Josh White, DPM, CPed

One out of three adults age 65 and older fall each year.  Falls are a silent killer that most podiatrists simply don’t think much about addressing.   Given the scale of the problem and the prevalence of risk factors, developing a specialty in fall prevention presents podiatrists with an opportunity that can significantly benefit their patients and their practice.

Conditions commonly seen by podiatrists and associated with increased risk for falling include:

• Foot pain
• Ankle weakness
• Limited ankle motion
• Postural instability
• Loss of proprioception
• Inappropriate shoe gear

Other risk factors podiatrists should be cognizant of include: dizziness, history of falls or near falls, peripheral neuropathy, impaired balance and drug interactions.  If any of these conditions are determined, a more comprehensive fall risk assessment is indicated.  See the sample podiatric fall risk evaluation form.

Balance and walking speed gradually decline with age.  This is attributable to decreased muscle mass and is exacerbated by reduced activity level. Weakening of the anterior tibialis muscle decreases the body’s ability to maintain balance and may affect the timing of toe clearance during the swing phase of gait.  Tripping can result from the toe catching on the floor.  Postural sway relates to the constant displacement and correction of the body’s center of gravity over it’s base of support.  Decreased muscle strength, particularly with decreased sensation can lead to increased postural sway and increase one’s risk for falling.

No assistive device is as effective at decreasing the likelihood of falls as a walker.  Patients though are often resistant to accepting such a device or a cane.  Unfortunately, the impetus to use a canes or walker often comes only after a fall occurs.   Ankle foot orthoses improve stability by reducing postural sway, increasing sensorimotor feedback and thus improving proprioception.   AFOs are only effective when worn and pose patient compliance issues relative to ease of use, impact on shoes that can be worn, comfort and appearance.  Fortunately, improved AFO designs fit more easily into shoes, are lightweight, offer ease of closure and still address risk factors that can contribute to increased risk for falling.

Medicare policy makes clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s.  The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”.  The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”  If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met:

• Muscle weakness (728.87)
• Ataxia, muscular incoordination (781.3)
• Gait abnormality/ staggering, ataxic (781.2)
• Osteoarthritis, localized primary ankle & foot (715.17)
• Arthropathy, unspecified, ankle and foot (716.97)
• Pain in joint, ankle, foot (719.47)
• Instability of joint, ankle & foot (718.87)
• Dropfoot (736.79)
• Hemiplegia (438.20)

Fall prevention requires a comprehensive approach to care of which custom AFOs may be one component.  Based on podiatric fall risk assessment, the podiatrist should consider prescription of primary and ancillary services.  Such services and conditions that each may address include:

Physical / Occupational Therapy :

• history of falls
• sensory deficits
• muscle weakness
• poor balance

Primary Care:

• vestibular abnormalities
• medication interactions
• history of seizures
• history of hypotension

Home Health Care

• difficulty leaving the home
• Muscle weakness
• hearing loss
• vision loss

By providing appropriate intervention, podiatrists can assume a leading role in a multidisciplinary approach to care.

Summary

There are some basic steps that podiatrists can take to develop a fall prevention program:

1. Create awareness within ones’s practice regarding the risk of falls and that the office is committed to offering appropriate preventative care.  Consider informational brochures and office posters.
2. Speak to community groups about the role of intervention to reduce patient risk.
3. Network with other physicians and specialists including physical therapists, occupational therapists and home healthcare workers to promote a team approach to care.
4. Perform fall risk assessment and consider use of balance AFO if appropriate risk factors are determined.

There is no simple fall prevention strategy that will work for all patients.  As falls result from of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall prevention strategy that encompasses a number of interventions and targets multiple risk factors is more likely to be successful.