Lower-limb factors associated with balance and falls in older adults: a systematic review and clinical synthesis

Key points

1. 01Reviewed 81 articles and grouped lower-limb fall influences into 8 clinical pathways.
2. 02Six pathways (range of motion, orthoses, strength, footwear, pain, deformity) showed a direct link with fall risk.
3. 03Two pathways (plantar skin/soft tissue and sensory loss) link only indirectly through balance and gait changes.
4. 04Going barefoot or in stocking feet was associated with sharply higher fall risk.
5. 05Practical steps include avoiding high heels and thick soft soles, plus range-of-motion and strengthening exercises.

How it was conducted

Design

Systematic review with narrative clinical synthesis, following PRISMA

Databases

Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Library, AgeLine

Participants

Community-dwelling adults older than 55

Eligible studies

Observational studies, clinical trials, systematic reviews, qualitative studies (case studies and series excluded)

Quality appraisal

STROBE for observational, CONSORT for RCTs, AMSTAR2 for reviews

Primary focus

Lower limb, foot, ankle, and footwear factors affecting balance, gait, and fall risk

What they found

• Search yielded 4347 articles; after duplicate removal 4281 were screened, 288 full texts were assessed, and 81 met inclusion criteria.
• Eight pathways were identified; 6 (range of motion, orthoses, strength, footwear, pain, deformity) supported a direct link with fall risk.
• Going barefoot or in stocking feet was associated with sharply increased fall risk (adjusted OR=11.2, 95% CI=2.4-51.8; Koepsell et al 2004).
• Adjusted OR for serious injury among shoeless or slipper wearers versus other shoes was 2.27 (95% CI 1.21-4.24; Kelsey et al 2010).
• Dual-task gait measures classified fallers with 92.3% sensitivity and 66.7% specificity (Commandeur et al 2018).
• A Berg balance score of 50 points or less increases fall probability (Lusardi et al 2017).
• Elevated heel height above 2.5 cm, low-collared shoes, and thick soft soles were identified as footwear features that may increase fall risk.

Limitations

• Qualitative narrative synthesis without meta-analysis, so effects across studies were not pooled.
• Some pre-2008 studies were included to complete pathways, and several pathways relied on expert opinion for hypothesized links.
• Strength of evidence varied considerably across the 8 pathways, and plantar skin/soft tissue and sensory loss lacked direct prospective fall evidence.
• Non-community-dwelling older adult populations were excluded, limiting generalizability.

Why it matters

For patients

Choosing supportive shoes worn indoors and out, avoiding high heels and thick soft soles, and doing ankle and foot strengthening or stretching may help lower your fall risk.

For clinicians

Screening older adults for limited ankle range of motion, weakness, foot pain, deformity, and footwear problems can identify modifiable fall-risk targets, with orthoses and exercise as candidate interventions.

For readers

This review maps lower-limb and footwear contributors to falls into clinical pathways while being clear that evidence strength differs and some links remain indirect.