Shoes

Proper distribution of forces in order to maintain the integrity of the skin of the foot is of primary importance. The shoe should fit properly and the volume of the shoe should appropriately accommodate the foot and any additions such as a foot orthotic or plastic ankle–foot orthosis (AFO). Generally, a sneaker or other athletic shoe with a removable inlay, or an extra-depth shoe with a removable inlay, is recommended. The inlay can be removed to accommodate fluctuating edema or the addition of an orthosis. In unilateral involvement the inlay can remain in the shoe on the uninvolved side, maintaining the fit on that side and balancing the patient in terms of height. It is recommended that the shoe have a soft upper (the portion of the shoe covering the dorsum of the foot) to reduce pressure in the presence of minor foot deformities such as bunions or hammer toes. Severe foot deformities may require a custom shoe made from a cast of the individual’s foot.

Foot orthotics

In general, flexible accommodative orthotics for the purpose of distributing forces to protect the skin and promote comfort are indicated. The bones of the foot of the geriatric patient are often functionally adapted and the joints may be restricted in terms of range of motion (ROM). Thus, attempting biomechanical correction may be inappropriate and may, thereby, contraindicate the use of rigid orthotic devices and necessitate careful consideration of the application of even semirigid devices.

Ankle–foot orthotics (AFO)

AFOs are frequently utilized with the elderly to improve ambulation status and gait quality. AFOs are capable of controlling the foot and ankle directly and the knee indirectly. For example, by positioning the ankle in dorsiflexion, a knee flexion moment can be produced to control genu recurvatum. Also, positioning the ankle in plantar flexion can produce a knee extension moment to assist in stabilizing the knee. Neuromuscular conditions such as hemiparesis due to a cerebral vascular accident as well as musculoskeletal pathologies such as arthritis commonly result in foot and ankle dysfunctions in the geriatric population, which can be managed in part with AFOs.

A common challenge is deciding whether to use a plastic or a metal AFO system. The metal AFO has little skin contact except for the calf band and shoe which are the reaction points of the orthosis. This quality is a distinct advantage of the metal system for patients with fluctuating edema or poor skin integrity. In comparison, the total-contact nature of the plastic AFO results in a greater ability to control the foot and ankle. Additionally, the plastic AFO is lighter in weight, more cosmetically acceptable and has the practical advantage of easy interchange among shoes. Plastic AFOs would appear to be the orthosis of choice for geriatric patients whenever possible. One strategy to determine whether a metal AFO system is indicated for a particular patient is to consider the sensory status and volume stability (i.e. presence or absence of fluctuating edema) of the patient and the reliability of the patient or support person to monitor the skin integrity of the involved lower extremity. Negative findings in two of these categories would indicate consideration of a metal AFO instead of plastic orthosis.

A soft AFO such as a neoprene ankle sleeve may be appropriate for controlling minor discomfort from arthritis or to encourage ankle stability when a more rigid system cannot be tolerated. Such orthoses accomplish their goals remarkably well in some cases by retaining heat and providing proprioceptive and kinesthetic sensory input. Medial collapse of the foot/ankle complex from a pathology such as posterior tibialis tendon failure or lateral ankle instability/malalignment may be optimally managed with a specialty AFO such as an Arizona AFO or Richie Brace.

Knee–ankle–foot orthoses (KAFO)

Although AFOs are tolerated well by the geriatric population, the addition of a knee joint and a thigh cuff to form a KAFO system results in a much less acceptable orthotic intervention. A KAFO has the advantage of controlling the knee as well as the foot and ankle directly, and indirectly influences the hip joint. A KAFO is the orthosis of choice in the presence of severe genu recurvatum, or knee buckling, which cannot be managed with an AFO.

Hip–knee–ankle–foot orthoses (HKAFO)

The addition of a hip joint and pelvic band to a KAFO results in an orthosis that is difficult to don and doff, less comfortable than shorter ones and more cumbersome to wear. For the geriatric population, the hip joint and pelvic band are most commonly added when rotation control of the lower extremity is required.