Start Good Habits Early

Starting off with the right approach is really important for two reasons: First, it’s usually easier to get your diabetes under good control in the early stages of the disease, and secondly, clinical studies show that achieving good control early provides benefits to your body that can last for decades.

Also, the diabetes habits you develop now will stick with you in the long-run. Really, we all know how hard it is to change behavior once we’re set in our ways!

So for example, you might want to take some time to look at the user’s manual that came with your glucose meter in order to learn how to set the alarms that will remind you to test at different times of day: before meals, about two hours after, and at wake time and bed time. You want those test times to become habit!

You’ll also want to set up some kind of reminders to get your essential medical tests done regularly:

the A1c blood test - every three months
blood pressure - every six months at least (take advantage of every doctor’s appointment to have this checked, especially if it’s been elevated or you’ve had concerns)microalbumin, lipids, and eye exam—all annually (unless concerns call for more frequent checks)

Another “habit” that you’ll want to nurture early on is keeping an upbeat attitude. The voice in your own head is very, very important: you’ll want it to act as a “cheerleader,” rather than a negative force always telling you that you’ve failed.

There’s no question that it’s hard to stay upbeat when you’ve been diagnosed with a chronic illness.

You might be thinking: How do I stay positive when I feel like I’m being punished? Or when I feel so overwhelmed by having a disease that requires so much attention?

Taking care of yourself with diabetes is indeed a “mental game,” requiring you to learn to function comfortably on a number of levels:

Personal (Emotional)—fighting off negative thoughts
Social—interacting with others in social situations without stress
Behavioral—preventing yourself from doing things you wish you wouldn’t, sometimes even self-destructive things

If you do find that you’re experiencing a mental struggle with your diabetes, connecting with other people walking in your shoes is often very comforting – and helpful.

Connecting with other PWDs (people with diabetes) regularly, either online or offline, is a habit worth forming!

Should I Pick Up the Pace?

Q: My doctor told me that I need to get more aerobic exercise, but I hate going to the gym! I do like to walk, but how fast and how long should I go to improve my cardiovascular health?

A:
I understand exactly what you mean about going to the gym; I'm not a big fan of it either. Personally, I prefer to exercise outdoors or at home. And like you, I really enjoy walking.

Recently, I've begun recommending what's known as interval walking to many of my patients. With interval walking, you alternate between short bursts of intensive effort and easier recovery periods, as opposed to walking at a steady, continuous, and potentially monotonous pace. In fact, studies show that you can get better results in 20 minutes of interval exercise than you would in an hour of steady-state exercise. And you can apply the principles of interval walking to a treadmill or elliptical trainer, to biking or swimming, or even to doing jumping jacks in your living room.

So how do you do interval walking? Instead of walking at a constant pace for your entire workout, as you've probably been doing, you should mix it up. That is, after a three-minute warm-up where you walk at an easy or moderate pace, you should alternate short bursts of very fast walking (15 to 60 seconds, depending on your conditioning) with recovery periods of slower walking after each fast burst. You can repeat each interval six to 12 times, or more depending on your fitness level. Aim for walking a total of 20 minutes to start. In general, the more intense the workout (in other words, the faster you go), the shorter the duration of that interval and the longer the recovery period. Conversely, when you're not working as hard, your work period will be longer and your recovery period will be shorter. For example, if you like taking an hour-long walk on weekends, you can certainly do intervals, but don't try to spend the entire hour working at high intensity. And always end with a two-minute cooldown at an easy pace.

I recommend that you do interval walking every other day, alternating it with some core-strengthening exercises. Not only will this type of walking improve your cardiovascular health, it will boost your metabolism so you burn more calories and fat, and that translates into faster weight loss.

Interval training is not only for the very fit. It works just as well for people who are less fit, and is even being used to help cardiac patients and people with lung disease get back in shape. That said, I do recommend that you talk with your doctor before embarking on this or any other exercise program.

Meal Schedule for Type 2 Diabetes

Q: What’s the best meal schedule for a diabetic? When should snacks be included?

A: I recommend eating a meal or snack every four to five hours. This allows enough time for your blood sugar to come back down to a healthy baseline after eating, but it’s frequent enough to help you manage your appetite and keep hunger pangs at bay, which is especially important if you’re trimming calories to lose a few pounds. In general, you can meet this guideline by eating breakfast, lunch, a mid-afternoon snack, and dinner, evenly spaced throughout your day. At all meals and snacks, combine a small to moderate amount of high-quality carbohydrates (vegetables, fruit, whole grains, beans/lentils) with a good dose of lean protein from foods like skinless turkey or chicken, egg whites, seafood, low-fat dairy, or beans/lentils (beans and lentils count as both a carb and a protein). The protein helps slow your body’s absorption of carbs and prevent spikes in your blood sugar. Here’s an example of an A+ day of eating designed for optimal blood-sugar control.

Breakfast:
Egg-white omelet with vegetables (spinach, mushrooms, peppers and/or onions)
One orange
Coffee with skim milk

Lunch:
2 cups hearty, low-sodium soup (lentil, black bean or minestrone) topped with ¼ cup shredded
reduced-fat cheese
Crunchy red-pepper sticks
Water

Snack:
Nonfat yogurt
1 apple

Dinner:
Homemade shrimp-and-broccoli stir-fry
¾ cup cooked brown rice
Zero-calorie seltzer

After Dinner:
Handful of almonds or pistachio nuts
Cup of decaf or herbal tea

Stop the Progress of Prediabetes

You can prevent this precursor to type 2 diabetes from developing into full-blown disease.

Nearly 24 million American adults are living with diabetes, according to figures released last month by the International Diabetes Federation. But what may be even more alarming is that there are also about 79 million Americans with a condition known as prediabetes — and many aren't aware of it.

Prediabetes means that while your blood sugar levels are higher than normal, that level isn’t high enough to warrant a diabetes diagnosis. However, a prediabetes diagnosis means it is time for action to prevent diabetes.

"In simple terms, there is a gap between what we call diabetes, which is a fasting blood sugar of 126 and above, and normal, which is less than 100 fasting," explains Vivian Fonseca, MD, a professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans. "In between, you have impaired fasting glucose. If you do a glucose tolerance test, and you are in the gap, you have prediabetes. You are at risk for getting diabetes in the future and you are also at risk for heart disease."

Research has also found that prediabetes may be more common in men than in women.

Type 2 Diabetes: Prevention

If you are told your blood sugar is abnormally high, you’ve just had a red flag waved in front of you. You’re being warned that unless you make some changes in your life today, your future will probably include a diabetes diagnosis.

"Walking 30 minutes a day and reducing weight by 5 percent can decrease the risk [of getting type 2 diabetes] by 60 percent over three years," says Dr. Fonseca. While there are medications that have the same effect, lifestyle change is less expensive and has fewer side effects, Fonseca says.

Cutting your weight is crucial. "One of the links with obesity is that fat induces a mild low-grade inflammation throughout the body that contributes to heart disease and diabetes," Fonseca explains. Without making any changes, you could develop type 2 diabetes within 10 years of first developing prediabetes.

Type 2 Diabetes: Who Should be Tested?

Prediabetes is a "silent" condition, says Fonseca. While some people may experience symptoms of diabetes such as fatigue or increased urination, most people’s blood sugar rises without any outward signs at all. This means you might not know you need to be tested for prediabetes — and even if you are screened, your doctor might not give you all the information you need to prevent it.

For these reasons, diabetes experts developed criteria for those who should be tested. The American Diabetic Association recommends that any adult age 45 or older should be tested for diabetes and prediabetes.

The ADA also recommends that any adult under age 45 who is overweight and has at least one of the following risk factors should be tested:

Family history (especially parent or sibling with diabetes) Physically inactive lifestyle Native American, African-American, or Hispanic heritage Prior gestational diabetes diagnosis Birth of a baby over nine pounds in weight High blood pressure or treatment for high blood pressure Polycystic ovarian syndrome (PCOS) diagnosis Dark, velvety rash around the armpits or neck History of heart disease If your test reveals that you have prediabetes, you should be tested again in one to two years, depending on your doctor’s recommendations.

Type 2 Diabetes: Types of Tests

There are two tests used to screen for diabetes and prediabetes:

Fasting plasma glucose: a test of your blood after you haven’t eaten for eight hours (usually overnight) Oral glucose tolerance test: a comparison of your blood taken first after eight hours without food (fasting) and then two hours later after you have consumed a sugary drink given to you by the lab technician. If you fit the screening criteria listed above, make an appointment to get tested as soon as possible. It could be the first step toward preventing the development of type 2 diabetes.

Why Are My Feet Hurting When I Walk?

Q: My feet have started to hurt a lot — so much that when I wake up in the morning I cannot walk barefoot for at least the first 20 minutes. I can't be on my feet too much anymore without pain. What might be causing this, and what can I do to get some relief?

