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Effectiveness of Foot and Ankle Exercise Programs on Reducing the Risk of

Falling in Older Adults A Systematic Review and Meta-Analysis of
Randomized Controlled Trials

Article  in  Journal of the American Podiatric Medical Association · November 2013

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Preventing Falls in Older People: The Role of Footwear and Lower-Extremity
Interventions
BASIC SCIENCE REVIEWS

Effectiveness of Foot and Ankle Exercise Programs on

Reducing the Risk of Falling in Older Adults
A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Michael Schwenk, PhD*†‡
Elise DeHaven Jordan, MSc*‡
Bahareh Honarvararaghi, MSc*‡
Jane Mohler, PhD*†‡
David G. Armstrong, DPM, PhD, MD*‡
Bijan Najafi, PhD*†‡

Background: Foot and ankle (FA) exercise programs might reduce the risk of falling in older
adults. We sought to systematically review the current literature on FA exercise programs
targeted at reducing the risk of falling in older adults.
Methods: A systematic literature search was performed in the PubMed database, the
Physiotherapy Evidence Database, the Cumulative Index to Nursing and Allied Health
Literature, and the Cochrane Central Register of Controlled Trials. Articles were included
based on the following criteria: 1) randomized controlled trial, 2) FA exercise program, and 3)
use of fall risk–related motor outcomes (strength, balance, flexibility, and functional ability) or use
of falls as an outcome. Weighted effect sizes (d) were calculated across studies for estimating
the overall effect of FA exercises on the most frequently reported motor outcome parameters.
Results: Eight publications met the inclusion criteria. Small to moderate overall effects were
found for balance (d ¼ 0.46, P , .001) and ankle flexibility (d ¼ 0.29, P ¼ .006). No significant
overall effects were found for ankle plantarflexor strength (d ¼ 0.11, P ¼ .223) and walking
performance (d ¼ 0.05, P ¼ .404). Controversial results were reported for other functional
measures. Effects varied depending on the type of intervention. Only one study reported
improved ankle evertor strength and a significant reduction in falls.
Conclusions: Evidence suggests that FA exercise can improve certain fall risk–related motor
outcomes and reduce falls. Limited effects on strength and functional ability might be related to
insufficient training intensity and lack of adherence. Further studies that include progressive
strength and flexibility training are necessary to validate which FA exercise programs are most
effective at preventing falls. (J Am Podiatr Med Assoc 103(6): 534-547, 2013)

At least 30% of individuals 65 years and older disability, and extent of functional impairment.3
experience one or more falls each year,1 and this Falls are a major health problem in older adults,
percentage increases to 40% after age 75 years.2 The causing fall-related sequelae, such as fractures,
incidence of falls and the severity of complications head injuries, and post-fall anxiety.4,5 Older adults
stemming from these falls increase with age, level of are hospitalized for fall-related injuries five times
The opinions and assertions contained herein are solely the responsibility of the authors and do not necessarily represent the
official views of the Qatar National Research Foundation or the German Academic Exchange Service, which funded this study.
*Interdisciplinary Consortium on Advanced Motion Performance College of Medicine, University of Arizona, Tucson, AZ.
†Arizona Center on Aging, University of Arizona, Tucson, AZ.
‡Southern Arizona Limb Salvage Alliance (SALSA), College of Medicine, University of Arizona, Tucson, AZ.
Corresponding author: Michael Schwenk, PhD, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP),
College of Medicine, University of Arizona, 1656 E Mabel St, Tucson, AZ 85724. (E-mail: mschwenk@surgery.arizona.edu)

