severe such as a fracture or infective arthritis. This is because a flare of a disorder can knock those who have 'just about been coping' with all of their other morbidity over the edge. With their body now unable to cope with a new complaint they often become immobile and unable to function as before.

Hallux Rigidus

Hallux Rigidus is a progressive disorder. The toe’s motion is decreased over time. Some causes are faulty function or biomechanics and structural abnormalities which can lead to OA.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systematic autoimmune inflammatory disease and results in persistent inflammation of synovial tissue especially of the wrists, hands and feet. Individuals with RA are 8 times more likely to have functional disability compared with adults in the general population from the same community.

Diabetic Foot Ulcers

Diabetic foot ulcer

15-20% of diabetics will develop a diabetic foot ulcer in their lifetime and effective monitoring is essential to prevent further issues developing alongside[20]. Up to 50% of patients with neuropathy never experience symptoms, so absence of neuropathic symptomatology must never be associated with absence of risk of foot ulceration.

Skin

With age, skin becomes thinner, loses fat, takes longer to heal and is more prone to damage.

Obesity

15% of men and 28% of women over 60 are obese and this significantly affects the biomechanics of the feet. Obese elderly tend to have a higher incidence of foot pain because of structural changes. This also has implications for day to day life, mobility and general well-being. They tend to have larger foot dimensions, thicker plantar fat pads under the heels, a lower hallux and overall foot strength. These contribute to generating a higher overall force, a greater plantar contact time with a greater contact area therefore greater pressure-time. Therefore providing interventions to combat their obesity ensures a reduction in foot pain, an increase in independence and better overall quality of life.[21]

Management

It is important that with older people you remember to think about the person as a whole and in terms of their condition of living with frailty and falls risk.

Prevention

  1. Regular Checks. Long-term conditions increase the likelihood of developing issues particularly those disorders which affect circulation. The signs of deterioration are subtle and therefore long-term vascular issues need to be monitored. It is essential that alongside regular check-ups those most vulnerable seek primary care advice as soon as any new issues arise such as blisters, cracks or obvious changes. Prevention is the best protection, you do this with your eyes, why is it different for your feet?
  2. Nails. As we age it is increasingly difficult to reach our toe nails but cutting them should not go to the wayside. Poorly looked after nails can become ingrown and infected resulting in pain and immobility. The nails get long, press against shoes, the pressure causes sores, the sores become infected and then ulcerated. You look after your fingernails, why not your toenails?
  3. Skin Quality. As we age our skin becomes dry, cracked, have a reduced circulation and a reduction in fat pad absorption. Once the dryness and cracked skin with sores sets in they are a rife place for infection. Cellulitis is common in elderly people and frequently reoccurs. You care about the skin on your face, why not your feet?
  4. Correct Footwear. Optimum alignment and weight distribution is essential to keep joints and soft tissues working effectively. A good pair of closed heel flat shoes with good shock absorption promotes good walking posture and balance whilst reducing any risk of chaffing or rubbing. Additionally they should be roomy enough to allow for minor swelling which occurs during the day. Why do you think runners spend so much on good quality running shoes?

Essential Care

Some basic essential care points can make all the different for elderly people.[22]

  • Ideally daily washing
  • A good and thorough drying routine
  • Avoiding talcum powder
  • Fresh socks
  • Moisturising the feet avoiding over application between the toes
  • Routinely buying new footwear and minimal use of slipper

Ulcers

See the diabetic foot.

Gout

Aside from the management of hyperuricemia and the pharmacology-side of the treatment physiotherapy is important. Patient education, optimising mobility and lifestyle modification are essential parts of the holistic gout management plan.

It is important that the elderly person with gout remains as active as possible during the attack of symptoms as the rest of their muscular system will atrophy and it may be difficult to get the muscle bulk and function back afterwards. Seated or weightbearing exercise plans are a suitable options alongside provision of mobility aids. For those elderly able to attend outpatient clinics ultrasound therapy may also be an option. As gout is an inflammatory disorder don't forget the efficacy of ice.

It is also that the person avoids alcohol, highly calorific food, sea food in the long term and if applicable to them, optimise their BMI. This will reduce the risk of ongoing flares.[23]

Toenails

Owning individual nail clippers and files prevents cross contamination of infections along with regular washing and maintenance.[14] Toenail cutting services may be an alternative option to those unable to cut their own nails.
Overall it is not always the physiotherapists job to manage the nail conditions however, basic advice is always worth sharing with the patient. The main thing to be aware of is that elderly patients might complain of common nail changes and dystrophies that cause pain, affect daily activities, are of cosmetic concern. Awareness of these conditions is essential for onward referral to optimally manage the issues.

Skin

Keeping feet moisturised is an essential part of caring for aged skin which is prone to drying out.

Bunions

A bunion may only need treatment if it is severe and causing significant pain and alteration to daily life. Non-surgical options include pain killers, bunion pads and orthotics all alongside appropriate footwear. It is important to be aware that surgery is the only way to correct a bunion and is not for cosmetic reasons alone.[24] The surgical options include an osteotomy, which is removal of the problematic part of the bone alongside correction of any soft tissue deformity which has occurred. Arthrodesis is also an option. This is when the metatarsophalangeal joint is fused and is only recommended in severe joint degeneration. 