A: What you are describing sounds like a painful condition known as plantar fasciitis. This is a situation where there is inflammation of the soft tissue along the sole of your foot, all the way from your heel to your toes. It may be caused by high-impact exercise, structural problems such as being flat-footed, arthritis, or ill-fitting shoes. It is also more common in people with diabetes. The most characteristic symptom of plantar fasciitis is severe shooting or burning pain in the feet in the morning. The pain typically improves after some movement, only to recur after periods of prolonged rest or intense activity.

Preventive measures include always wearing shoes that fit well, stretching in the morning, afternoon and evening and before any exercise, limiting high-impact exercises, and maintaining ideal body weight, as obesity does predispose to plantar fasciitis. The key is to exercise carefully rather than eliminating exercise altogether. Treatment includes surgical and nonsurgical approaches, though surgery is a last resort and is rarely necessary. Night plints, orthotics, and physical therapy may hasten your recovery, but if the condition is left untreated, it will not resolve itself. In severe cases, injections with steroids or treatment with ultrasound may be warranted.

Foot Anatomy: Your Amazing Feet

Despite delicate foot anatomy, your feet are able to take a pounding every day. Help them go the distance by identifying and correcting common foot problems, from corns and calluses to Athlete's foot and hammertoes.

The human foot has 42 muscles, 26 bones, 33 joints, and at least 50 ligaments and tendons made of strong fibrous tissues to keep all the moving parts together … plus 250,000 sweat glands. The foot is an evolutionary marvel, capable of handling hundreds of tons of force — your weight in motion — every day. The foot’s myriad parts, including the toes, heel, and ball, work in harmony to get you from one place to another. But the stress of carrying you around puts your feet at high risk of injury, more so than other parts of your body.

Many foot problems, including hammertoes, blisters, bunions, corns and calluses, heel spurs, claw and mallet toes, ingrown toenails, toenail fungus, and athlete’s foot, can develop due to neglect, ill-fitting shoes, and simple wear and tear. Your feet also can indicate if your body is under threat from a serious disease. Gout, for instance, will attack the foot joints first.

Foot Problems: Athlete's Foot
Caused by a fungus that likes warm, dark, and moist environments like the areas between the toes or on the bottoms of the feet, athlete’s foot can inflame the skin and cause a white, scaly rash with a red base. The athlete’s foot fungus also causes itching, burning, peeling, and sometimes a slight odor; the infection can also migrate to other body parts. You can avoid athlete’s foot (also called tinea pedis) by keeping your feet and toes clean and dry and by changing your shoes and socks regularly. Over-the-counter antifungal creams or sprays can be used to treat athlete’s foot. If these remedies do not work, however, you may need to see a podiatrist and ask about prescription-strength medication.

Foot Problems: Hammertoes
If your second, third, or fourth toe is crossed, bent in the middle of the toe joint, or just pointing at an odd angle, you may have what’s called a hammertoe. Hammertoes are often caused by ill-fitting shoes. Early on, wearing inserts or foot pads can help reposition your toe, but later it becomes fixed in the bent position. Pain then sets in and you may need surgery. Because hammertoes are bent, corns and calluses often form on them.

Foot Problems: Blisters
It’s this simple: If your shoes fit well, you won't have blisters. Soft pockets of raised skin filled with clear fluid, blisters are often painful and can make walking difficult. It’s important not to pick at them. Clean the area thoroughly, then sterilize a sewing needle and use it to open the part of the blister located nearest to the foot’s underside. Drain the blister, slather with antibiotic ointment, and cover with a bandage. Follow these same care steps if a blister breaks on its own.

Foot Problems: Bunions
A bunion is a crooked big-toe joint that sticks out at the base of the toe, forcing the big toe to turn in. Bunions have various causes, including congenital deformities, arthritis, trauma, and heredity. A bunion can be painful when confined in a shoe, and for many people, shoes that are too narrow in the toe may be to blame for the formation of bunions. Surgery is often recommended to treat bunions, after conservative treatment methods like over-the-counter pain relievers and footwear changes fail.

Foot Problems: Corns and Calluses
Corns and calluses form after repeated rubbing against a bony area of the foot or against a shoe. Corns appear on the tops and sides of your toes as well as between your toes. Calluses form on the bottom of the foot, especially under the heels or balls, and on the sides of toes. These compressed patches of dead skin cells can be hard and painful. To relieve the pain, you may want to try placing moleskin or padding around corns and calluses. Don’t try to cut or remove corns and calluses yourself — see a podiatrist for care.

Foot Problems: Plantar Fasciitis and Heel Spurs
It’s common for doctors to confuse heel spurs and plantar fasciitis when a patient comes to them with heel pain. Heel spurs are found in 70 percent of patients with plantar fasciitis, but these are two different conditions. Plantar fasciitis is a painful disorder in which the tissue that connects the ball of the foot to the heel – the fascia – becomes inflamed. Heel spurs are pieces of bone that grow at the heel bone base and often develop after you’ve had plantar fasciitis. The heel spurs themselves are not painful; it’s the inflammation and irritation caused by plantar fasciitis that can hurt. Heel spurs are often seen on X-rays of patients who do not have heel pain or plantar fasciitis.

Foot Problems: Claw Toes and Mallet Toes
Claw toe causes all toes except the big toe to curl downward at the middle of the joints and curl up at the joints where the toes and the foot meet. Calluses and corns may often form when someone has claw toes. While tight shoes can be blamed for claw toes, so can nerve damage to the feet (from diabetes or other conditions), which weakens foot muscles.

With mallet toes, the last joint of the toe bulges, and a painful corn will grow near the toenail. Generally the second toe is affected because it’s the longest. Injuries and arthritis are among the causes of mallet toe.

Foot Problems: Gout
Gout is a type of arthritis caused by a build-up of uric acid in joint tissues and joint fluid, which happens when the body is unable to keep uric acid levels in check. One of the first places for this build-up to occur is in the big toe joint — temperature-wise, the toes are the body’s coolest parts, and uric acid crystallizes with temperature changes. You’ll know a gout attack when it happens: The toe will get warm, red, and swollen and will be painful to even the slightest touch. The best way to prevent a gout attack is to learn to identify triggers, including high-purine foods, red meat, seafood, and alcohol. Applying ice, keeping hydrated, and staying bed may help, too.

Foot Problems: Ingrown Toenails
The right way to clip toenails — straight across — is key to foot health. If you don’t cut them properly, the corners or sides of the nail can dig into skin and become ingrown. Other causes of ingrown toenails include shoe pressure, a fungus infection, and even poor foot structure. When you cut your toenails, use larger toenail clippers and avoid cutting nails to short, as this can also cause ingrown toenails or infection.

Foot Problems: Toenail Fungus
Toenail fungus can give nails an unattractive, deformed appearance. It can alter the nail’s color and spread to other nails, even fingernails. Avoiding toenail fungus is difficult, especially if you walk through wet areas where people tend to go barefoot, such as locker rooms and swimming pools. People with chronic conditions, such as diabetes or immune deficiency diseases like HIV, are especially vulnerable and may want to keep their shoes on.

Shin Pain While Walking

Q: I love walking, but when I walk at a fast pace my shins really start to hurt. What can I do to stop the pain?

A: First, make sure your walking shoes have good arch support, since shin splints often happen because of a fallen arch or flat feet. Also, try to avoid walking hills until you've walked on a flat surface for at least five minutes. This will warm up your shins so they don't become overstressed.

If you want to strengthen your shins, here's an easy towel exercise you can do! Sit in a chair, your feet bare, and place a rolled-up towel just in front of your toes. Grab the towel between your toes and your forefeet and unroll it, flexing the arches of your feet at the same time. Try to do this for 15 to 30 seconds every other day. It will help you keep up the good work and stay fit.

Is Stress Raising My Blood Sugar?

Q: I have a really stressful job. I find that when I test my blood sugar at work or in the evening after work that my levels are markedly higher than on the days I don't work. I take my food to work with me, so my diet doesn't change from day to day. Is it the stress that is boosting my levels?

A: Is your physical activity level also the same during both times? If not, the difference may be simply because you are burning more calories during your off-work days. But if your diet and activities are similar during your on- and off-work days, it is possible that occupational stress is the cause of your higher sugar levels. Psychological stress from a demanding job or other life situations has been implicated in high glucose levels in otherwise healthy individuals. This is true especially among those who have limited social support or who have little authority to make changes at their job.

We are also learning that in people with diabetes, stress complicates glucose control. The mechanism for this is twofold. First, some individuals eat more while under stress, which then raises their sugar level. Second, during stressful times the body produces hormones as a survival mechanism to ensure that there is enough energy to respond to the particular stressor. These hormones facilitate the breakdown of stored fat and glycogen. In this process, glycogen is converted into glucose, increasing its concentration in the blood. These hormones also affect blood pressure, heart rate, and the immune system.

Stress reduction is one of the key elements of diabetes management. Unfortunately, there is no specific method that works for everyone. I recommend consulting your doctor or a psychologist to find what works for you.

Wardrobe Malfunctions: Are Your Clothes Causing You Pain?

From skinny jeans to sky-high stilettos, your clothing, shoes, and accessories may be a source of chronic pain that no amount of style will alleviate.

What's causing your chronic pain? Turns out, it could be your wardrobe.