534 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
more often than they are for injuries from other
causes,6 and the associated costs of care and
institutionalization from injurious falls substantially
burdens the health-care system.7
It has been well described that falls result from
the interaction between environmental hazards and
physiologic risk factors, such as muscle weakness,
poor balance, impaired vision, and slow reaction
time.1,8 More recently, foot problems, which affect
approximately 30% of older adults,9-11 are a common
reason for consultation in primary care and in
podiatric medical, orthopedic, rheumatologic,
sports medicine, and geriatric specialty care12 and
have been associated with falls.13 Specifically, foot
pain, reduced range of motion, toe weakness, and
toe deformity have each been shown to be
independent risk factors for falling.14,15 It has been
demonstrated that ankle dorsiflexion range of
motion16-18 and the toe plantarflexor muscles19,20
are specifically linked to balance control and gait
performance. The toes play an important role in
stabilizing the foot during standing and walking,19,20
and adequate range of motion at the ankle and toes
is necessary to conduct basic everyday motor
functions, such as walking and sit-to-stand motions,
safely and efficiently. At least 108 of ankle dorsi-
flexion is necessary for the stance phase of gait,21
whereas rising from a chair requires maximum
dorsiflexion between 218 and 368.22
Several studies have demonstrated that aging is
associated with significant changes to the musculo-
skeletal and sensory characteristics of the foot.
Older adults tend to have more pronated feet,
reduced ankle joint flexibility, and toe plantarflexor
weakness and to experience a reduction in plantar
tactile sensation.23 Differences such as decreases in
physical activity levels possibly contribute to the
observed age-related issues with ankle joint range
of motion and toe plantarflexion strength.24
Given the age-related decline in foot strength
and flexibility and the emerging evidence that foot
problems increase the risk of falls, established
guidelines for falls prevention recommend that
older adults have their feet examined by a
podiatric physician as a precautionary measure.25
However, these guidelines do not specify which
intervention activities might be performed, and too
few randomized controlled trials have been exe-
cuted to provide clinical practitioners with ger-
mane information concerning the prevention of
falls.13 In addition to advice about footwear and
foot orthoses, intuitively, it may be good practice
to recommend exercise programs that focus
specifically on strengthening and stretching the
Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013
foot and ankle (FA). Systematic reviews document
that exercise programs can significantly reduce the
risk of falling26,27; however, most of the existing
studies have concentrated on muscle groups
proximal to the FA. The effectiveness of specific
FA exercise programs has not been systematically
reviewed. This review aims to evaluate the effects
of specific FA exercise programs on improving fall
risk–related motor outcomes and reducing falls in
older adults.
Methods
Search Strategy
A systematic literature search was performed
according to the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses)
statement.28 Articles were searched for in the
PubMed database, the Physiotherapy Evidence
Database (PEDro), the Cumulative Index to Nursing
and Allied Health Literature, and the Cochrane
Central Register of Controlled Trials. The search
was tailored specifically to retrieve literature
focusing on FA exercise programs in older adults
aimed at improving motor performance and pre-
venting falls. The search terms were foot, ankle, and
toes combined with AND to exercise, stretching
exercise, resistance training, and strength. The
database search was conducted without using
language restrictions and was limited to articles
with publication dates up to April 30, 2013.
Reference lists of relevant articles were subsequent-
ly hand searched to identify additional appropriate
articles. The Google Scholar database was used to
check the related citations of relevant articles to
identify additional appropriate articles.
Study quality was coded using the PEDro scale,
which is widely used to rate the quality of
randomized controlled trials.29 The scale is based
on the list developed by Verhagen et al30 using the
Delphi consensus technique. The PEDro scores are
summarized, and high-quality studies are those with
scores of 6 to 11; fair quality, 4 to 5; and low quality,
less than 4.31
Study Selection and Data Extraction
Two reviewers (M.S. and B.H.) screened the titles
and abstracts from all of the literature searches to
identify potentially relevant trials based on the
following inclusion criteria: 1) randomized con-
trolled trial, 2) use of an FA exercise program, and
3) use of fall risk–related motor outcome param-
535
eters (strength, balance, flexibility, and functional
ability) or use of falls as an outcome parameter.
The reviewers obtained full-text copies of all of the
trials that met the inclusion criteria for the
systematic review. Next, the two reviewers inde-
pendently extracted information about study char-
acteristics, types and modalities of FA exercise
interventions, and fall risk–related outcomes of
interventions.

Statistical Analysis

Because most randomized controlled trials reported

continuous measures related to fall risk, effect sizes
(the Cohen d) were defined as the standardized
mean difference between the exercise and control
groups divided by the pooled SD,32 correcting for
sample size bias and baseline differences. Effect
sizes with 95% confidence intervals (CIs) were
calculated from the randomized controlled trials
that reported sufficient data on intervention effect
on fall risk–related motor outcomes. To interpret
the effect size, we used the Cohen criteria: 0.2 and
greater indicates small effect; 0.5 and greater,
moderate effect; and 0.8 and greater, large effect.32
When the pooled SD of the difference scores was
not provided, an estimate was calculated using the
following formula33:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SD21 þ SD22
SDpooled ¼
2
Positive effect sizes indicate benefits of exercises
training. To compare study results, effect sizes were
calculated for similar motor outcome parameters, if
available. Mean effect sizes and 95% CIs were
calculated for each outcome parameter. Because
effect sizes of large studies are more likely to be
reliable estimates of the efficacy of an intervention
than those of small studies, sizes were weighted by
the number of participants in each study. The
homogeneity statistic Q was calculated to deter-
mine whether a weighted mean effect size charac-
terized a common effect size. A significant Q value
indicated the absence of homogeneity. To standard-
ize Q, the I2 statistic was calculated; I2 ranges from
0% to 100%, with low values suggesting homogeneity
and large values suggesting heterogeneity. To
provide a visual representation of the effect sizes
and associated 95% CIs, forest plots were construct-
ed. All of the meta-analyses were conducted with a
software program (MetaXL, version 1.32; EpiGear,
Wilston, Australia).
Figure 1. Flowchart showing the literature search
and the extraction of studies meeting the inclusion
criteria. RCT indicates randomized controlled trial.
Results
The search yielded 606 articles, with eight publica-
tions meeting the inclusion criteria (Figure 1). Table
1 illustrates the study characteristics, exercise
interventions, training modalities, and results of
the studies included in the review.
Study Characteristics
Five studies included community-dwelling older
adults13,16,24,34,35 and three included institutional-
ized older adults.36-38 Only one study specifically
included older adults with diagnosed foot problems
(foot pain).13 The mean age of the participants
ranged from 73.1 to 84.0 years, and sample sizes
ranged from 16 to 305.
Types and Modalities of Exercise Interventions
Types and modalities of exercise interventions are
displayed in Table 1. The intervention periods
ranged from 8 weeks to 12 months. The frequency
of exercise training ranged from two times per week
to daily. Adherence to the exercise programs varied
considerably. Some studies reported good adher-
ence,13,35 whereas adherence was low24 or not
specified16,36-38 in other studies. One study reported
minor adverse events, such as worsening joint pain
and exacerbation of preexisting musculoskeletal
conditions, related to the exercise training interven-
tion.35

