Fall prevention begins at the foot: stability, sensitivity and the right footwear

What lies behind it

Upright standing and walking represent a complex biomechanical feat. The human body relies on a sophisticated sensory model known as proprioception. Thousands of specialized mechanoreceptors are located within the skin of the plantar surface. These nerve endings continuously detect pressure, skin stretch, and the texture of the ground. The most important receptor types include Merkel cells for sustained pressure, Meissner corpuscles for fine touch and slippage detection, and Pacinian corpuscles for vibration. Ruffini corpuscles also register tissue stretch caused by shifts in the centre of gravity.

These highly sensitive sensors transmit their signals via peripheral neural pathways through the spinal cord directly to the brain and cerebellum. The nervous system processes this information in real time to adjust body posture. Compensatory movements often occur reflexively via the calf and foot musculature. When the foot contacts the ground, the body must immediately ascertain how hard, sloped, or slippery the surface is. Only then can the shift in the centre of gravity be safely controlled.

If the anatomy of the foot changes or if sensation on the sole is diminished, this information chain slows down. The body's centre of gravity sways more significantly because the brain responds to positional changes with a delay. The mechanics of the toes also play a central role. The hallux region, or big toe, serves as a crucial lever during the late stance phase of gait. If mobility in the metatarsophalangeal joint is restricted, or if an excessively long toenail exerts pressure on the distal phalanx, the entire roll-over movement of the foot is altered.

Excessive callus formation, known medically as hyperkeratosis, acts like a thick insulating layer within this system. Mechanical stimuli from the ground are transmitted to the underlying receptors in a severely attenuated form. The brain receives an imprecise picture of the environment. As a result, affected individuals unconsciously walk with greater caution, stiffen their gait pattern, and lose the ability to flexibly compensate for minor surface irregularities.

Typical signs

Incipient gait instability usually manifests insidiously. Many affected individuals first notice an altered sensation when walking on uneven ground, such as cobblestones or gravel in the garden. A feeling arises akin to walking on cotton wool or an unfamiliar surface. To compensate for the lack of stability, the base of support widens. While an increased distance between the feet expands the static base of support, it impairs dynamic adaptation during rapid changes of direction.

Another typical warning sign is stubbing the toes on small obstacles. If the toes are not sufficiently elevated during the swing phase of the leg, they catch on carpet edges or door thresholds. This frequently points to reduced mobility in the foot joints or to excessively long nail plates. Repeatedly losing slippers while climbing stairs also indicates a lack of coordination between the foot and the footwear.

An example involving a 74-year-old female patient from the district of Unterallgäu serves as an illustration. She reported at our practice that she felt increasingly insecure within her own four walls and felt her way along door frames at night on her way to the bathroom. The examination revealed a pronounced hyperkeratotic plaque beneath the metatarsal heads as well as severely thickened nail plates. Sensitivity testing using a monofilament demonstrated a markedly reduced perception of pressure. Following professional debridement of the callus and shortening of the nails, tactile feedback improved measurably, restoring noticeably greater confidence to the patient after just a few days.

These mechanical and sensory causes must be distinguished from central nervous system disorders. A sudden loss of coordination, gait accompanied by rotational vertigo, or unilateral paralysis of the dorsiflexor muscles are not purely podiatric problems: they require immediate specialist medical evaluation.

Everyday causes

In the home environment, several risk factors frequently coincide. An underestimated factor is incorrect nail length. Excessively long toenails bump against the toe box of the shoe with every step. This creates posterior pressure on the distal phalanx, which obstructs the normal roll-over movement. The toes cannot extend properly, impairing balance during the push-off phase. Furthermore, continuous compression causes micro-trauma to the nail, promoting nail detachment or fungal nail infections.

A second primary cause lies in the choice of footwear, particularly slippers. Open-backed mules, clogs, or slip-ons without heel straps are popular choices. These shoes provide no guidance to the hindfoot. To avoid losing the shoe when lifting the leg, the toes unconsciously claw into the footbed. This persistent contraction of the toe flexors leads to deformities such as hammer toes or claw toes and alters the mechanics of the entire plantar arch. At the same time, many older slippers have worn, smooth soles that offer little grip on tiles or parquet flooring.