A number of chronic pain issues can be traced to what you wear. The problem is most common in women — a whopping 88 percent wear shoes that are too small for them — but men can be fashion pain victims too. Among the high-style culprits are ultratight skinny jeans and mega pursesthat border on suitcase size. We've scoured the racks for some of the common clothing choices that cause chronic pain – and we've researched some painless alternatives.

Toe Pressure: High Heels and Pointy Shoes
Stilettos and other dramatic styles may be fashionable, but they are waging war on your feet on a daily basis, says Neil M. Scheffler, MD, a podiatrist at Sinai Hospital in Baltimore, Md. The result can ultimately be chronic pain. “High heels place the foot in a ‘toe-down’ position with the heel up, which puts a great deal of pressure on the front of the foot, mainly on the metatarsal bones,” he says. This creates short-term discomfort and can lead to long-term pain and other problems. “With continued wearing of high heels, the Achilles tendon shortens, creating an imbalance that can lead to foot deformities as well as postural symptoms.”

Flimsy Support: Flip-Flops and Flats
Considering the problem with high heels, you might think that wearing flip-flops or other flats would be the proper course of action for pain management, but these styles can cause pain in other ways. “Because flip-flops have no support for the foot, mechanical disorders are exaggerated,” says Dr. Scheffler. “Flip-flops are notorious for causing heel and arch pain called plantar fasciitis.” Instead, Scheffler suggests wearing running shoes. “I explain to my patients that to run 26-plus miles in a marathon, you need a great shoe,” he says. “Why not use this technology for everyday footwear?” Running shoes are supportive, give great cushioning, have adequate toe room, and are often available in varying widths, he adds.

Excess Baggage: Heavy Purses and Bags
Chiropracter Brett Winchester, an instructor at Logan College of Chiropractic in Chesterfield, Mo., has noticed a dangerous trend when it comes to women’s handbags and chronic pain. “With larger purses, many women are tempted to carry more items, which adds stress to the neck and shoulder areas,” he says. “We recommend a reasonably sized purse that can be draped across the shoulders and allows the arms to swing freely for walking.” For pain management or prevention, center the weight of the purse in the middle of your back or chest to balance your center of gravity.

Sciatica in Your Pocket: Men's Wallets
If you’re a man looking for easy pain treatment, simply take your wallet out of your back pocket whenever you are sitting, says Dr. Winchester. Sitting on your wallet creates a two-fold pain problem. “First, the wallet can put direct pressure on the sciatic nerve,” he says. “Second, it can create a pelvic unleveling, which can prompts imbalances throughout the body. Such problems can become prevalent among men who commute for long periods of time.”

Too Tight: Skinny Jeans
You may think you look good in stylish clothing choices like skinny jeans, miniskirts, and other tight clothing, but you might not like the long-term chronic pain that can result from wearing them. “There are reported cases of these jeans causing a nerve disorder called lateral femoral cutaneous nerve entrapment, though this would be considered rare,” says Winchester. “Other issues these jeans can create include the lack of hip extension. In human gait the hip is designed to have a certain amount of extension and flexion.” Skinny, tight jeans can hamper this motion, which can create pain problems in the lower back.

Unfit for the Job: Bras
Women can do themselves a favor when it comes to pain management or, better yet, prevention, by simply taking the time to find a bra that fits them well. Winchester says bras that fit poorly can create chronic pain problems in several ways. “Ill-fitting bras cause deep grooves in the shoulder area and can rub on the lower part of the rib cage,” he explains. “Most noticeably, an ill-fitting bra can also affect cosmetic appearance and everyday activities.” The pain management solution is simple: “Buying bras is like buying shoes,” says Winchester. “They must be tried on in the store first before purchasing. Specialty stores that only sell bras are usually great places to make an informed purchase.”

Vein Surgery For Younger-Looking Legs

Unsightly veins can make your legs look older and make you feel self-conscious, but leg vein surgery and other treatment options can help.

If you have varicose veins or spider veins in your legs, you’re not alone. It is estimated that more than half of American women and one-third of American men have leg vein problems.

These issues can make you feel insecure about exposing your legs, since they can make your legs appear unsightly and older. Fortunately, there are a number of treatments that can remove or improve the appearance of leg vein problems.

Treatment Options for Leg Vein Problems

In most cases, leg vein conditions are not dangerous, so most people choose to treat varicose and spider veins for cosmetic reasons. But in some cases leg vein problems need to be treated, possibly with vein surgery, because they can lead to blood clots, sores, skin ulcers, or painful irritation in the legs.

Whether your want to treat your leg veins for cosmetic or medical reasons, your treatment options include:

Sclerotherapy. Sclerotherapy is the most common treatment for leg vein problems. In this procedure, a doctor injects a solution into the vein that causes it to collapse; this stops the flow of blood and causes the vein to fade. Sclerotherapy can be performed without anesthesia in a doctor's office, and you can return to your normal activities immediately after the treatment. You may need multiple treatments to achieve desired results. Side effects of sclerotherapy may include pain, redness, sores, or bruising around the injection site; spots, brown lines, or tiny red blood vessels around the treated vein; and bulges of clotted blood in the treated vein. According to the American Society of Plastic Surgeons (ASPS), each session of sclerotherapy

Laser surgery. Laser surgery can be used to treat spider veins that are 3 millimeters in size or less. This procedure involves targeting lasers at spider veins so they will slowly fade and disappear. Laser vein surgery is non-invasive, and you will be able to return to your normal routine immediately. But it can take two to five treatments to completely remove spider veins, and the heat from the laser can be painful. Possible side effects include temporary redness or swelling around the treated area, temporary discoloration on skin that may last one to two months, and burns from the laser. According to the ASPS, laser vein surgery costs an average of $400 per session.

Endovenous leg vein treatment. Endovenous radiofrequency and laser treatment involves placing a small tube into a larger varicose vein and sending radiofrequency or laser energy into the vein, causing it to shrink. Like sclerotherapy and laser surgery, endovenous treatments can usually be performed in the doctor's office and you can return to your normal activities immediately. In some cases, endovenous treatment can lead to slight bruising. An endovenous treatment generally costs $2,000to $3,000 and may be covered by insurance if deemed medically necessary.

Vein surgery. In some cases of severe varicose veins, a surgery known as surgical ligation and stripping may be necessary. This procedure requires anesthesia and has to be performed in an operating room. Your surgeon will tie affected veins closed and completely remove them from your leg. The risks of vein surgery include reactions to anesthesia, bleeding, blood clots, wound infection, scarring, nerve damage, and pain that may last up to four weeks after surgery. Vein surgery is significantly more expensive than non-surgical treatments, but may be covered by medical insurance if your leg veins are affecting your health.

If you’re concerned about varicose or spider veins in your legs, talk with your doctor. He or she can take X-rays and ultrasound images of your veins to further diagnose your condition, and refer you to a doctor who specializes in vein diseases, if necessary.

Night splint treatment of plantar fasciitis pain

Both the traditional adjustable night splint and a dorsal night splint improved plantar fasciitis pain in a retrospective study, with results trending in favor of the dorsal design, which provides less stretch but may improve patient compliance.

Plantar fasciitis is a common cause of subcalcaneal heel pain. It is a condition that affects about 10% of the population at some time during life and accounts for one million orthopedic outpatient visits annually.1,2 In approximately 85% of patients, the etiology is undetermined, but associations with obesity3 and limited ankle dorsiflexion of less than 10° have been reported as significant independent risk factors.4

Plantar fasciitis is typically characterized by pain and tenderness predominantly over the medial calcaneal tuberosity, which can ultimately limit physical activity. Symptoms are frequently reported to be worse in the morning as it is thought that the plantar fascia stiffens overnight, losing its ability to stretch optimally and eventually triggering pain.5 Unrelenting or nocturnal pain is an indication that the pain may be related to a different condition (e.g., tumor, infection, inflammatory arthropathy),6 while bilateral involvement should raise suspicions of a systemic disease.7

The treatment of plantar fasciitis aims at affecting the anatomical, biochemical, and environmental factors that may contribute to the development of the condition. Conservative treatment can be effective, as demonstrated in the literature, and is the initial treatment of choice.8, 9 Treatments should address any gastrocnemius-soleus complex tightness through stretching and an eccentric-based strengthening program.10 The associated inflammatory process should be a less important focus, as nonsteroidal anti-inflammatory drugs and steroid injections have failed to show long-term benefits.11 It is believed that night splints act to place the ankle in anatomical position such that nocturnal contractures of the gastrocnemius-soleus complex is reduced and further tension on the complex, which is thought to be unfavorable to plantar fascial healing, is avoided.12 This can be performed with a traditional adjustable night splint or more recently, with dorsal night splinting.

Previous studies have compared various methods of conservative treatment of plantar fasciitis against one another, but to our knowledge there is no study comparing the treatment of plantar fasciitis between two different types of night splints in the peer reviewed literature. In this retrospective study we sought to determine the clinical benefit of applying a dorsal night splint and to compare it to an adjustable night splint in treating plantar fasciitis.

