The Ageing Foot
Original Editor - Ewa Jaraczewska based on the course by Helene Simpson
Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson
Introduction[edit | edit source]
Foot problem in elderly can vary and its aetiology is often multifactorial. However the three major foot pathologies are: pain, neuropathy, and deformities. [1] According to statistic one in four elderly persons have foot pain. [2] It can effect normal walking and could contribute to falling and functional disability in older adults. [3]The foot pain may be caused by musculoskeletal pathologies, vascular and neurological disorders.[4] The most common orthopedic deformities in elderly include hallux valgus, prominent metatarsal heads and abnormal medial arch structure.[3] Overall foot deformities and other foot conditions are highly prevalent in senior older than 65 years [5], and they are connected with frailty level and decreased physical activity in older people. [1]
Risk factors[edit | edit source]
The following are the risk factors for foot problems in aged population:
- Gender (women more frequently than men)[2][6]
- Obesity[1]
- Chronic conditions, including diabetes and osteoarthritis[1]
- Peripheral neuropathy[6]
- Neurological disorders (stroke, Parkinson's Disease)[1]
- Lower extremity oedema (can be related to vascular or cardiac pathology)[6]
- Inappropriate footwear underlying geriatric syndromes and conditions[1]
Age-Related Changes in the Foot[edit | edit source]
Physiological changes[edit | edit source]
Skin[edit | edit source]
The weight bearing activities place specific demands on the skin of the plantar surface. The epidermis and dermis have certain thickness and the epidermis fingerprint like pattern allows to generate enough friction during normal walking. The depth and the connection with adipose tissue makes the dermis resistant to shear stresses. However, all aspects of the skin change as the person ages. These changes affect not only superficial skin, but also vascular response, thermoregulation, sensory perception, and injury response, [7]and include:
- flattening of the dermo-epidermal junction [2]
- decreased contact between dermis and epidermis, causing the skin to separate along this interface [8]
- loss of elastin and collagen fibres in dermis. The dermis becomes atrophic. There is a reduction of fibroblasts and collagen becomes disorganised. [8]The remaining collagen fibres become thicker and stiffer [9]
- limited abilities to recoil by the thick collagen, which leads to increased compression and development of hyperkeratosis (corns and calluses)[10]
- alteration in plantar skin mechanical properties leading to increased hardness[2]and dryness
- a reduction in density of sweat glands contributing to impaired thermoregulation [2][8]
- loss of subcutaneous fat and decreased dermal vascularity leads to impaired thermoregulation [8]
- diminished sensation to touch, pressure, and vibration due to decreased mechanoreceptors (Meissner and Pacini corpuscles) [8]
Overall, the thickening of the exterior layer of the skin and presence of calluses may cause severe pain and disability, including plantar lesions. Custom-made orthotics supporting medial arch and unloading of the metatarsal heads are the best management strategies supported by research
- Hyperkeratosis may result in considerable pain and disability. the stratum corneum and granulosum become hypertrophied, placing pressure on nerves in the papillary dermis. Plantar lesions are more likely to form in older people with hallux valgus or lesser toe deformity, due to elevated and abnormally distributed plantar pressures. Indeed, peak pressures under the metatarsal heads when walking have been shown to be between 9 and 12% higher in older people with calluses at these sites. optimum management of hyperkeratosis in older people requires off-loading strategies to address the underlying mechanical cause. Clinical trials have shown that when used in isolation, scalpel debridement of hyperkeratosis has only a small, short-term effect on pain [16], and that the use of pressure-relieving foot orthoses in conjunction with scalpel debridement has a greater effect than scalpel debridement alone
Unload the metatarsals: customised orthotics to support medial arch, unload metatarsal heads
Soft Tissue[edit | edit source]
deeper plantar soft tissues anchor the skin to the underlying bony architecture of the foot, protect underlying blood vessels and nerves and attenuate the shear forces that are applied when walking. The metatarsal pads,maintain their thickness, but demonstrate greater stiffness, dissipate more energy when compressed and are slower to recover after the load is removed
The mean stiffness of the plantar soft tissues at big toe, first metatarsal head, third metatarsal head, fifth metatarsal head, and the heel significantly increased with age[11]