Alongside nail length and footwear, chronic conditions play a major role. Diabetic polyneuropathy or peripheral arterial disease damages fine neural pathways and blood vessels. Pain and pressure perception decline. Pressure points and blisters are no longer recognized in time. Pain avoidance strategies develop in which patients adopt antalgic postures, which further increase the risk of falls due to altered foot alignment.

Care errors also contribute to the development of instability. Performing self-care on the feet becomes increasingly difficult with age due to restricted mobility or declining vision. Cutting nail edges rounded often leads to ingrown nails, the pain of which makes normal weight-bearing impossible. Improper use of razor blades or sharp rasps for callus removal produces uneven skin surfaces and tender spots.

When medical evaluation is necessary

Not all gait instability can be managed purely through podiatric care. Certain warning signs necessitate prompt medical evaluation by a general practitioner, neurologist, or orthopaedic specialist. Evaluation is necessary to rule out serious underlying conditions or to initiate targeted pharmacological and physiotherapeutic treatment.

Urgent medical evaluation is required for the following findings:

• Sudden onset of sensory disturbances, numbness, or tingling in the legs and feet
• Unilateral foot drop during gait, which may indicate weakness of the fibular (peroneal) nerve
• Open wounds, ulcers, dark skin discolouration, or signs of inflammation such as redness, swelling, and localized heat
• Severe rest pain in the feet or calf cramps during short walking distances
• Recurrent dizziness, lateral gait deviation, or new-onset coordination impairment throughout the body

If such symptoms are present, podiatry serves as an adjunct measure. The practitioner then collaborates closely with treating medical specialists to safeguard foot health within the broader framework of medical care.

What podiatric treatment can achieve

Medical podiatry operates at the intersection of skin, nail, biomechanics, and the nervous system. The initial treatment begins with a comprehensive medical history and clinical assessment. This involves evaluating not only the condition of the skin and nails, but also analyzing gait, joint mobility, and static pressure distribution. Using tests such as the Rydel-Seiffer tuning fork and the Semmes-Weinstein monofilament, the condition of the peripheral nerves can be accurately documented.

A central component is podologische Komplexbehandlung (comprehensive podiatric treatment) (services). During this procedure, thickened nails, such as those affected by onychauxis or onychogryphosis, are painlessly reduced to a physiological thickness using rotating diamond and carbide burrs. The nails are expertly shortened and the nail borders smoothed to relieve all pressure from the nail fold. This restores proper toe leverage during gait.

Calloused areas and painful corns, known medically as clavi, are professionally removed under strict hygiene guidelines adhering to our practice standards (hygiene). The use of scalpel-guided debridement techniques allows hyperkeratoses to be precisely smoothed without damaging the underlying healthy skin. Once the thick calloused barrier is removed, the mechanoreceptors of the plantar surface can again receive unaltered ground stimuli.

If toe deformities cause pressure points or friction, we craft custom silicone orthoses. These bespoke pressure relief devices correct toe alignment or protect sensitive joints from mechanical overload. For ingrown or involuted nails, nail brace techniques are employed to immediately alleviate pain and enable normal weight-bearing on the foot.

A clinical case study illustrates this effect: An 81-year-old male patient from Upper Swabia suffered from painful corns beneath the second metatarsal head of both feet. To avoid pain, he walked exclusively on the lateral borders of his feet, leading to severe ankle instability. Following careful enucleation of the clavi and the application of a pressure-redistributing insole, the patient was immediately able to place his feet flat again. The antalgic gait pattern vanished, and his walking confidence increased significantly within a few days.

The intervals between treatments depend on individual findings. For patients with diabetes or a strong propensity for hyperkeratosis, intervals of four to six weeks have proven effective.

What you can do yourself

Alongside professional care in the practice, targeted measures in daily life can contribute significantly to your stability. Selecting the correct slipper takes top priority. A safe slipper should meet the same criteria as a good outdoor shoe.

When selecting footwear, pay attention to the following features:

• A firm heel hold provided by a closed heel counter or an adjustable heel strap
• A non-slip, treaded outsole made of rubber or synthetic material offering grip even on wet tiles
• Adequate space in the forefoot area so the toes are not compressed
• Adjustable fastenings such as hook-and-loop straps or laces to adapt to fluctuating foot volume throughout the day
• A flat heel with a maximum height of one to two centimetres to maintain a neutral pelvic position

Regular inspection of one's own feet is equally important. Those who cannot view their plantar surfaces directly due to restricted mobility may use a handheld mirror or ask family members for assistance. Check for redness, pressure spots, small skin fissures, or changes in the nails.