Methods

Records of patients who were treated for plantar fasciitis with either dorsal night splints or adjustable night splints between September 2006 and August 2008 were retrospectively reviewed after obtaining IRB approval. The diagnosis of plantar fasciitis and determination of pre- and post-treatment scores on the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale were established through a consistent method of history, physical exam, and radiographs by the senior author during clinic visits with 170 patients during this time frame. All patients were randomized by entry into practice—patients received the dorsal night splint based on entry into the clinic during the first year and the traditional adjustable splint for entry during the second year of the study. From September 2006 to August 2007, all patients diagnosed with plantar fasciitis by the senior author were placed in a dorsal night splint, enrolled in physical therapy, and given silastic heel cups.

From September 2007 to August 2008, all patients diagnosed with plantar fasciitis by the senior author were placed in a traditional adjustable night splint, enrolled in physical therapy, and given silastic heel cups. All patients in both study groups were given the same prescription for formal and home-based eccentric Achilles exercises and stretching, as well as massage, iontophoresis, and ultrasound. No orthotics or corticosteroid injections were given.

Patients’ records were reviewed for the date of onset of splint treatment and the date symptoms resolved, the side on which the splint was used (right or left foot), age and gender of the patient, and the presence of a calcaneal stress fracture. Patients with a calcaneal fracture were excluded (41 patients), as were patients with metatarsal stress fractures and all other patients with other unrelated or concomitant foot diagnoses. Patients with partially locked records as established by university rules and regulations were also excluded (four patients).

The traditional adjustable night splint used in this study has adjustable flexion straps and adjusts from 10° to 90° of dorsiflexion (Figure 1a). The dorsal night splint has a rigid support on the dorsum of the foot and ankle (Figure 1b), but does not provide the same range of adjustable dorsiflexion as the traditional night splint, instead ranging from neutral to 5° of dorsiflexion. Although the dorsal night splint does not provide as much of a stretch as an adjustable device, the dorsal design is thought to be more comfortable, which could improve patient compliance.

Results

Of the 170 patient records reviewed, 125 were analyzed after excluding the patients with calcaneal stress fractures and partially locked records. The average patient age was 51.3 years. Of the 125 patients, 79 were male (63.2%) and 46 female (36.8%). Eighty-seven used adjustable night splints (69.6%) and 38 used dorsal night splints (30.4%). Two patients had metatarsal stress fractures (Table 1).

The average age of patients who used the traditional adjustable night splints was 49.5 years, while the average age of patients who used dorsal night splints was 55.6 years (p= 0.021, two-sample t-test). Of the patients who used dorsal night splints, 44.7% were male (n=17), and 55.3% were female (n=21). Of the patients who used traditional adjustable night splints, 33.3% were male (n=29), and 66.6% were female (n=58). Of the patients who used dorsal night splints, 47.4% were treated on the left foot (n=18), and 52.6% were treated on the right foot (n=20). Of the patients who used traditional adjustable night splints, 42.5% were treated on the left foot (n=37), and 57.5% were treated on the right foot (n=50). There were no statistically significant differences in gender or side between the dorsal night splint group and the adjustable night splint group (Table 2).

The overall average pre-treatment AOFAS hindfoot score was 77.3 out of a possible 100 points and average post-treatment AOFAS hindfoot score was 91.2 (average score change was 13.9). The average time for resolution of symptoms was 119.5 days (Table 3). The average increase in AOFAS score from initial treatment to post treatment was 12.5 when using an adjustable night splint compared with 17.1 when using a dorsal night splint. Controlling for age, this change was not found to be statistically significant (p= 0.146, ANOVA). The average time taken until symptoms resolved using an adjustable night splint was 118.6 days (median 84 days) compared with 108.3 days (median 49 days) in patients who used a dorsal night splint, a difference that was not statistically significant (p = 0.260, ANOVA model, log transformation on time to resolution).

Discussion

The plantar fascia is a thickened fibrous aponeurosis that originates from the medial and lateral tubercles of the calcaneus and runs forward into the proximal phalanges to form the longitudinal foot arch. The function of the plantar fascia is to provide static support of the longitudinal arch and dynamic shock absorption. Plantar fasciitis is considered a self-limited condition, with symptoms resolving in 80% to 90% of cases within 10 months.8 The literature-based natural history of plantar fasciitis serves as a historical “control” group to which this study’s splinting techniques are compared.

In most cases, plantar fasciitis will respond to multiple modalities of conservative measures.11 In one long term follow up study, investigators found that 80% of patients treated conservatively for plantar fasciitis had complete resolution of pain after four years.8 If it is left untreated, it may lead to further calcification of the plantar calcaneal tuberosity where the plantar fascia and intrinsic muscles are attached, which leads to a condition known as “heel spur syndrome.” This condition induces greater pain than plantar fasciitis and is difficult to treat.5 Common predisposing factors for plantar fasciitis include obesity, female gender, middle age and excessive pronation, which can lead to fascial damage and secondary gastrocnemius-soleus contracture as well as contracture of the intrinsic muscles, especially the flexor digitorum brevis. The primary goal of treatment should be to place the fascia at proper length to heal during both weightbearing and nonweightbearing activities.

In a previous study, night splints were cited as the best treatment by approximately one third of the patients with plantar fasciitis.11 Night splints usually are designed to keep a person’s ankle in a neutral or slightly dorsiflexed position overnight. Most individuals naturally sleep with the feet plantar-flexed. Bedding on the dorsal aspect of the foot further accentuates this position through the five to eight hours per night that an individual sleeps. This causes the plantar fascia to remain in a foreshortened position. Theoretically, night splints should resist secondary nighttime contraction of the gastrocnemius-soleus complex and intrinsic musculature, as well as gravitational forces, which act to place the fascia in a shortened position. This is accomplished by placing the foot at 90° to the ankle and applying mild dorsiflexion to the digits to utilize the pulley properties of the plantar fascia. Maintaining the proper length of the plantar fascia during the healing period prevents the fascia from healing in a shortened position, which could cause further pain while weightbearing.

Wapner and Sharkey recommended 5° of dorsiflexion in the night splint and reported improvement, based on physical examination in 11 of 14 patients (79%).12 The results of a prospective crossover study of 37 patients by Powell et al also support the efficacy of night splints, with 88% of their patients reporting improvement in symptoms after one month of treatment based scores on the AOFAS Ankle-Hindfoot Rating System and the Mayo Clinical Scoring System.2 In contrast, Probe et al found no statistically significant benefit in adding traditional night splinting to a standard nonsurgical protocol of anti-inflammatory medication and stretching in a prospective randomized study of 116 patients based on scores from the SF-36 (Short Form Health Survey). In our study there was an average AOFAS score change of 13.9 and an average time to resolution of pain of 119.5 days. We believe our data is in the range of what has been published. In a prospective evaluation of posterior (adjustable) night splinting of 33 patients, Batt et al noted an average time to resolution of pain of 87 days;8 Wapner and Sharkey reported resolution within four months.12

Our study shows a decreased time for resolution of symptoms in patients who used the dorsal night splints (median 49 days/ average 108.3 days) when compared with patients who used the adjustable night splints (median 84 days/ average 118.6 days). There was also a higher average increase in AOFAS scores in the patients who used dorsal night splints (17.1) compared with adjustable night splints (12.5).

Limitations of our study include the fact that a disproportionate percentage of patients fell into one treatment group, with 69.6% in the adjustable night splint treatment group and 30.4% in the dorsal night splint treatment group. This was a consequence of the randomization of patients entering the study per year. Another limitation is the inability to control for physical therapy compliance and exercise volume, though this is a standard challenge in most other relevant studies. Furthermore, the time patients actually spent in a splint overnight is unknown and could influence results. Although the results of this study were not significant, most prior studies of plantar fasciitis treatment do not have adequate power to detect a statistically significant treatment effect difference.14

Roos et al performed a prospective randomized trial comparing use of foot orthoses, foot orthoses and night splints, and night splints alone, concluding that foot orthoses and anterior night splints were effective for both short- and long term treatment of plantar fasciitis at 12 weeks and 52 weeks. The study did not reach statistical significance and called for further evaluation of treatment measures and direct comparisons of splint types.15 Our study reveals that there is a trend towards higher efficacy of dorsal night splints over adjustable night splints in the treatment of plantar fasciitis. Although the results of this study were not significant, we believe that follow up prospective randomized controlled studies with a larger cohort population may yield significant results in comparing outcome and efficacy of night splints.

By Selene G. Parekh, MD, MBA, Olubusola A. Brimmo, MD, Ryan May, BS, and Bret C. Peterson, MD.

Should I Be Concerned About Varicose Veins?

Q: I am 64 years old and have only recently started developing varicose veins in my legs. I'm using compression stockings, but they're uncomfortable during the warm months. What other options do I have to deal with them? Aside from the increased risk of a blood clot, do they pose any serious health risks? Will the varicose veins start to look worse as I get older?