536 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
 The types of FA exercise interventions used in the
articles varied. Three studies were categorized as
strength exercise programs (Table 1). One of these
studies evaluated toe grasping exercises (beanbag
transfer and towel gathering) performed in a sitting
position by nursing home residents.36 Another study
evaluated an ankle power training program using
either elastic band exercises or weight training
exercises for improvement in ankle movement
time.35 Simoneau et al34 evaluated the effects of
long-term ankle strength training (12 months) using
a calf raise machine in a training facility and elastic
bands for home training.
Three studies evaluated combined strength and
functional training programs focusing on the
FA.24,37,38 Two of these studies combined ankle
strengthening and a walking program and compared
it with an inactive control group in nursing home
residents.37,38 A single study was specifically de-
signed to investigate the added value of foot
gymnastics (group training and home training)
combined with conventional exercises (aerobic,
resistance, and stretching exercises) compared with
conventional exercises only.24
One study evaluated a calf-stretching home
exercise program.16 A standardized stretching pose
in which one foot was placed on the floor in front of
the body with the knee slightly bent and the other
knee was kept straight with the heel touching the
floor was used to stretch the calf muscles. Partic-
ipants held this static stretch position for 15 sec and
completed ten repetitions, for a total of 150 sec of
stretching during each session.
Another study evaluated a multifaceted podiatric
medical intervention that included a home-based FA
exercise program including strengthening exercises
using elastic bands, specific toe strength training
devices (Archxerciser; Elgin, Westmont, Illinois),
body weight–bearing exercises (toe lifts), and
stretching.13 The other elements of the multifaceted
intervention were advice on footwear, subsidy for
footwear, new foot orthoses, a falls prevention
education booklet, and routine podiatric medical
care for 12 months.
Fall Risk–Related Outcome Parameters
Reported in Studies
Fall risk–related motor outcomes differ substantial-
ly among the studies, which limits the ability to
compare results (Table 1). Five studies13,34,35,37,38
reported strength parameters; all of these studies
assessed ankle plantarflexor strength, three evalu-
ated ankle dorsiflexion strength,13,34,35 and one
Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013
additionally evaluated ankle inversion/eversion,
hallux flexor, and lesser toe flexor strength.13 Two
studies assessed ankle power.24,35 Most of the five
studies that assessed balance used conventional
balance tests, such as the functional reach test16 or
time stance tests.37,38 Only two studies used
objective biomechanical tests for a detailed assess-
ment of balance parameters such as postural
sway.13,36 Functional ability was most often quan-
tified by walking (5 studies); most of the studies
used timed walking tests,13,16,33,34 and only one
study used an electronic system for a detailed
documentation of FA training–related changes in
gait parameters.24 Other functional measures in-
cluded modified versions of the Timed Up and Go
test,16,24 the alternate step test,13 and the sit-to-
stand test.13 Three studies reported on flexibility
and measured ankle dorsiflexion range of mo-
tion,13,16,24 and only one of the three additionally
measured range of motion of ankle inversion/
eversion and of the first metatarsophalangeal
joint.13 Of the eight studies reviewed, only two
reported falls as an outcome parameter.13,37
Methodological Quality of the Studies
The results of quality rating using the PEDro scale
are presented in Table 2. The PEDro score averaged
6.4 points (range, 3–9) for all of the articles
included. Study quality varied, with most studies
(n ¼ 5, 62.5%) rated as high quality (score 6), two
as fair quality (score of 4–5), and one as low quality
(score ,4). The most frequent methodological
limitations were a lack of blinding of study
personnel, therapists, or participants and an uncon-
cealed group allocation. Two studies did not
perform statistical between-group comparisons but
only within-group comparisons. One study reported
point measures but not variability data, which are
required for calculating effect sizes (the Cohen d). A
variety of studies did not correct the statistical
analysis for multiple testing of parameters.36-38
Training Effects on Fall Risk–Related Outcome
Measures
Strength/Power. Results of FA exercise inter-
ventions for improvement in muscle strength or
muscle power are displayed in Table 1. Only
one study34 reported a significant training effect
(d ¼ 1.85; 95% CI, 0.86 to 2.85) on ankle
plantarflexor strength, whereas five other studies
did not report positive results on ankle plantarflexor
strength13,35,37,38 or power.24,35 A meta-analysis
537
Table 1. Qualified Clinical Studies Demonstrating Foot and Ankle Exercise Interventions
Exercise
Study Study Parameters Interventions Modalities Results