the heel pad retains its thickness of 18-20 mm with age, but becomes stiffer and dissipates more energy when compressed . older people with forefoot pain, peak pressure under the lateral metatarsal heads is 10% higher than in individuals without forefoot pain [2]
stiffness, does not absorb shock, heel and adipose tissue becomes stiffer, plantar fascia with less recoil due to stiffness, less ability to store the energy
changes in gait pattern: more pull off vs push off, less propulsion,
Achilles tendon complaints, range of motion changed (reduction in dorsiflexion), increased risk of falls, less shock absorption
Plantar fascia: The thickness of plantar fascia was significantly increased with age and BMI whereas gender, walking activity, exercise and running did not seem to affect the plantar fascia thickness.[12]
Range of Motion[edit | edit source]
joint physiology, including a reduction in the water content of the cartilage, the synovial fluid volume and the proteoglycans. The collagen fibres in the cartilage undergo a cross-linking process, resulting in increased stiffness[2]
reduced range of motion in lower extremity joints observed in older people. Several studies have shown that ankle dorsiflexion-plantarflexion and subtalar joint inversion-eversion range of motion are 12-30% lower in older people
This study supports the concept that ankle mobility contributes to the performance of dynamic tasks, while the plantar-flexor muscle strength helps to develop a standing static balance. Identification of alterations in ankle function is warranted and may assist in the design of tailored interventions[13]
reduced range of motion in the joints of the foot and ankle is strongly associated with impaired balance and functional ability in older people[2]decreased ankle dorsiflexion range of motion is a risk factor for falls
Muscles Strength[edit | edit source]
reduced muscle mass, due to a reduction in both the size and number of muscle fibres and the development of large, slow-twitch motor units as type II fibres become denervated. Foot muscles are therefore highly susceptible to age-related atrophy, a process that may also be exacerbated by the long-term wearing of ill-fitting footwear. [2]:
- Decreased ankle plantarflexor strength is associated with difficulties in rising onto the toes
- toe plantarflexor weakness impairs the grasping function of the toes when performing weight-bearing activities, resulting in impaired balance and functional ability
- increased risk of falls
- development of toe deformities, as a reduced thickness of intrinsic musculature has been identified in older people with hallux valgus and lesser toe deformities
Biomechanical Changes[edit | edit source]
middle age, there is a trend towards a gradual lowering of the arch, as evidenced by greater medial contact of the midfoot, observed from footprints
The lowering of the medial longitudinal arch associated with ageing has implications for how the foot functions when walking more pronated foot function older foot exhibits reduced midfoot and metatarsal mobility and a less plantarflexed calcaneus at toe-off
less propulsive gait pattern and suggest that older people adopt a ‘pull-off' rather than ‘push-off' strategy to generate forward momentum when walking.
The general tendency towards flatter and more dynamically pronated feet with advancing age may partly explain the increased prevalence of foot disorders and foot symptoms in older people
planus foot posture is associated with an increased likelihood of hammer toes and overlapping toes
pronated dynamic foot function is associated with hallux valgus and overlapping toes
Physiotherapy Intervention[edit | edit source]
stretch, mobilisation, stimulate plantar sensors, Hammer toes
Sub Heading 3[edit | edit source]
Resources[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 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.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Menz HB. Biomechanics of the ageing foot and ankle: a mini-review. Gerontology. 2015;61(4):381-8.
- ↑ 3.0 3.1 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.
- ↑ 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.
- ↑ 6.0 6.1 6.2 Simpson H. The Ageing Foot Course. Plus 2022
- ↑ Fenske NA, Lober CW. Structural and functional changes of normal aging skin. J Am Acad Dermatol. 1986 Oct;15(4 Pt 1):571-85.
- ↑ 8.0 8.1 8.2 8.3 8.4 Levine JM. Clinical aspects of aging 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 aging skin. Cutis. 1989 May;43(5):414-24.
- ↑ Periyasamy R, Anand S, Ammini AC. The effect of aging on the hardness of foot sole skin: a preliminary study. Foot (Edinb). 2012 Jun;22(2):95-9.
- ↑ Kwan RL, Zheng YP, Cheing GL. The effect of aging 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.
