Is a walking boot an appropriate treatment modality for acute foot pain post fall?

Walking Boot for Acute Foot Pain Post Fall

A walking boot is an appropriate treatment modality for acute foot pain following a fall, especially when there is suspected fracture, significant pain with weight-bearing, or need for immobilization during the healing process. 1

Diagnostic Considerations Before Boot Application

Before prescribing a walking boot, consider:

• Ottawa rules for determining need for imaging:

  • Point bone tenderness of the navicular
  • Point bone tenderness of the base of the fifth metatarsal
  • Inability to bear weight or walk 4 steps immediately after injury 2

• Exclusionary criteria for Ottawa rules (requiring more caution):

  • Penetrating trauma, pregnancy, skin wounds

  • 10 days after trauma

  • Return visit for continued foot pain
  • Polytrauma, altered sensorium
  • Neurologic abnormality affecting the foot
  • Underlying bone disease 2

Indications for Walking Boot Use

Walking boots are particularly indicated for:

• Suspected fractures when immediate casting is not available
• Plantar foot ulcers (removable walkers)
• Significant pain with weight-bearing
• Need for immobilization with ability to remove for wound inspection
• Protection during healing after acute trauma 2, 1

Types of Walking Boots

1. Removable Walker Boots:

   • Advantages: Can be removed for wound care, hygiene, and sleep
   • Best for: Exudating plantar foot ulcers, ulcers with active mild infection, or when frequent inspection is needed 2

2. Fixed/Non-removable Walker Boots:

   • Advantages: Better compliance, cannot be removed by patient
   • Best for: Patients with poor adherence to treatment 2

3. Ankle-high vs. Knee-high Boots:

   • Knee-high provides better immobilization
   • Ankle-high may be better tolerated but provides less support 2, 3

Benefits of Walking Boots

• Prevents foot from being dragged during swing phase of gait
• Provides clearance between foot and ground
• Maintains stable posture during stance phase
• Reduces pressure on injured areas 3
• Allows for earlier mobilization compared to complete non-weight bearing 1

Limitations and Considerations

• Creates leg length discrepancy that can alter gait mechanics 4
• May cause compensatory changes in knee, hip, and low back biomechanics 4, 5
• Slower walking speed compared to normal footwear 5
• Patient adherence may be an issue with removable devices (worn only 28% of steps in some studies) 2
• Cost considerations (relatively high for many removable knee-high walkers) 2

Optimizing Walking Boot Use

• Consider boots with greater forefoot rocker profiles to mitigate gait deviations 5
• Evaluate need for contralateral shoe lift to address leg length discrepancy 4
• For patients with diabetes or neuropathy, ensure proper fit to prevent new pressure points 2, 1
• Instruct patients on proper gait pattern to minimize compensatory movements 1

Follow-up Recommendations

• Evaluate response to treatment every 4-6 weeks 1
• Consider referral to foot specialist if no improvement occurs after six weeks 1
• Assess for development of secondary knee, hip, or low back pain during treatment 4

Walking boots represent an effective treatment modality for acute foot pain following falls, offering protection, immobilization, and pain relief while allowing for some mobility. The design and type of boot should be selected based on the specific injury pattern, patient factors, and treatment goals.