Strength Training Programs Focused on the Foot and Ankle

Kobayashi et n ¼ 19
al,36 1999 Age (mean [years]): 82.8
Participants: facility
residents
Setting: nursing home
Simoneau et n ¼ 23
al,34 2007 Age (mean [years]): IG,
78.5; CG, 76.2
Participants: community
dwelling
Setting: facility/home
Webber et al,35 n ¼ 50
2010 Age (mean [years]): 75.0
Participants: mobility
impaired
Setting: facility
Combined Strength and Functional Training Programs Focused on the Foot and Ankle
Hartmann et n ¼ 56
al,24 2009 Age (mean [years]): 75.9
Participants:
independently living
Setting: training facility/
home
Schoenfelder,37 n ¼ 16
2000 Age (mean [years]): 82.8
Participants: older adults
Setting: nursing home
IG: toe grasping exercises: T: 10 min Balance
Beanbag transfer F: 33 weekly Postural sway
Towel gathering (all D: 8 weeks Track length (eyes open): "a
exercises performed while Track length (eyes closed): "a
sitting) Area (eyes open): "a
CG: group physical Area (eyes closed): NSa
exercise MA distance of x-axis (eyes open): "a
MA distance of x-axis (eyes closed): "a
MA distance of y-axis (eyes open): NSa
MA distance of y-axis (eyes closed): NSa
IG: strength training of ankle Training facility: Strength
PF muscles using a calf T: NA Ankle PF MVC torque: "b
raise machine (facility) F: 23 weekly Ankle DF MVC torque: NSb
and elastic bands (home D: 12 months
training) Home:
CG: upper body exercise T: NA
F: 13 weekly
D: 12 months
IG1: ankle DF/PF power T: 45 min Strength/power
training using weight F: 23weekly Ankle DF/PF
machines D: 12 weeks Peak power: NS
IG2: ankle DF/PF power Peak torque: NS
training using elastic Foot movement time
bands IG1: NS
CG: upper body exercise IG2: "
IG1: Training facility: IG1 versus IG2:
Foot gymnastics: T: 5 min Power
Heel/toe lifts (sitting and F: 23 weekly Ankle DF/PF power: NS
standing) D: 12 weeks Function
Tip-toe/heel walking Home: Expanded TUG test: NS
Move/spread toes T: 10 min Walking parameters: NS
Grabbing/playing F: Daily Flexibility
Skill games with feet D: 12 weeks Ankle DF ROM: NS
Stretching
Conventional aerobic,
resistance, and stretching
exercises
IG2:
Only conventional
aerobic, resistance, and
stretching exercises
CG: no exercise
IG: T: 20 min Strength
Heel/toe lifts (standing) F: 33 weekly Ankle PF strength (No. of heel raises): NS
Walking D: 3 months Balance
CG: no exercise Parallel stance: NS
Semitandem stance: NS
Tandem stance: NS
Function
Walking: NS
Falls: NS

538 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
Table 1. continued
Exercise
Study Study Parameters Interventions Modalities Results

Schoenfelder n ¼ 81 IG: T: 20 min Strength

and Age (mean [years]): 84.0 Heel raises (standing, F: 33 weekly Ankle PF strength: NS
Rubenstein,38 Participants: older adults ankle weights) D: 3 months Balance
2004 Setting: nursing home Walking Parallel stance: NS
CG: no exercise Semitandem stance: "a
Tandem stance: NS
Function
Walking: NS
Ankle Stretching Exercise Programs
Gajdosik et n ¼ 19 IG: static calf-stretching T: 5 min Balance
al,16 2005 Age (mean [years]): 73.1 exercises F: 33 weekly Functional reach: NS
Participants: community- CG: no exercise D: 8 weeks Function
dwelling women Modified TUG test: "
Setting: home Walking speed: NS
Flexibility
Ankle DF ROM: "
Multifactorial Interventions Including Foot and Ankle Exercises
Spink et al,13 n ¼ 305 IG: T: 30 min Strength
2011 Age (mean [years]): 73.9 Range of motion: foot F: 33 weekly Ankle DF: NS
Participants: community rotation D: 6 months Ankle PF: NS
dwelling with foot pain Strength: Ankle inversion: NS
Setting: home Ankle inversion/eversion, Ankle eversion: "
adductor hallucis (elastic Lesser toe PF: NS
bands) Hallux PF: NS
Toe plantarflexion Balance
(Archexerciser, stone Postural sway
grasping) Area (floor, barefoot): "
Ankle DF (without Area (foam, barefoot): NS
weights) Area (floor, shod): NS
Ankle PF (toe lifts during Area (foam, shod): NS
standing) Maximum balance range
Stretching: Displacement (barefoot): NS
Adductor hallucis (elastic Displacement (shod): "
bands) Coordinated stability
Calf stretching Errors (barefoot): NS
Additional podiatric Errors (shod): NS
medical and falls Lateral stability
prevention interventions Displacement (barefoot): NS
CG: routine podiatric Displacement (shod): NS
medical care Function
Alternate step test: "
Walking: NS
Sit-to-stand: NS
Flexibility
Ankle DF test: "
Ankle inversion/eversion: "
First MTPJ: NS
Falls
Proportion of fallers and multiple fallers: NS
Incidence rate: #
Fractures: NS