— Tania-- Wichita, KS

A:

Varicose veins can be very unpleasant, particularly from a cosmetic point of view. These enlarged and tortuous veins usually show up in the legs; they are subject to high pressure when you’re upright and therefore likely to be uncomfortable and perhaps even painful while you're standing or walking. Varicose veins can also sometimes itch, and scratching them can cause ulcers. Ulcers that infect your veins can lead to blood clots — this is a condition known as superficial thrombophlebitis and is usually isolated to superficial veins. In rare cases, these blood clots can extend into deep veins, becoming a more serious problem. Still, varicose veins very rarely bring on serious complications. More than anything else, they are considered to be a cosmetic problem, which, unfortunately, can worsen as you grow older.

One of the options you might wish to consider to reduce the appearance of your varicose veins is surgical intervention. Vein stripping is one particular surgical treatment that can help. There are also newer, less-invasive treatments such as ultrasound-guided foam sclerotherapy, radiofrequency ablation, and endovenous laser treatment, each of which has its own pros and cons. Nonsurgical treatment options include elastic stockings, elevating the legs, and exercise.

Learn more WWW.CKPA.NET .

Doctors amputate frostbitten feet of Alaska runner

ANCHORAGE, Alaska (AP) — An All-American distance runner who spent more than two days in freezing winter temperatures without winter gear has had his legs amputated just above the ankles.

Marko Cheseto, 28, is one of several Kenyan runners who competed for the University of Alaska Anchorage in cross-country and track. The amputations were reported Monday on the UAA Athletic Department website.

Cheseto was seen at about 7 p.m. in a UAA building on Nov. 6, a Sunday night, as two snow storms started to blanket the city. His roommates reported him missing the next morning. The disappearance prompted a citywide search.

Cheseto was found early the following Wednesday outside a hotel near the campus. He was wearing athletic shoes, a jacket and blue jeans but no hat or gloves. He was suffering from hypothermia and severe frostbite on his feet and hands.

The hotel manager told the Anchorage Daily News when Cheseto was found, paramedics could not remove the runner's shoes because they were frozen to his feet.

UAA officials said Cheseto's hands are expected to make a full recovery but his lower extremities were severely injured and required amputation. He is expected to remain hospitalized for recovery and rehabilitation, UAA officials said.

University of Alaska Anchorage police interviewed Cheseto after he was found and reported he had suffered a "personal crisis" when he disappeared. Authorities concluded he had spent the entire time outside.

In a statement on the athletic department website, Cheseto thanked volunteers and professionals who searched for him.

"As some may know, I've been going through a lot of personal issues," he said. "While I am still recovering — both physically and emotionally — I will do my very best to give back to the community that has helped me so much and to my home country, Kenya. I sincerely apologize for any problems that I may have caused."

Cheseto left the campus one day after accompanying the UAA cross-country team to the NCAA Division II West Region championships in Spokane, Wash.

Cheseto had won the West Region championship the two previous seasons. Cheseto had used his final season of cross-country eligibility but was expected to compete in spring track. He took last season off following the suicide of teammate William Ritekwiang, who also was from Kenya.

Cheseto was studying for a nursing degree at the school.

Athletic Director Steve Cobb said the university will continue to support Cheseto.

"We take our responsibility and commitment to the student-athletes entrusted to our care very seriously," he said on the athletic department website. "It was meaningful that our community was there for us in our time of need and we are sincerely appreciative of everyone's efforts."

How to Wear High Heels Without Pain

Discover the "healthy" way to wear heels. Plus, our favorite pairs for the holiday season.

The Best "Healthy" High Heels for the HolidaysThat pain that you feel at the end of a long night—no, it's not a hangover and it's not exhaustion. We're talking about something worse—the pain that's caused by a seemingly evil and malicious pair of high heels. But, believe it or not, not all high heels are created equal. In some cases, they can actually be healthier for your feet than flats. "Excess pronation is a condition that affects 75 percent of the population and has been related to many conditions, such as heel pain (otherwise known as plantar fasciitis), knee pain, and even lower-back pain," says podiatrist Phillip Vasyli.

In this case, doctors actually recommend wearing shoes with a slight heel, as opposed to our trusty flats. "The popular trend of ballet flats has caused us to see an increase in many of the aforementioned conditions due to a lack of overall support and flimsy shoe construction," Vasyli says.

Generally, there are a few things to look for when you're shopping for stilettos. First, make sure the heels are of moderate proportions, not the towering Lady GaGa variety. Save those for dinners out, where you'll be sitting for most of the evening.

Vasyli recommends opting for well-constructed "quality" shoes, especially those that have shock absorbing materials in the ball of the foot, and using an insert like Orthaheel, which he invented. He also suggests wearing your highest heels for only short periods at a time and giving them a little bit of closet time now and then."If you feel the need to wear higher-heeled shoes daily, then take a more comfortable shoe to get to and from work and wear the higher shoes while you're sitting at your desk," he adds.

Also, while you're having a ball, be conscious of the weight that's being distributed onto the ball of your foot. "The higher the heel, the more the shoe increases the arch height and also changes the 'arch position'," Vasyli says. He suggests looking for shoes that "contour" to your arch and distribute your weight over the entire foot, not just the ball of the foot.

By Jené Luciani

5 Lies You Shouldn't Tell Your Doctor

There isn't a lot your body can hide in one of those crinkly numbers. Maybe that's why so many women refuse to reveal much else at doctor visits. About a third of men and women in the United States admit to lying to their M.D.'s, according to a 2010 survey. But keeping secrets can be dangerous, especially if the information you're withholding leads to a wrong diagnosis. Besides, "a doctor's job is to advocate for your health, not judge," say Gary Fischer, M.D., a general internist at the University of Pittsburgh Medical Center. Here's why it's time to tell the whole truth -- and nothing but.

"I never smoke."

The real deal: Jean Thilmany has been lighting up a couple of times a month for the past 20 years. But because the 42-year-old Saint Paul resident doesn't consider herself a smoker, she never mentions it to her doctor. "I don't smoke often enough for it to affect my health," she says. Actually, if you puff even the occasional cigarette at happy hour, your doctor needs to know. Yes, cancer is a concern, but equally important, those smokes affect your circulation and increase your risk for blood clots.

"Nothing has changed since my last visit."

The real deal: Really? When your doctor asks "What's new?" she doesn't mean only medically. Whether you're in a tense relationship or fretting about work woes or money matters, chronic stress can trigger high blood pressure, migraines, tummy troubles and heart palpitations, Dr. Fischer says. "The stress hormone cortisol throws other hormones, like estrogen and progesterone, out of kilter," says Jerilynn Prior, M.D., director of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia. This does more than mess with your period: Estrogen helps prevent bone loss, and progesterone aids bone growth.

The good news: Although prolonged periods of stress can have serious health consequences, there is a lot you can do. Talk to your physician; she can suggest stress busters, like relaxation exercises and yoga. In some cases she may recommend that you speak to a mental health professional who can help you work through your problems.

"I'm not taking anything."

The real deal: More than 50 percent of Americans take supplements, according to the Centers for Disease Control and Prevention. The few natural remedies that you use may not seem noteworthy to you, but they are to your physicians. "A decade ago many women took Saint-John's-wort for PMS only to learn that it can make birth control pills less effective," says FITNESS advisory board member Mark Moyad, M.D., director of preventive and alternative medicine at the University of Michigan Medical Center. And that's not the only interaction your physician wants to watch out for. Using ginseng with antidepressants puts you at risk for serotonin syndrome, a potentially fatal condition that causes diarrhea, fever and seizures. Because fish oil can thin the blood, you should stop taking it a week before dental work or surgery and don't combine it with another blood thinner, like aspirin, without checking with your doctor. Too much vitamin D can cause kidney stones, while too much vitamin C can cause heartburn. So make a list of the pills you pop, including vitamins, supplements and meds (OTC and prescription), and bring it with you to your appointment.

"I feel fine."

The real deal: About one in eight women struggle with depression at some time, but recognizing that you need help isn't easy. Twice as many women as men are affected. In addition to having persistent feelings of sadness, guilt, hopelessness and irritability, depressed women may gain or lose weight. "Tell your physician about any significant changes in your mood, thinking or behavior that affect your ability to function at home, at work or with your friends," says David Fassler, M.D., clinical professor of psychiatry at the University of Vermont College of Medicine in Burlington. She'll probably rule out other potential causes, such as viruses, thyroid disorders and medication side effects, and then conduct a psychological evaluation herself or refer you to a mental health expert. The happy news is that there are many treatment options, including psychotherapy and antidepressants.

"I eat a healthy diet."

The real deal: After three days of swigging nothing but a concoction of lemon juice, maple syrup and cayenne pepper, Catherine Howe Bryant, 32, felt light-headed, lethargic and, not surprisingly, famished. "I dropped a few pounds, but I felt awful," admits the Winston-Salem resident. Still, Bryant does a liquid cleanse whenever she wants to "feel better" about her body. She's never told her doctor. What she and other women don't realize is that extreme diets can do real damage. "When your body doesn't get the protein it needs to generate new cells and tissue, it starts to burn muscle tissue, including the heart's cardiac muscle," says Arthur Frank, M.D., medical director of the George Washington University Weight Management Program in Washington, D.C. This can lead to heart palpitations, arrhythmias and many other cardiac problems. Putting yourself into starvation mode slows your metabolism in the short term and ultimately makes it difficult to maintain weight loss.

