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Letter Urging HHS to Inform Seniors that Appropriate Footwear Decreases Risk of Falls

December 28, 2004

Tommy Thompson
Secretary, Department of Health and Human Services
200 Independence Avenure, SW
Washington, DC 20201

Dear Secretary Thompson,

An important study of urgent importance to America’s seniors was recently published on the effect of footwear on the risk of falls in older adults. The study found that people not wearing shoes (i.e. barefoot or in stockings) had an 8- to 11-fold greater risk of falling than those wearing athletic or canvas shoes.[1] This study was funded by two parts of HHS, the National Institute on Aging and the Centers for Disease Control and Prevention. Although the public health implications of this study are enormous and they demand high-level attention by HHS, we are not aware that that you or the Surgeon General have issued any alert despite the fact that this study was published almost four months ago.

We strongly urge you to immediately warn senior citizens about this highly preventable increased risk of falls. A warning, similar to that enclosed, should be included along with the Social Security checks mailed out to over 47 million seniors. In addition, an announcement from yourself and Surgeon General Carmona will emphasize the importance of this crucial safety message to everyone in this country.

As you know, falls are the leading cause of nonfatal and fatal injury in older Americans.[2],[3],[4] More than 11,000 Americans aged 65 and older die from fall-related injuries each year,[5] and that number is steadily rising as our population ages. One in three Americans over the age of 65 falls each year, and 20% to 30% of those who fall suffer serious injury such as hip fractures or head traumas, severely affecting quality of life and risk of premature death.[6],[7] 250,000 elderly Americans suffer hip-fractures every year, 87% of which are due to falls.[8] Falls also diminish mobility and quality of life due to fears of falling again[9].

Beyond the devastating impact on the individual, falls are costly to our health care system. Among older Americans, falls are the leading cause of hospital admissions for trauma4. Nearly 40% of all nursing home admissions are in some way related to falls.[10] A study of people aged 72 and older found that the average cost of a fall injury (not including physician services) was $19,440.[11] The total cost for all fall injuries in older Americans was $27.3 billion in 1994, and is expected to reach $43.8 billion by 2020.[12]

This case-control study, published by researchers at the CDC, Group Health Cooperative, and the University of Washington in the September 2004 issue of Journal of the American Geriatrics Society, monitored 1,371 adults, aged 65 and older, over a two-year period. 327 fall cases were compared with 327 controls. Wearing athletic or canvas shoes was consistently associated with lowest risk of falling, whereas going shoeless was associated with highest risk. Wearing shoe styles other than athletic/canvas shoes was associated with more modestly, but significantly, elevated risk of falling (30% to 50% increased risk relative to athletic/canvas shoes). These associations held up across several multivariate analyses that controlled for age, sex, gait abnormality, grip strength, and activity.[13] Another analysis of the same study by the same authors found that shoe characteristics associated with a greater risk of falls included greater heel height and smaller shoe contact area with the walking surface.[14]

You must promptly lead the effort to ensure that elderly Americans are properly informed about this life-saving new information. When such a simple act as putting on a pair of sneakers can reduce the risk of a crippling or fatal injury to as little as one-eleventh of the risk for those people going barefoot or wearing stockings, it is irresponsible for the Department of Health and Human Services not to fulfill its duty to our elderly population to make these findings common knowledge by widely disseminating the results and the warnings.


Nicholas Stine
Research Associate

Sidney M. Wolfe, M.D.
Public Citizen's Health Research Group  

Attention Seniors:

Falls are the leading cause of both nonfatal and fatal injury in older Americans. A recent study has shown that not wearing shoes dramatically INCREASES risk of falls. Persons wearing athletic or canvas shoes have up to an 11 times LOWER risk of falling than those not wearing shoes. Protect yourself from serious injury and potentially devastating medical bills by:

  • Not walking barefoot or in stockings or slippers
  • Wearing shoes both outdoors and in your home
  • Wearing athletic or canvas shoes instead of high heels, sandals, boots, or other shoe styles
  • Replacing old or ill-fitting shoes


[1] Koepsell TD, Wolf ME, Buchner DM, Kukull WA, LaCroix AZ, Tencer AF, Frankenfeld CL, Tautvydas M, Larson EB. Footwear Style and Risk of Falls in Older Adults. Journal of the American Geriatric Society 2004; 52:1495-1505.

[2] Sattin RW. Falls Among Older Persons: A Public Health Perspective. Annual Review of Public Health 1992; 13: 489-508.

[3] Murphy, SL. Deaths: Final Data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.

[4] Alexander BH, Rivara FP, Wolf ME. The Cost and Frequency of Hospitalization for Fall-Related Injuries in Older Adults. American Journal of Public Health 1992; 82(7): 1020-3.

[5] Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2003). National Centerfor Injury Prevention and Control, Centers for Diease Control and Prevention (producer). Available from: URL: [Accessed October 24, 2004].

[6] Huasdorff JM, Rios DA, Edelber HK. Gait Variability and Fall Risk in Community-Living Older Adults: a 1-year Prospective Study. Archives of Physical Medicine and Rehabilitation 2001; 82(8):1050-6.

[7] Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing Falls Among Community-Dwelling Older Persons: Results from a Randomized Trial. The Gerontologist 1994: 34(1): 16-23.

[8] Centers for Disease Control and Prevention. A Tool Kit to Prevent Senior Falls [Online]. (2004). National Centerfor Injury Prevention and Control, Centers for Diease Control and Prevention (producer). Available from: URL: [Accessed October 24, 2004].

[9] Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of Falling and Restriction of Mobility in Elderly Fallers. Age Aging 1997; 26: 189-193.

[10] Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. New England Journal of Medicine 1988; 319:1701-1707.

[11] Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health Care Utilization and Costs in a Medicare Population by Fall Status. Medical Care 1998; 36(8): 1174-88.

[12] Englander F, Hodson TJ, Terregrossa RA. Economic Dimensions of Slip and Fall Injuries. Journal of Forensic Science 1996; 41 (5): 733-46.

[13] Koepsell TD, Wolf ME, Buchner DM, Kukull WA, LaCroix AZ, Tencer AF, Frankenfeld CL, Tautvydas M, Larson EB. Footwear Style and Risk of Falls in Older Adults. Journal of the American Geriatric Society 2004; 52:1495-1505.

[14] Tencer AF, Koepsell TD, Wolf ME, Frankenfeld CL, Buchner DM, Kukull WA, LaCroix AZ, Larson EB, Tautvydas M. Biomechanical properties of shoes and risk of falls in older adults. J Am Geriatr Soc. 2004 Nov;52(11):1840-6.

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