Simple exercises performed daily are suitable for activating intrinsic foot muscles and improving neural feedback. Grasping small objects such as tissues or marbles with the toes strengthens the intrinsic foot musculature. Gently rolling the sole of the foot over a spiky ball stimulates circulation and activates mechanoreceptors. Practising a single-leg stance, secured by holding onto the back of a chair, trains balance reflexes in the ankle joint.

When trimming nails, ensure they are cut or filed straight across. The corners must not be rounded deeply, as this encourages the nail borders to become ingrown. Optimal nail length is achieved when the nail plate aligns flush with the tip of the toe.

Common errors

In daily practice, we frequently encounter misconceptions and care errors that unintentionally elevate the risk of falling. The most widespread error is wearing woollen socks or stockings without grip soles on smooth wooden floors or tiles. Friction between sock and floor is extremely low, easily causing slips. Even non-slip grip socks fail to provide the stability of a firm shoe, as they offer no lateral support to the foot.

Another misconception involves using scissors with curved blades on hard nails. The high pressure exerted during cutting can cause the nail to splinter. Longitudinal and transverse cracks often extend deep into the nail bed, causing painful inflammation. Antalgic posturing immediately leads to an altered gait pattern.

Equally critical is the excessive use of corn planes or chemical callus remover plasters purchased from pharmacies. These remedies frequently remove too much tissue or produce chemical burn-like skin damage. The body responds to over-debridement with accelerated hyperkeratosis formation, creating a vicious cycle of cornification disorders and injury risk.

Finally, diminishing sensation in the feet is often passively accepted as inevitable. Many affected individuals view sensory disturbances as a normal sign of ageing and inform neither their doctor nor their podiatrist. The earlier altered sensitivity is identified, the more effectively preventive measures, such as custom orthotic insoles or targeted sensory re-education, can be initiated.

Scientific evidence and context

The importance of foot health in fall prevention is well documented in scientific literature. International studies demonstrate that foot problems and inappropriate footwear represent independent risk factors for falls in older age. A landmark study by Menz et al. (2006) showed that older adults with foot pain, hallux valgus, hammer toes, or nail deformities exhibit significantly poorer balance and fall more frequently than individuals without these impairments [1].

A randomized controlled trial by Spink et al. (2011) investigated the efficacy of a multidimensional podiatric intervention. The combination of podiatric foot care, provision of orthotic insoles, footwear advice, and targeted foot exercises led to a 36 per cent reduction in fall rates among participants compared to the control group [2]. These findings highlight that structured podiatric measures contribute directly to patient safety.

Systematic reviews within the Cochrane Collaboration also underscore the role of multifactorial interventions. While single-component measures such as isolated muscle strength training are effective, integrated approaches that incorporate environmental adaptation, footwear review, and podiatric assessment achieve the largest effect sizes [3].

Furthermore, biomechanical studies on plantar sensation demonstrate a direct correlation between callus thickness and pressure perception. Excessive hyperkeratosis reduces mechanoreceptor sensitivity by up to 40 per cent [4]. Professional debridement of these hyperkeratoses demonstrably restores sensory feedback and improves postural control mechanisms while standing.

Treatment in Memmingen

At our practice FREITAG® Podologie GmbH at Kempterstr. 25 in Memmingen, we combine professional expertise with a calm, attentive treatment environment. Our goal is to preserve your mobility and gait stability into advanced age. As a specialized practice, we care for patients from Memmingen, Unterallgäu, and the adjacent regions of Allgäu and Upper Swabia.

Owner Helga Maria Freitag is a state-recognized podiatrist and sektorale Heilpraktikerin (sectoral practitioner of podiatry) (sectoral practitioner). Thanks to this additional qualification, we can independently perform podiatric assessments and therapies without requiring a physician's prescription. Our spectrum is complemented by specializations such as expertise in cryotherapy. You can learn more about our background and quality standards in the about section.

If you notice increasing walking instability in yourself or a family member, we invite you to contact us. Via our contact page, you can arrange an appointment for a thorough foot examination and consultation. We examine the condition of your feet, trim your nails professionally, relieve painful areas, and provide comprehensive advice on selecting suitable footwear.