Abbreviations: ", significant increase; #, significant decrease; CG, control group; D, program duration; DF, dorsiflexion; F,
frequency; IG, intervention group; MA, maximum amplitude; MTPJ, metatarsophalangeal joint; MVC, maximal voluntary contraction; NA,
not available; NS, not significant; PF, plantarflexion; ROM, range of motion; T, training time of single session; TUG, Timed Up and Go.
a
The P values are reported for pre-post changes in the IG. Between-group changes are not reported.
b
Outcomes after the 12-month training period (results for the 6-month interim analysis are not reported in the table).
c
Result of the v2 test for comparing the percentage of participants who stayed the same or improved versus declined from pretest
to 3 months posttest (a between-group statistic using the metric values of motor outcome parameters is not reported).

Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013 539
Table 2. Results of Quality Scoring Using the PEDro Scale
Gajdosik Hartmann Kobayashi Schoenfelder Simoneau Spink Webber
et al,16 et al,24 et al,36 Schoenfelder,37 and Rubenstein,38 et al,34 et al,13 et al,35
Item 2005 2009 1999 2000 2004 2007 2011 2010

Eligibility criteria X X X X X X X X
specified
Random allocation X X X X X X X X
Concealed X X – – – – X X
allocation
Groups similar at X X – X X X X X
baseline
Participant blinding – – – – – – – –
Therapist blinding – – – – – – – –
Assessor blinding – – – – – – X X
,15% dropouts X X – X – X X –
Intention-to-treat X X – – – X X –
analysis
Between-group X X – – X X X X
statistical
comparison
Point measures X X X – X X X X
and variability
data
Sum score 8 8 3 4 5 7 9 7

Abbreviations: PEDro, Physiotherapy Evidence Database; X, criterion is evidenced in the article; –, criterion is not evidenced, not
applicable, not coded, or could not be determined in the article.

using ankle plantarflexor strength (if reported) or,
alternatively, ankle plantarflexor power did not
find an overall effect of FA exercise training on
these parameters (d ¼ 0.11; 95% CI, 0.06 to 0.29;
P ¼ .223) (Fig. 2). One study37 was not included
in the meta-analysis because no variability mea-
sures were reported, which are required for
calculating effect sizes (d). No significant training
effects were reported in any study for ankle
dorsiflexion strength13,34,35 or power.24,35
One study13 evaluated strength parameters be-
yond ankle dorsiflexion/plantarflexion strength and
reported significant improvements in ankle eversion
strength but not in hallux flexor strength or lesser
toe flexor strength following the multifaceted
intervention approach including FA exercises.
Balance. Two studies, which used postural sway
measurements, reported significant improvements
in some but not all of the parameters (Table 1) after
toe grasp training36 and FA strength and flexibility
training.13 No improvement in balance performance
was found after a stretching exercise intervention.16
Two studies documented postural balance using
stance tests incorporating different foot positions
(parallel, semitandem, and tandem). One of these
studies reported that a significantly larger propor-
tion of participants of the intervention group
showed maintenance or improvement in balance
over time with the semitandem stance compared
with the control group at completion of the exercise
program. However, no statistics were reported for
between-group changes of point measures (stance
time), which limited the comparability of the results
with those of other studies.
A meta-analysis was performed using the results
of four studies (Fig. 3). Two of these studies13,36
provided a variety of postural sway parameters
(Table 1), but only the parameter with the highest
effect size in each study was included in the
analysis (ie, sway area on floor barefoot13 or sway
area eyes open36). Moderate to high effect sizes
were obtained for studies that used strengthening
and stretching training (d ¼ 0.51; 95% CI, 0.28 to
0.74)13 or toe grasp training (d ¼ 2.62; 95% CI, 1.36
to 3.88) and that objectively evaluated postural
sway. In contrast, no effects were obtained for two
studies that used either calf-stretching exercises or
FA strength and functional training and convention-
al measures of balance performance (Fig. 3).
Overall, the meta-analysis revealed a moderate
effect of FA exercise training on balance perfor-
mance (P ¼ 0.46; 95% CI, 0.26 to 0.66; P , .001).

540 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
Figure 2. Forest plot of effects of foot and ankle (FA) exercise training on ankle plantarflexor strength/power.
The dotted vertical line corresponds to the summary effect size for the sample. The solid vertical line
correspondents to an effect size of 0 (no effect). CI indicates confidence interval; I, intervention; O, outcome
parameter used for calculating effect size.

