Open mouth…insert (bare)foot


  1. “Around one in three older people falls each year with one third of over 65s and half of of over 80s falling each year.”


Falling sucks. People get hurt when they fall. Most older adults can’t withstand the impact of a fall and get seriously hurt. There is research demonstrating that people older than 80 that sustain a fractured hip have a higher prevalence of death. One way that we can keep people from dying is to keep people from hitting the floor. There are many ways to do this and the article below will emphasize how footwear plays a role.


  1. “The shoe features which have been shown to influence balance performance include heel height, heel collar height, and sole thickness and hardness.”


I am going to take the low hanging fruit first. The density of the foam that is on the bottom of the shoe will play a role in how a person balances. Think about standing on a bed and how unstable it is. Now, think about standing on a waterbed…a little more unstable. The less stable the bottom of the shoe the decreased stability you will have when on your feet. There were shoes at one time that were advertised to “improve your balance”, needless to say it didn’t work out so well. When we place more cushioning under our feet, we lose a little of our stability because we are decreasing the role that one of our three senses, proprioception, systems have in maintaining balance.


When we increase the height of the heel, a few things happen. First, we place more weight over the front of the foot and decrease the weight bearing over the back of the foot. This changes the base of support during walking, as the person will have an earlier heel off (when the heel leaves the ground) and a quicker heel strike. This is one reason, in my opinion, that a person wearing heels doesn’t take a large stride. Doing so would impair the balance because the base of support would be very narrow during portions of the gait cycle.


Another thing that happens when a person adds a heel is that the person becomes a little taller. There is a good t.v. episode about this on Seinfeld. Raising your height will make balancing a little more difficulty because the center of gravity has gone a little higher. Think of it this way, when you are on an unstable surface, what’s the easiest way to keep your balance…squat slightly to lower your base of support. This is why wrestlers are so well balanced during the match because the squat down when they are being pushed and pulled.


The heel collar height is a little harder for me to rationalize. The higher the collar, the less mobility the ankle will have. The lower the collar, the less external stability will be provided to the ankle. I could make a case for both.


“Lord and Bashford evaluated balance in 30 older women when barefoot, wearing low heeled walking shoes, wearing high-heeled shoes and wearing their own shoes. The worst balance performance was seen when subjects wore high heels.”

Is this surprising? I included the quote because the author’s name was Lord…just kidding. Story time:


I tell all of my patients that I would not have them do anything that I either haven’t done or am willing to try. I had a patient once whose main goal was to be able to walk in heels. Needless to say, she called me out on the carpet for trying to teach how to walk in high heels based on book knowledge and not on actual experience. She went out and bought me a pair of heels. I wore the heels the entire treatment session. I got some catcalls from coworkers during the session. The best part of the story is the following. After the session I through the heels in the back seat of the car. That night I gave my wife’s mom a ride in the car. She looked into the back seat and must have seen the heels. She didn’t mention anything in the car…possibly because she mostly speaks polish and didn’t want to start a conversation that she wouldn’t be able to understand, but she told my wife when I got home. BOY DID I GET AN EARFUL! After I explained myself and it is still a funny story that I get to live to tell.


“The aim of this study was to examine the effects of usual footwear (versus going barefoot) on balance in frail older women attending a geriatric day hospital”


Remember what I said about the different portions of the shoe? If a person is barefoot, the center of gravity is lower, there is no cushion and there is decreased ankle stability. Two of the three may favor barefoot walking. I thought for sure that barefoot would be the answer…Read more to see how wrong I was.


“Berg Balance Scale was used to assess balance…under two conditions in this study: shoes on and shoes off. The order of testing with shoes on and off was counterbalanced so that 50% of patients were tested ‘shoes on’ first and 50% ‘shoes off’ first so as to avoid an order effect when testing”


First, you can see my report on the Berg Balance Scale from many years ago. I’m sure that the research has changed slightly, but the basics will still hold true. It’s important that the authors of the study changed the order of performing the testing for different patients in order to get a good idea of how patients perform. For instance, in high school no one liked the dreaded POP QUIZ! But when the teacher did a review for a test and gave a “wink wink”, you knew that the question would show up on the test. This is the same concept. If the participant already knows what’s on the test (seeing as they do the test twice), we would expect the second score to be slightly, is not significantly, elevated from the first score.


“One hundred elderly females were assessed with a mean age of 82…most were living in the community, required a mobility aid and had had a fall in the previous year.”


This is good information. A study can only be generalized to the population that the study was performed. For instance, the results of this study can not be generalized to a barefoot running group or a military group. It sounds obvious, but you’d be surprised how many “professionals” read an abstract (summary) of an article and start applying the “research” immediately in practice.


“There was a significant improvement in the mean BBS score of 2.5 when shoes were on”


I was wrong. I expected barefoot to win hands-down. This is because I have read a lot of research on barefoot walking and running. I came in biased and was WRONG! There I said it…mark this date. Moving on. Come back next week when I have a better chance of being right again.


Horgan NF, Crehan F, Bartlett E. The effects of usual footwear on balance amongst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.



Link to article



Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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