Whether you're trying to slim down for a beach vacay or training for a race, clue your doc in. She can help you devise a sensible plan and refer you to a nutritionist for a dietary tune-up that's safer than a detox or cleanse.

Vitamin D: Who Should Take a Supplement

Vitamin D provides a wide range of health benefits. It is effective in preventing rickets and treating other bone diseases such as osteoporosis. According to the Mayo Clinic, getting enough vitamin D may prevent high blood pressure and protect against certain types of cancer. It may also promote weight loss for women. A growing body of research links heart health to sufficient vitamin D. Most recently, a large-scale study in the American Journal of Cardiology discovered that boosting vitamin D levels in heart patients who were deficient cut their risk of death by 60%, among other significant findings.

Getting enough vitamin D

It's estimated that 30-50% of Americans suffer from vitamin D deficiency. The human body produces vitamin D, which is actually a hormone, when exposed to sunlight. However, during the winter, it is impossible to get enough exposure anywhere north of San Francisco or Philadelphia. People in southern states who slather on sun block or who stay indoors most of the time may not be getting enough either. The same goes for people who are housebound due to illness or whose work keeps them inside all day. In addition to lack of sunshine, other conditions may increase likelihood of vitamin D deficiency:

Infants who are exclusively breastfed. Mother's milk may not provide sufficient levels. The American Academy of Pediatrics recommends a supplement of 400 IU per day.

Older adults. The elderly do not synthesize vitamin D as effectively as younger people and tend to spend more time indoors.

People with dark skin. The pigment melanin can reduce the body's ability to produce vitamin D from sunlight.

Obese people. Body fat alters the way vitamin D is released into the system.

Choosing a vitamin D supplement

If you are shopping for a supplement, research suggests that vitamin D3 is more effective than vitamin D2. Food sources rich in vitamin D include cod liver oil, fatty fish (such as mackerel), eggs, and fortified milk and orange juice.

There is some debate over how much vitamin D to take. The National Institutes of Health recommends 600 IU per day for adults but some experts say that taking a supplement that contains between 1000-2000 IU can be beneficial. Its important to stay within the appropriate range--there is a toxicity risk at over 10,000 IU. The best way to determine how much you might need is to have your physician administer a simple blood test and make a recommendation based on the current level in you system.

Higher heels linked to increase in foot problems

St. Louis (KSDK) -- Your high heels may be doing more harm than you think.

Doctors say they're seeing more and more women coming in with foot problems because the high heel heights are soaring and there seems to be less support in some of those shoes.

Ten or 15 years ago, the problems were a lot easier to fix, but now doctors say women are set on wearing higher heel, so they're doing a lot more long term damage.

"The higher the heels the worse the problems," said Dr. Rick Lehman, an orthopedic surgeon. "As these new shoes come out the incidents of foot problems have gone through the roof."

Dr. Lehman said the high heels can cause bunions, plantar fasciitis and achilles tendon problems.

Dr. Lehman says if you're going to wear high heels, make sure to stretch your feet, wear a wide enough shoe and give your feet a break if they start to hurt.

Neuropathy diminishes pain, sensations in feet

The condition is caused by poor blood-glucose control associated with diabetes

Dealing with neuropathy

• Keep blood glucose levels in your target range.

• If you have problems, get treatment immediately.

• Check your feet every day. If you can’t feel pain, you might not notice an injury.

• If your feet are dry, use a lotion on your skin but not between your toes.

• Wear well-fitting shoes and socks.

• Use warm water to wash your feet, and dry them carefully.

• Get special shoes, if needed. If you have foot problems, Medicare may pay for shoes.

• Be careful with exercising. Talk with a diabetes clinical exercise expert.

Source: American Diabetes Association, www.diabetes.org


It’s a very uncomfortable situation: the loss of sensation on your feet.

Not being able to feel whether the ground is hot or cold, or whether your shoes don’t fit right. Or worse, not noticing the damage you could be causing to your feet.

“When you realize you’ve lost pain, you are in trouble,” says Dr. Andrew Boulton, professor of medicine in the division of endocrinology, diabetes and metabolism of the University of Miami Miller School of Medicine.

Boulton has witnessed the consequences of not feeling pain.

The patient who walked around without noticing he had a nail through his shoe. Another one who took a stroll on the beach not realizing the hole slowly carved on his foot by the hot sand. Or the man who felt asleep near a chimney and woke up to the smell of something burning — his feet.

Boulton is an expert on neuropathy, a disease prompted by poor glucose control, among other factors. The condition causes nerve damage, impairing feeling in the foot.

Neuropathy acts similarly to an electrical circuit being disrupted. The nerves send messages to your brain about heat, cold, touch and pain. Nerves communicate how and when to move your muscles, and also have control over systems like sweat glands or digestive functions. So when these nerves are damaged, communication stops.

It’s important to take steps to prevent foot injuries, Boulton says.

“Use your eyes and look where you are walking,” he says. “All this is preventable. This doesn’t need to happen if you look after your feet.”

This is important advice since diabetes is the most common cause of foot ulcers, says Dr. Robert Kirsner, professor of dermatology at the University of Miami Miller School of Medicine.

“Because patients don’t have sensation, they may not have any symptoms,” Kirsner says. “That’s why it’s critical that patients with diabetes examine their feet regularly, and when they go to their physician, their feet get examined.’’

Ulcers or foot wounds can cause serious problems if they don’t heal because, in worst cases, this increases the chances of amputation.

“If we can heal the ulcer faster and better, those complications can be diminished,” he says. Eliot Prince, a patient of Kirsner, is well aware of the importance of looking after your feet.

The 47-year-old Miami native credits Kirsner for saving the toes on his left foot. About seven years ago Prince, who had been diagnosed with diabetes in 1992, had noticed that two toes on his left foot were darkening and had started to swell.

He went to Nassau, hoping that the salty waters of the island would heal his foot. He was putting his socks on when his hand slipped, removing some of the skin. He flew back to Miami the next day. At the hospital he was told it could be gangrene and that his two toes might have to be cut off.

“I didn’t have gangrene but if you would have seen them you’d thought I had gangrene because my toes were black.”

He wanted a second opinion, and a friend told him about Kirsner.

“He cut off the skin, examined it. He knew what he was looking for,” Prince says. Kirsner told him that the wound was treatable and prescribed him a cream that eventually healed his foot.

People with neuropathy can also develop ulcers. They have to wear special shoes to remove pressure from the wound, Kirsner explains.

“That’s the most important thing with neuropathic foot ulcers, to remove pressure off the wound,” he says.

Special shoes or boots improve the way people walk by making them take fewer steps and shortening the length of their stride.

Another foot-related complication is excessive dryness, a sign that the sweat glands aren’t working properly. In those cases, special moisturizers are prescribed to help deal with the discomfort. When you have dry, cracked feet, you are more likely to get a fungus infection, Kirsner explains.

Fungus cause microscopic changes on the skin; it’s an opening that allows bacteria to come in and cause an infection.

“A fungal infection on a diabetic patient is more important than in other patients because infections on diabetic patients have more complications,” Kirsner adds.

By Douglas Rojas-Sosa

EXERCISE AND NEUROPATHY: Not mutually exclusive

A classic case of innovative research turning conventional wisdom on its head is changing the way clinicians approach exercise in patients with diabetic neuropathy.

For decades, patients with type 2 diabetes and peripheral neuropathy were cautioned against weight-bearing exercise out of fear that the accompanying stress on the foot would lead to plantar ulcers. Then, in 2003, scientists began to report surprising findings.

“Prior to those studies, the feeling was that weight-bearing exercise was too risky to recommend to patients who lacked sensation,” said Joseph LeMaster, MD, MPH. LeMaster, for many years an associate professor in the Department of Family and Community Medicine at the University of Missouri, will move to the University of Kansas this fall. “There was evidence that people with neuropathy had increased plantar pressures, and those were considered an independent risk factor for foot ulcers.”

In 2003, LeMaster and his colleagues published a study of 400 diabetes patients with a history of foot ulcers and found that increased weight-bearing activity didn’t increase the risk of reulceration. Moreover, the most active subjects saw the most significant risk reduction, and the effects were the same regardless of whether subjects retained foot sensation.1

That same year, researchers from Washington University in St. Louis reported in Clinical Biomechanics that diabetes patients with a history of plantar ulcers were 46% less active and accumulated 41% less daily stress on the forefoot than nondiabetic and diabetic control subjects without a history of such ulcers.2 At first, the finding seemed so counterintuitive that people weren’t sure what to make of it. The authors ultimately concluded, conservatively, that subjects with a history of plantar ulcers were susceptible to injury at relatively low levels of tissue stress.