One study37 that reported balance parameters was
not included in the meta-analysis because no
variability measures were reported for quantifica-
tion of effect sizes.
Flexibility. Three studies evaluated ankle flexi-
bility by measuring ankle dorsiflexion range of
motion (Table 1). Two studies, which either used
specific calf-stretching exercises16 or strengthening
and stretching exercises in the multifaceted inter-
vention,13 reported significant improvements. In
contrast, no significant improvements in ankle
flexibility were identified in the foot gymnastics
study conducted by Hartmann et al.24 A meta-
analysis of these three studies revealed a small
overall effect of FA exercise training on ankle
dorsiflexion range of motion (d ¼ 0.29; 95% CI, 0.09
to 0.50; P ¼ .006), whereas the highest effect was
found for the study16 that used calf stretching as a
single intervention (d ¼ 2.04; 95% CI, 0.91 to 3.18)
(Fig. 4). One study used additional FA flexibility
measures and found a significant improvement in
ankle inversion/eversion but no changes in dorsi-
flexion of the first metatarsophalangeal joint.13
Functional Ability. Five studies evaluated FA
exercise effects on walking performance; however,
none of these studies reported significant improve-
ments (Table 1 and Fig. 5). Negative results were
confirmed by a meta-analysis that included four
studies that provided sufficient data for calculating
effect sizes for walking speed (overall effect: d ¼
0.05; 95% CI, 0.24 to 0.14; P ¼ .404) (Fig. 5).
Contradictory results were found for other func-
tional ability outcomes. The study that compared
combined conventional exercise and foot gymnas-

Figure 3. Forest plot of effects of foot and ankle (FA) exercise training on balance performance. The dotted
vertical line in corresponds to the summary effect size for the sample. The solid vertical line correspondents to
an effect size of 0 (no effect). CI indicates confidence interval; I, intervention; O, outcome parameter used for
calculating effect size.

Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013 541
Figure 4. Forest plot of effects of foot and ankle (FA) exercise training on ankle flexibility. The dotted vertical
line in corresponds to the summary effect size for the sample. The solid vertical line correspondents to an
effect size of 0 (no effect). CI indicates confidence interval; DF, dorsiflexion; I, intervention; O, outcome
parameter used for calculating effect size; ROM, range of motion.

tics with a conventional exercises–only control
group did not find any significant improvement in
the expanded Timed Up and Go test. 24 The
expanded Timed Up and Go test provides separate
results for sit-to-stand, gait initiation, walking,
turning, and stand-to-sit. One study that used a
calf-stretching exercise program found a significant
improvement in mobility performance verified by a
modified version of the Timed Up and Go test that
included advanced functional activities (rising from
a chair without the aid of the arms), walking, stair
ascending and descending, and sitting down.16
The study by Spink et al13 that evaluated a
multifaceted intervention that included FA exercis-
es shows a significant improvement in the alternate
step test but no changes in sit-to-stand performanc-
es. The study that evaluated an ankle power training
program found a specific improvement in foot
movement time in the elastic bands group but not
in the machine-based exercise group compared with
a control group.35
Falls. Only two studies reported falls as an
outcome parameter.13,37 One study that evaluated
a 3-month combined FA strength and walking
training regimen in nursing home residents reported
nonsignificant changes in fall rates after 3 and 6
months of follow-up.37 A study using a 12-month
multifaceted podiatric medical intervention that
included FA exercises reported a 36% reduction in
falls in the intervention group compared with the
control group (incidence rate ratio, 0.64; P ¼ .01).13
In addition to the reduced fall rate, fewer partici-
pants in the intervention group experienced a
fracture resulting from a fall during the trial than
in the control group. However, this result did not
reach significance (P ¼ .07), potentially owing to a
lack of statistical power required to demonstrate a
convincing relationship between exercise interven-
tions and a reduction in injurious falls.39

Figure 5. Forest plot of effects of foot and ankle (FA) exercise training on walking speed. The dotted vertical
line in corresponds to the summary effect size for the sample. The solid vertical line correspondents to an
effect size of 0 (no effect). CI indicates confidence interval; I, intervention; O, outcome parameter used for
calculating effect size.

