Objective <p>To investigate the effects of square-step exercise on fall fear, balance ability, activities of daily living, and fall risk in older patients with ischemic stroke. Methods: Sixty-two older ischemic stroke patients hospitalized in the Department of Neurology from January to September 2024 were enrolled. The subjects who met the inclusion criteria were divided into two groups according to the unit (n1 = n2 = 31). The control group received routine care, while the intervention group, in addition to routine care, underwent square-step exercise training. The scores of Short Falls Efficacy Scale-International, Berg Balance Scale, Modified Barthel Index, and Morse Fall Scale in older patients with ischemic stroke were assessed and analyzed before and after the intervention.</p> Results <p>After a 12-week intervention, the intervention group demonstrated superior improvements in fall efficacy (SFES-I score), balance ability (BBS score), and fall risk (MFS score) compared with the control group (<i>P</i> &lt; 0.05). Regarding activities of daily living (MBI score), both groups showed improvement compared to baseline after the intervention; however, the difference between the intervention and control groups was not statistically significant (<i>P</i> = 0.250).</p> Conclusion <p>Square-step exercise enhances fall efficacy levels and alleviates fear of falling in older ischemic stroke patients. It also demonstrates efficacy in improving balance ability and reducing fall risk.</p> Trial registration <p>ChiCTR2600127548, Date:02/07/2026. (Retrospectively registered).</p>