These studies flung open the door to further investigations, however. In 2004, scientists confirmed in Diabetes Care that neuropathic patients who exercised more had lower rates of ulceration than those who were relatively sedentary.3 Two years after that, in 2006, researchers in Italy reported that, far from being deleterious, exercise could help prevent neuropathy’s onset or modify its natural history.4 Right on cue, then, in 2008, Washington University researchers reporting on the Feet First study noted that promoting weight-bearing activity did not lead to significant increases in foot ulcers.5 Finally, in 2010, the American Diabetes Association, together with the American College of Sports Medicine, acknowledged this accumulating body of evidence and published new guidelines that, for the first time, endorsed weight-bearing exercise for patients with diabetic neuropathy in the absence of foot ulcers.6

“The new guidelines represent a big change,” said Michael Mueller, PT, PhD, a professor of physical therapy at Washington University School of Medicine. “For the first time, people with diabetic neuropathy are explicitly encouraged to do weight-bearing exercise.”

Although this rhythmic chronology outlines what appears to be a straightforward investigation that changed medical practice, the story is more nuanced. A number of questions have bedeviled researchers, and continue to. For example, what’s the chicken and what’s the egg? That is, do people get more ulcers because they get less exercise, or do they exercise less because of their ulcer history? Or, for that matter, are other variables involved that no one yet understands? These and other issues, such as how to distinguish those at highest risk of ulceration from their peers and how to adjust exercise regimens accordingly for individual patients, are only now starting to become clear.

Foundations

Back in 2002, Mueller published a paper in Physical Therapy whose relevance to this issue was not immediately clear, but which turned out to have a big impact. In that article, he proposed a “Physical Stress Theory” (PST) of tissue adaptation, the premise of which was that changes in the relative level of physical stress cause a predictable adaptive response in biological tissues.7 In a nutshell, the theory suggests that tissues respond to stress in predictable ways: stress levels that are too low lead to reduced stress tolerance and atrophy; mid-level stress produces no change; moderately high levels increase tolerance; and too much stress leads to injury and tissue death. The goal for practitioners seeking to increase their patients’ strength and resilience was to identify the levels that increased tolerance and work carefully from there.

Mueller also made several points that affected later researchers:

1. Stress exposure is a composite value comprising magnitude, time, and direction of stress application.

2. Extreme deviations from the maintenance stress range have serious consequences.

3. Individual stresses combine in complex ways to contribute to the overall level of stress exposure, and tissues are affected by the history of recent stresses.

4. Excessive stress can arise due to a brief, high-magnitude stress; a long duration of low-magnitude stress; or a repetitive application of moderate stress.

5. Inflammation occurs immediately after injury, reduces the injured tissue’s stress tolerance, and requires that the tissue be protected from further stress until the inflammation subsides.

Many of these points turned out to be crucial to understanding how to manage diabetic neuropathy in the context of exercise.

Variability

The lead author of the 2004 study in Diabetes Care was David Armstrong, DPM, MD, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson. An important aspect of his team’s findings was not just that more active subjects were less prone to ulcers, but that variability in activity was an important predictor of ulcer risk. Eight of 100 patients with diabetic neuropathy ulcerated during the average evaluation period of 37 weeks, and although they were significantly less active than those who remained ulcer-free, there was also much more variability in their exercise levels, as measured by high-capacity computerized accelerometer/pedometers.

“People who had wide swings in activity were at greater risk,” Armstrong told LER. “An example would be someone who’s not very active, then suddenly remembers their grandkid’s birthday and leaps off the couch, runs to the car, then spends an hour and a half walking around the mall. They do more in a couple of hours than they usually do in two days.”

When Armstrong and his colleagues first evaluated their data, they were flummoxed.

“We sat there wondering what was going on,” he said.

Their conclusion, however, echoed Mueller’s observations about the importance of tissue stress levels and the consequences of extreme deviation in them.

“We believe what we’re seeing is that it’s just like a lot of other places in the body,” Armstrong explained. “If you don’t use it, you lose it. If skin is allowed to atrophy, then maybe it’s weaker than skin that’s getting tenderized, as it were, by frequent activity.”

Armstrong noted that patients must be monitored carefully, as they were in his study, and that exercise has to be optimized for the individual.

“People can’t run a marathon with profound neuropathy, but we’d like to try to train them so they could slowly become more active,” he said. “We want to dose activity the way you’d titrate a drug.”

As for the chicken-and-egg problem—which comes first, the ulcer or the lower activity levels?—researchers are continuing to probe the reasons first ulcers appear. Manish Bharara, PhD, a research assistant professor at SALSA and a colleague of Armstrong’s, speculated that overall control of blood glucose levels may affect the resilience of damaged tissues.

“In diabetes patients, metabolic control affects other aspects of physiology, and could affect the quality of the tissue that is regenerated as someone heals,” he said.

A couple of Armstrong’s earlier papers may shed light on the issue, as well. In a 2001 article in the Journal of the American Podiatric Medical Association, Armstrong and his colleagues noted that diabetic patients with a history of neuropathy or ulceration took more steps per day inside the home than outside, and that only 15% of them wore their prescribed footwear inside.8 A paper in Diabetes Care in 2003 reported that subjects with foot ulcers wore their off-loading devices for only a minority of steps taken each day.9 Noncompliance with preventive footwear or curative devices could conceivably be similar in effect to low activity levels, then, in that both are associated with ulceration and poor healing. One possible explanation is that, compared to high-activity patients, low-activity patients are taking significantly fewer steps per day in footwear designed to help their feet avoid injury or heal (activity studies have not consistently reported compliance data).

“It even turns out that sometimes just standing for long periods can be potentially dangerous,” Armstrong noted.10 “This is all about better identifying risk and helping us better coach activity. We’re trying to get people moving, and in a lot of ways, that’s how we measure success.”

Individual cases

The Feet First study made it clear that clinicians must carefully consider the patient’s history when prescribing exercise, according to lead author LeMaster.

“In that study, we felt that the exercise program, combined with the careful monitoring we conducted, showed that the benefits of exercise outweighed the risks,” he said. “But it’s quite another thing to say that people who have lots of recent foot ulcers should go out and do this. A good percentage of the people in the study had had prior ulcers, and we didn’t find that to be a predictor [of ulceration during the trial]. But we restricted people from walking if they had any breakdown during the study.”

People with a history of frequent and recurrent ulcers, he added, should be viewed in a different category than those included in the research. Furthermore, the study’s subjects had their feet examined weekly by a physical therapist for the first three months, and had a hotline to call if they showed signs of ulceration later.

Mike Mueller, a coauthor of the 2008 Feet First paper, likened the evolving view of exercise in those with neuropathy to a similar evolution in thinking about exercise in cardiac patients a few decades ago.

“There was a time when the prevailing opinion was that if you’d had a heart attack, you should not exert yourself,” Mueller said. “We came to learn that if you monitor the heart carefully and keep it within a safe range, exercise is beneficial. It’s similar with the neuropathic foot, although we’re still learning what the guidelines should be.”

Adjusting exercise programs to the individual based on variables such as ulcer history is still an emerging field, he noted, and based both on the evidence provided by research and on clinical experience.

“I believe that once you’ve had a full-thickness ulcer, you’re in a whole different category,” he said. “Even a mild one sends up a red flag that you’d better watch this person. There’s so much heterogeneity in the group of people who have diabetes and neuropathy that the program really needs to be tailored to the individual.”

Joint biomechanics

Part of the problem with such tailoring is that only recently has research begun to describe the relationship between biomechanics and diabetic neuropathy.

For example, a 2007 paper in the Journal of Applied Biomechanics found that diabetic subjects with neuropathy had stiffer ankles than diabetic subjects without neuropathy.11 It’s known that normal mobility allows the foot to flexibly dissipate impact, then become rigid during push-off.12 Restricted mobility in the foot and ankle joints, then, could hinder this transition and contribute to abnormal plantar loads.13

Citing such evidence, Smita Rao, PhD, an assistant professor of physical therapy at New York University, published a paper in 2006 outlining how changes in muscle could account for decreased range of motion (ROM) and increased stiffness in patients with diabetes.14 In a subsequent article in Gait & Posture, she and her colleagues reported that decreased sagittal motion of the first metatarsal and lateral forefoot and frontal motion of the calcaneus were key elements that could contribute to increased, sustained plantar loading in patients with diabetes and neuropathy.15

“There’s a big push to emphasize exercise in patients with diabetes and peripheral neuropathy, but those patients are also at higher risk for tissue breakdown, so I wanted to explore the mechanisms that put them at risk,” Rao told LER. “We showed in the Gait & Posture paper that a lot of these patients try to reduce the effects of their stiffness by walking slower and taking shorter steps. When I examine them, I want to look at ankle range of motion, all the mechanical factors that may affect tissue breakdown; but I also want to assess how they walk, find focal regions of high pressure, then put those two together to see if walking is the best activity for this person. Some might need protective footwear, and some should ride a stationary bike instead.”

In her current research, Rao and her colleagues at NYU are examining ways to bring a number of fields together.

“My grandfather had diabetes, so I have a personal connection to the field,” she said. “All these negative effects begin with high blood sugar, so we’re trying to combine medical, surgical, and rehabilitative interventions in patients with diabetes and neuropathy.”