References

  1. ↑ Menz HB. Foot problems in older people: assessment and management. Elsevier Health Sciences; 2008.
  2. ↑ Rodríguez-Sanz D, Tovaruela-Carrión N, López-López D, Palomo-López P, Romero-Morales C, Navarro-Flores E, Calvo-Lobo C. Foot disorders in the elderly: A mini-review. Disease-a-Month. 2018 Mar 1;64(3):64-91.
  3. ↑ 3.0 3.1 Menz HB. Biomechanics of the ageing foot and ankle: a mini-review. Gerontology. 2015 Nov 11;61(4):381-8.
  4. ↑ Menz HB, Morris ME, Lord SR. Foot and ankle characteristics associated with impaired balance and functional ability in older people. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2005 Dec 1;60(12):1546-52.
  5. ↑ Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Foot pain, plantar pressures, and falls in older people: a prospective study. Journal of the American Geriatrics Society. 2010 Oct;58(10):1936-40.
  6. ↑ SnowBrains. How Far Does the Average Human Walk in a Lifetime? [ONLINE] http://snowbrains.com/brain-post-how-far-does-the-average-human-walk-in-a-lifetime/ [Accessed 21/03/17 @19:20]
  7. ↑ Thomas MJ, Roddy E, Zhang W, Menz HB, Hannan MT, Peat GM. The population prevalence of foot and ankle pain in middle and old age: a systematic review. Pain. 2011 Dec 1;152(12):2870-80.
  8. ↑ 8.0 8.1 Ikpeze TC, Omar A, Elfar JH. Evaluating Problems With Footwear in the Geriatric Population. Geriatr Orthop Surg Rehabil. 2015 Dec;6(4):338-40. doi: 10.1177/2151458515608672. PMID: 26623172; PMCID: PMC4647201.
  9. ↑ Menz HB, Jordan KP, Roddy E, Croft PR. Musculoskeletal foot problems in primary care: what influences older people to consult? Rheumatology (Oxford). 2010 Nov;49(11):2109-16. doi: 10.1093/rheumatology/keq206. Epub 2010 Jul 25. PMID: 20660499; PMCID: PMC2954366.
  10. ↑ Nix SE, Vicenzino BT, Smith MD. Foot pain and functional limitation in healthy adults with hallux valgus: a cross-sectional study. BMC musculoskeletal disorders. 2012 Oct 16;13(1):197.
  11. ↑ Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. Journal of foot and ankle research. 2010 Sep 27;3(1):21.
  12. ↑ Scott G, Menz HB, Newcombe L. Age-related differences in foot structure and function. Gait & posture. 2007 Jun 1;26(1):68-75.
  13. ↑ Health in Aging. Foot Problems. [ONLINE] Accessed from http://www.healthinaging.org/aging-and-health-a-to-z/topic:foot-problems/ [23/03/2017]
  14. ↑ 14.0 14.1 Woodrow P et al (2005) Foot care for non-diabetic older people. Nursing Older People; 17: 8, 31-32.
  15. ↑ NHS Direct. Bunions. [ONLINE] Accessed from: http://www.nhs.uk/conditions/Bunion/Pages/Introduction.aspx [23/03/2017].
  16. ↑ González-Martín C, Alonso-Tajes F, Pérez-García S, Seoane-Pillado MT, Pértega-Díaz S, Couceiro-Sánchez E et al. Hallux valgus in a random population in Spain and its impact on quality of life and functionality. Rheumatol Int. 2017;37(11):1899-1907.
  17. ↑ Mortka K, Lisiński P. Hallux valgus—a case for a physiotherapist or only for a surgeon? Literature review. Journal of physical therapy science. 2015;27(10):3303-7.
  18. ↑ Nguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthritis Cartilage. 2010 Jan;18(1):41-6. doi: 10.1016/j.joca.2009.07.008. Epub 2009 Sep 1. PMID: 19747997; PMCID: PMC2818204.
  19. ↑ Menz HB, Morris ME. Footwear characteristics and foot problems in older people. Gerontology. 2005 Aug 24;51(5):346-51.
  20. ↑ Frykberg RG et al (1998) Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care; 21: 10, 1054-1055.
  21. ↑ Steele, J. Mickle, K. Munro, B. 2009. Fat flat frail feet: how does obesity affect the older foot. XXII Congress of the International Society of Biomechanics.
  22. ↑ Soliman A, Brogan M (2014) Foot assessment and care for older people. Nursing Times; 110: 50, 12-15.
  23. ↑ Chowalloor PV, Keen HI, Inderjeeth CA. Gout in the elderly. OA Elderly Medicine 2013 Aug 01;1(1):2.
  24. ↑ Bunion. NHS Choices. [ONLINE] http://www.nhs.uk/Conditions/Bunion/Pages/Treatment.aspx Accessed 29/03/2017.
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