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Footwear, Osteoporosis & Ageing: Evidence-Based Guidance and Policy Implications

Abstract

Osteoporosis increases the risk of fractures among older adults, especially following falls. Footwear is a modifiable factor that influences gait, balance and slip/trip risk. This paper examines biomechanical, epidemiological and policy-relevant evidence linking footwear design to fall and fracture risk in ageing populations, and provides recommendations (“dos and don’ts”) and policy interventions to reduce fragility-fracture burden.

1. Introduction

Ageing populations face increased prevalence of osteoporosis and fragility fractures. Bone fragility combines with impaired proprioception, reduced muscle strength, and slower reaction times to elevate fall risk (Cooper et al., 2011). Because most fractures in older adults result from ground-level falls, fall-prevention strategies — including proper footwear — are vital.

Footwear affects gait biomechanics, balance, stability, plantar pressure distribution, and the body’s center of gravity (Menant et al., 2008). Poor footwear (slippers, sandals, backless shoes, worn-out soles) increases the risk of slipping and tripping, particularly in indoor environments where most falls occur.

2. Scientific and Epidemiological Evidence

2.1 How Footwear Affects Balance and Gait

Footwear characteristics such as heel height, sole hardness, tread pattern, heel-counter stiffness and fastening system influence postural stability in older adults (Sherrington & Menz, 2003).
Evidence shows that:

  • Low-heeled shoes with firm, slip-resistant soles improve balance (Menz & Lord, 1999).

  • Overly soft or excessively flexible soles impair proprioception and reduce stability (Menant et al., 2008).

  • Secure fastening (laces/Velcro) improves gait control and reduces shoe–foot movement (Menz et al., 2001).

2.2 Epidemiological Data: Footwear, Falls and Fractures

Large cohort and case-control studies provide strong associations:

  • In the MOBILIZE Boston Study, being barefoot, in socks, or wearing slippers was associated with higher risk of serious fall injury (OR ≈ 2.3) (Koepsell et al., 2004; Kelsey et al., 2010).

  • A study of 1,371 adults ≥65 years found athletic shoes had the lowest fall risk, while socks or being barefoot had the highest (OR ≈ 11.2) (Koepsell et al., 2004).

  • In hip-fracture admissions, more than 70% of patients wore unsafe shoes (slippers, sandals, unstable shoes) at the time of the fall (Hourihan et al., 2001).

  • In aged-care facilities, slippers and socks were significantly associated with fall recurrence (Lord et al., 2004).

2.3 Relevance to Osteoporosis

Because osteoporotic bones fracture easily, even a mild fall can cause hip, spine or wrist fractures (WHO, 2003). Footwear affects the likelihood and severity of falls by influencing slip resistance and gait stability. Thus, footwear should be integrated into fracture-prevention strategies alongside calcium/vitamin D, anti-resorptive therapy, and environmental modifications.

3. Recommended Footwear: The Dos & Don’ts

3.1 Dos

  • Wear enclosed, well-fitting shoes with firm heel counters (Menz & Lord, 1999).

  • Choose low, broad heels to maintain a stable center of gravity (Sherrington & Menz, 2003).

  • Use slip-resistant soles with adequate tread for indoor and outdoor walking (Menant et al., 2008).

  • Select lightweight shoes that reduce gait fatigue (Menz et al., 2001).

  • Use orthotics when indicated for foot deformities or neuropathy (Bus et al., 2016).

  • Wear appropriate shoes indoors, particularly in slippery-surface homes or eldercare facilities (Lord et al., 2004).

3.2 Don’ts

  • Avoid high heels (>3–4 cm) which reduce balance (Menz & Lord, 1999).

  • Avoid slippers, flip-flops, backless shoes and open sandals — all linked to fall-related injuries (Kelsey et al., 2010).

  • Avoid smooth, hard soles with low friction coefficients (Menant et al., 2008).

  • Avoid heavy, bulky footwear that alters gait mechanics.

  • Avoid worn-out shoes with poor tread or stretched fasteners.

4. Policy and Clinical Implications

4.1 Include Footwear Assessment in Osteoporosis & Geriatric Care

Healthcare systems should incorporate footwear review into routine assessment for older adults and persons with osteoporosis (NICE, 2015).

4.2 Create National “Age-Safe Footwear Standards”

Governments and regulatory bodies should set guidelines on:

  • Heel height limits

  • Required slip resistance

  • Heel counter stiffness

  • Minimum fastening requirements

This parallels successful standards in occupational safety footwear.

4.3 Public Health Campaigns

Community awareness programs should educate elderly individuals, caregivers and facilities on safe footwear, alongside exercise and home hazard reduction.

4.4 Subsidy & Social Support Programs

Older adults, especially those in low-income settings, may need subsidized access to safe footwear — similar to spectacles or mobility aids.

4.5 Research Priorities

Further study is needed on:

  • Long-term effects of footwear interventions on fracture rates

  • Cost-effectiveness of national footwear programs

  • Culturally adapted footwear for warm climates or rural settings

5. Conclusion

Footwear is a low-cost, high-impact factor in fall and fracture prevention among older adults, especially those with osteoporosis. Scientific and epidemiological evidence strongly supports the use of low-heeled, slip-resistant, supportive shoes for improving stability. Policies that integrate footwear into national osteoporosis and elderly-care frameworks can reduce fractures, disability, and healthcare burdens.

References

Biomechanics & Gait Studies

  1. Menz HB & Lord SR. (1999). Footwear and postural stability in older people. Journal of the American Podiatric Medical Association, 89(7), 346–357.

  2. Sherrington C & Menz HB. (2003). An evaluation of footwear worn at the time of fall-related hip fracture. Age and Ageing, 32, 310–314.

  3. Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. (2008). Effects of footwear features on balance and stepping in older people. Gerontology, 54, 18–23.

  4. Menz HB, Lord SR, McIntosh AS. (2001). Agerelated changes in postural stability and gait. Gait & Posture, 13, 1–6.

Fall Risk & Epidemiology
5. Koepsell TD et al. (2004). Footwear and the risk of falls in older adults. Journal of the American Geriatrics Society, 52(9), 1495–1501.
6. Kelsey JL et al. (2010). The MOBILIZE Boston Study: slip resistance and fall-related injuries. Journal of Gerontology A, 65A, 217–223.
7. Hourihan F, Warren L, Flicker L. (2001). Slippers and hip fractures. Age and Ageing, 30(5), 456–458.
8. Lord SR, Tiedemann A, Chapman K. (2004). The effect of footwear on balance and falls in older adults in residential care. Journals of Gerontology Series A, 59(10), 1057–1062.

Osteoporosis Background
9. Cooper C, Campion G, Melton LJ. (2011). Hip fractures in older adults: a global perspective. Osteoporosis International, 2, 285–289.
10. WHO. (2003). Prevention and Management of Osteoporosis. World Health Organization Technical Report Series.

Clinical & Policy Guidelines
11. NICE. (2015). Falls in older people: assessment and prevention. UK National Institute for Health and Care Excellence.
12. Bus SA et al. (2016). Footwear and orthotic devices in older adults. Journal of Foot and Ankle Research, 9, 43

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