542 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
Discussion
The aim of this study was to review the studies that
have evaluated the effects of FA exercise programs
on improving fall risk–related motor outcomes and
reducing falls in older adults. Overall, this system-
atic review and meta-analysis demonstrates that FA
exercises are effective for improving balance
performance and ankle flexibility, whereas evidence
for improvement of FA strength and functional
abilities is insufficient. Only one study provided
evidence for the effectiveness of FA exercises in
reducing the number of falls in older adults.
Foot and ankle exercises were found to be
effective for improving postural balance in nursing
home residents and community-dwelling elderly
individuals, particularly if specific toe-strengthening
exercises (toe grasping) are included. Adequate toe
flexor strength is crucial for maintaining balance,15
although it remains unclear whether the substantial
balance improvements reported in one study after 8
weeks of toe grasping exercises36 are related to
improved toe flexor strength because it was not
measured. The author of this paper discussed other
potential mechanisms of toe grasp training, such as
triggering of mechanoreceptors at the bottom of the
foot, that are relevant for postural adjustment. Also,
this study had several methodological limitations
(PEDro score of 3), and further high-quality studies
are required to examine the effectiveness of specific
toe-strengthening exercises for improving balance.
Limited range of motion of the ankle is related to
reduced balance and functional ability and is a
significant risk factor for falls.18 Evidence from
studies included in this review shows that flexibility
in terms of ankle dorsiflexion range of motion can
be improved using FA exercise training. A specific
home-based 8-week calf-stretching regimen was
found to be most beneficial.16 As a result of calf
stretching, participants also improved in the ad-
vanced Timed Up and Go test, which included
functional activities such as chair transfer, walking,
and stair ascending/descending. However, it re-
mained unclear which specific functional activities
were improved by the calf-stretching exercises
because the authors did not report which specific
parts of the Timed Up and Go test changed (eg, stair
descending); the study reported only the total
duration of the test.
The results of this review reveal that evidence for
the improvement of ankle dorsiflexion/plantarflex-
ion strength or power by using FA exercise training
is insufficient because only one of six studies
reported a significant improvement. Importantly,
Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013
negative results might be related to a lack of
strength training intensity, particularly in studies
that did not use training machines. The study that
reported positive results used a standardized
progressive resistance training regimen based on
machines and elastic bands and adjusted the
training intensity based on the one-repetition
maximum. In contrast, some studies that reported
negative results24,37 did not clearly describe wheth-
er training intensity was properly adjusted accord-
ing to guidelines of progressive resistance training
in older adults.40 Some exercise programs included
heel raises with body weight and increased the
number of repetitions over the training period but
did not use additional weights, thus most likely
lacking in adequate training intensity.37 Another
study specifically focused on improvement of ankle
movement time by encouraging participants to
perform concentric movements as fast as possible,
whereas ankle strength and power were only
secondary outcomes. The authors discussed that
sample size was calculated for movement time and
that a much larger sample size would be required to
detect significant changes in ankle strength or
power.35 Note that the results of non–randomized
controlled trials, which were not included in this
review, suggest that an adequate adjustment in
training intensity results in significant improve-
ments in ankle strength, even if using elastic bands
only. For example, Ribeiro et al41 used a progressive
resistance exercise program with elastic bands with
adjusted intensity according to the American
College of Sports Medicine guidelines for strength
training.42 A color-coded series of elastic bands with
varying tension was used to provide progressive
resistance to the muscles. The starting elastic band
level was determined by finding the point at which
the participant could perform 6 to 8 repetitions of
the exercise displaying good quality before fatigue.
Improved ankle strength was associated with
significant improvement in balance and functional
performance. This suggests that a simple and low-
cost exercise program, if adequately adjusted
relative to intensity, can significantly reduce the
risk of falling, even after a short training period of 6
weeks. Further studies should explore similar
exercise programs using a randomized controlled
trial design.
Most of the studies included in this review
quantified ankle plantarflexion/dorsiflexion strength
only and did not obtain other strength parameters,
thus potentially missing gains in strength in other
FA muscles as a result of exercise training. This
assumption is supported by the study by Spink et
543
al13 that assessed a variety of FA strength param-
eters but did not identify a training-related improve-
ment in FA plantarflexion/dorsiflexion strength.
Still, they discovered significant improvements in
ankle eversion strength, a parameter that has been
previously linked to balance performance.43 Spink
et al13 found a significantly reduced fall rate in the
intervention group compared with the control
group. One potential mechanism for the exercise-
related reduction in fall risk might be improved
ankle stability caused by gains in ankle evertor
strength (peroneal muscles), although this relation-
ship has not been examined yet.
Foot and ankle characteristics, particularly
ankle flexibility, plantar tactile sensation, and the
strength of the toe plantarflexor muscles, are
significant independent predictors of balance and
functional ability in older people.18 In the present
review, controversial results were observed re-
garding the impact of FA exercises on functional
ability. Although a few authors reported improve-
ments in functional ability verified by the advanced
Timed Up and Go test16 or alternate step test,13 no
evidence was found for an exercise-related im-
provement in walking performance. An important
reason for negative results might be a lack of
adherence in studies that specifically investigate
the impact of FA exercises on gait performance.24
For example, a study designed to demonstrate the
added value of FA exercise in a conventional falls
prevention program failed to show additional
ameliorative effects of FA training on gait param-
eters.24 The authors concluded that complementa-
ry foot gymnastics intended to strengthen the
muscles of the feet and increase ankle joint range
of motion had no additional effects on these
parameters. However, a major reason for the
limited effectiveness might be the limited adher-
ence to the home-based exercise program. Almost
half of the participants (43%) never performed the
foot gymnastics, and only 13% of participants
performed the exercises daily. The authors’ sole
analysis was intention-to-treat, without secondary
adherence analyses evaluating a potential associ-
ation between adherence to the exercise sessions
and training effects. Despite the low compliance
and nonsignificant results, the findings of this study
should be incorporated into future studies. For
example, within-group pre-post changes indicated
that specific gait parameters, such as gait initiation,
changed significantly only in the group in which
additional FA exercise was performed; however,
between-group changes were not significantly
different. Nevertheless, results may indicate that
544 November/December 2013  Vol 103  No 6  Journal of the American Podiatric Medical Association
the additional FA training improved specific
aspects of gait, which should be investigated in
future studies by using a detailed gait analysis.
Several authors discussed that negative results
might be related to small sample sizes limiting the
statistical power35,37,38 or to a short training
period.24 In addition, cognitive impairment might
be a potential factor for lack of effectiveness of FA
training in some studies. Two studies37,38 that found
limited effectiveness of FA strength training partly
included cognitively impaired older adults (Mini-
Mental State Examination score 20). Cognitive
impairment has been repeatedly identified as a
negative predictor of training response.44,45 It
remains unclear whether cognitively impaired indi-
viduals with limited executive functions were able
to follow the training instructions. No subanalysis
was provided to determine whether cognitive status
negatively affected training gains. Neither study
performed training sessions according to specific
guidelines developed for exercise training with
cognitively impaired patients.46
Which FA Exercise Interventions Provide
Evidence for Preventing Falls in Older People?
Evidence for the effectiveness of FA exercise for
reducing the number of falls is provided in only one
study.13 This study is a methodologically sound
randomized controlled trial (PEDro score of 9) with
a large sample size, ensuring adequate statistical
power for documenting an intervention-related
association with falls. In addition, the authors used
a variety of established outcome measures for
documenting changes in various domains of motor
performance. The home-based training program
used different methods for progressive resistance
training, including elastic bands, body weight, a
specific device for strengthening the foot muscles
(Archerxerciser), and flexibility training.47 Com-
pared with another home training study that did
not demonstrate a specific effect of FA exercise,
potentially due to low adherence,24 adherence in the
study by Spink et al13 was promoted by regular
telephone calls. Adherence to the exercise interven-
tion was generally good, with more than half of the
participants performing 75% of the exercise ses-
sions. Also, this was a multifactorial intervention
that included other podiatric medical interventions,
and the authors reasoned that the reduction in fall
rate is most likely a result of the significant
improvements related to ankle strength (ankle
eversion), ankle range of motion, balance, and
functional ability. The observed improvements in
the intervention group in strength and range of
motion, in conjunction with improvements in some
balance measures, suggest that the intervention
resulted in changes in the musculoskeletal system,
thus reducing the risk of falling. Adherences to
other parts of the multifaceted intervention, such as
provision of footwear, were only minor. However,
the effect of the other falls prevention interventions
cannot be ruled out.
Future Research
Several authors of studies included in this review
have requested further studies for evaluating FA
exercise regimens.13,24,36,37 Future studies should
be designed according to established guidelines for
falls prevention trials,48 including a randomized
controlled trial design, a proper case definition (eg,
individuals with disabling foot pain),13 a standard-
ized fall definition, and prospective daily recording
of falls. Studies should be adequately powered to
report a potential reduction in falls and, more
ideally, injurious falls.39 Motor outcome measures
should include established measures of FA
strength and range of motion47 and validated tests
for balance and functional performances. 49-51
Ideally, balance parameters and spatiotemporal
gait parameters should be assessed objectively by
biomechanical methods, which are suitable for use
in large-scale studies and can be applied in a
clinical environment or in the participant’s
home.52,53 Intervention components should include
exercises focused on strengthening and stretching
of the ankle and foot as described by protocols of
established studies.47 Intensity of training should
be adjusted during the training period according to
the principles of progressive resistance training as
described in exercise guidelines for older adults.40
If cognitively impaired older adults are included,
specific guidelines for effective exercising in this
target group should be included.46
Limitations
We did not adjust the meta-analysis according to
study quality, which may have biased the results.
However, effect sizes were weighted by the number
of participants in each study. We found that studies
with larger sample sizes generally had higher
methodological quality. We, therefore, believe that
this meta-analysis provides a reliable estimate of FA
exercise effects on fall risk–related motor outcome
parameters.
Journal of the American Podiatric Medical Association  Vol 103  No 6  November/December 2013
Conclusions
There is evidence that FA exercise can improve
selected fall risk–related motor outcomes, such as
balance and ankle flexibility. Limited effects on
ankle strength and functional ability might be
related to insufficient training intensity and lack of
adherence. Only one multifaceted intervention,
which included FA exercise and other podiatric
medical interventions, provided evidence for a
significant reduction in the fall rate, which most
likely was due to FA exercises. More studies with
adequate sample size, sensitive measurement meth-
ods, and standardized training protocols, including
progressive resistance training and flexibility exer-
cises, are required to evaluate the effectiveness of
such training regimens and to provide evidence-
based recommendations.
Financial Disclosure: This study was supported in
part by a postdoctoral research fellowship from the
German Academic Exchange Service and by a grant
from the Qatar National Research Foundation
(award number NPRP 4-1025-3-276). The sponsors
had no role in the design or conduct of the study;
the collection, management, analysis, or interpreta-
tion of the data; or the preparation, review, or
approval of the manuscript.
Conflict of Interest: Guest editor, Bijan Najafi,
PhD, was not involved in the review and acceptance
of this paper.
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