Exercise and balance

Other research has looked at the importance of augmenting exercise with balance training, which has been shown to improve clinical balance measures in neuropathic patients.16 A study published in Diabetes Care in 2010 demonstrated, moreover, that six weeks of such training reduced the risk of falls in 16 older patients with type 2 diabetes and mild to moderate neuropathy.17 In that research, exercise sessions included a balance/posture component (lower-limb stretches and leg, abdominal, and lower-back exercises) and a resistance and strength-training component using machines. The regimen led to better reaction times and affected sensory, motor, and cognitive processes, leading to a significant decline in risk of falls.

Lead author Steven Morrison, PhD, director of research in the School of Physical Therapy at Old Dominion University in Norfolk, VA, told LER that his group’s work was motivated partly by the fact that older diabetes patients’ risk of falling is 10 to 15 times that of healthy age-matched controls, which affects their confidence and ability to exercise.

“To be balanced, you need a certain amount of strength and a certain amount of coordination,” he said. “We found that after six weeks of training, type 2 diabetic individuals become more like the control group—there’s very little difference in terms of how much they sway and what their balance is like.”

Monitoring

David Sinacore, PT, PhD, a professor of physical therapy and medicine at Washington University, and one of the researchers involved in studies of exercise and neuropathy there, emphasized that monitoring—by clinicians or the patients themselves—is crucial to successful exercise programs in those with diabetic neuropathy, particularly if they also have foot deformities such as those resulting from Charcot arthropathy.

“I’m a firm believer that these folks need to exercise for their diabetes,” he said. “But if they start to develop lesions, they need to be addressed.”

Of course, as most clinicians know, there is often a gap between ideal and real-world monitoring levels.

“It’s hard for these patients to check the bottom of their feet regularly, so they sometimes don’t do it,” Sinacore said.

One way to help is with temperature monitoring. Sina­core recommends foot-temper­ature gauges that patients can use right after exercising, some of which are hook-shaped to ease plantar access.

“When we monitor them here, we check temperature before and after exercise,” he said. “We’re looking for hot spots and temperature dif­ferences that may indicate that they’re developing a lesion.”

In such cases, therapists recommend that patients de­crease their exercise levels for a while and have their footwear modified to relieve pressure.

David Armstrong agreed that thermometry provides a way of keeping track of the damage caused by weight-bearing exercise.

“We want our patients to dose their activity by checking their skin temperature just as they dose their insulin by checking their glucose,” he said.

His colleague, Manish Bharara, conducts innovative research in this aspect of care.18

“In the last decade we’ve learned that a four-degree difference between two similar sites on both feet is an ulcer risk,” he said. “If the pattern persists over multiple days, the patient should reduce activity and immediately see a doctor.”

Bharara and his colleagues are developing a thermometry scale to address some of the inconveniences typically associated with measuring foot temperature at several sites. Patients stand on it—it’s similar to a bathroom scale—while it measures foot temperature at 20 sites on each foot and records the data. The scale speaks to the patient—telling him, for example, that his right big toe temperature is 5° warmer than the left. Moreover, if the scale detects an abnormal pattern for more than two days, it can be programmed to send a message to the physician’s office and make an appointment.

“Something like this could really help manage patients’ diabetes better, because the biggest barrier is compliance,” Bharara said.

New research

Other researchers are examining variables that affect neuropathic patients’ exercise capabilities, as well. For example, at the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University in Chicago, Bijan Najafi, PhD, associate professor of applied biomechanics, has studied factors including gait initiation in this context.19 As opposed to the measures of steady-state walking—such as rate or number of steps—typically used in exercise studies, a prolonged gait initiation phase (the period between upright posture and steady-state gait) may be associated with increased fall risk.

“During the initiation of the step, there’s an important acceleration phase, and it creates a lot of resistive force,” Najafi said. “We’ve found that neuropathy patients have longer gait initiation. This makes sense, because to reach steady-state gait, people have to gather somatosensory feedback to find the speed at which they can walk safely and minimize energy costs. Neuropathy patients have impaired somatosensory feedback, though. But we believe that if we can provide a good exercise to compensate, we may be able to improve the gait initiation phase.”

One way to help, Najafi thinks, is to take a cue from the dance world.

“If you’re trying to explain a movement problem to a dancer he may not get it, but if you put a mirror in front of him and show him the correct position of the joints, he can improve his motor skills,” he said. “The brain is plastic, and if it realizes there’s an error, it will try to minimize it next time. So we hope that by letting neuropathy patients observe their errors this way, they may improve their motor skills.”

Cary Groner is a freelance writer based in the San Francisco Bay Area.

Orthotic management of the pes cavus foot

Pes cavus foot occurs in about 8% to 15% of the population, but it does not get nearly as much attention in the medical literature as does its counterpart, pes planus.1 Sixty percent of individuals with cavus feet develop foot pain.2

Although medical knowledge regarding pes cavus exists, the research and treatment options, as well as any theories or hypotheses as to why humans develop this deformity, are quite limited. Traditionally, we have considered pes cavus a neuro­muscular problem with a surgical answer.3 By combining what is known with what we can hypothesize, perhaps we can establish a new and more successful approach to pes cavus.

Classification of pes cavus foot

Pes cavus has a variety of classifications. However, many of these overlap, which can lead to confusion. The most common classification system categorizes pes cavus as neuromuscular, congenital, or traumatic. Researchers often differentiate idiopathic from congenital pes cavus.4 A large retrospective survey reviewed 465 patients with pes cavus and found that 81% were classified as having idiopathic pes cavus and 19% had neuromuscular pes cavus.5 Another study reviewed 77 patients in a pes cavus clinic and found that 33.8% of cases were idiopathic and 66.2% were neuromuscular.4 Despite this discrepancy between the two studies, each study found that a significant portion of the pes cavus patients had no known etiologic source of deformity.

The high-arched foot has also been classified according to footprint morphology, radiography, visual inspection, and, most recently, the Foot Posture Index (FPI).2,6-8 The FPI is the most comprehensive of these methods because it distinguishes all foot types, not just the cavus foot, using point-based criteria. This statistically validated and consistent tool defines the cavus foot as any foot that has an FPI score between -5 and -12 on a scale from -12 to +12. A normal foot has a score between 0 and +5.

The structure of pes cavus falls into anterior, posterior, and global categories.3 The anterior cavus is either total (indicating plantar flexion of the entire forefoot) or local (plantar flexion of the first ray only). The posterior type has a high calcaneal inclination angle but no forefoot equinus. The global type, sometimes referred to as combined cavus, is a combination of both deformities.

With regard to function, the pes cavus foot has also been classified as either flexible or rigid. The myofascial band of the plantar aponeurosis maintains the deformity with the windlass effect.9 This effect tends to maintain greater rigidity in some individuals and less in others, depending on the flexibility of the patient’s midtarsal joint. The short and long plantar ligaments may also develop contractures due to decreasing motion across their respective joints, maintaining a more rigid cavus foot.10 Although this type of pes cavus classification is often the least emphasized, function may prove to be the most important consideration relative to orthotic therapy. These two variations of functioning cavus feet, though similar in appearance, act very differently. Anecdotally, one popular assumption holds that pes cavus deformity begins as a flexible entity and will become rigid if it is not treated. However, no evidence currently supports this speculation.

The classification of pes cavus according to so many different parameters may signal that its origins have escaped the medical community. Classifying pes cavus as idiopathic gives it a place to fit, but this approach may be shortchanging our knowledge of the imbalance in muscle forces and strength associated with this condition.

Pathomechanics of pes cavus foot

Originally, researchers thought posterior tibial tendon dysfunction (PTTD), which is now referred to as adult-acquired flatfoot (AAF), was idiopathic unless it was associated with a specific traumatic incident.11 Lower extremity practitioners learned to test the tibialis posterior muscle to stage this disorder prior to treatment and found that there was a progressive character to the weakness and imbalance that resulted in the deformity.11

Practitioners began to evaluate adolescent flatfoot based on the strength of the tibialis posterior and the overpowering of the peroneus brevis muscle.12 This evolution of thought became a focus of investigation simply because several people pursued the obvious rationale that there must be a mechanical origin to flatfoot, not just a convenient category called idiopathic. Can muscle imbalance, the progression of deformity, and the resultant symptoms also be the basis of a theory for the mechanical origin of pes cavus?

I have yet to encounter non-neurologic pediatric cavus feet. If the tibialis anterior muscle is weak at birth, then the peroneus longus muscle will not have a strong enough antagonist. This would disrupt Kirby’s rotational equilibrium concept,13 leading to progressive plantar flexion of the first ray during osseous development toward adulthood. The plantar flexion of the first ray from the overpowering peroneus longus would force the talus into a more dorsiflexed position. This in turn would increase arch height and calcaneal inclination. This pattern of muscle imbalances and reactions is similar to the pattern that occurs with AAF, but produces a different morphology. The increased arch height would lead to a smaller contact area on the ground. Accordingly, there would be more pressure on the metatarsal heads and heel, resulting in symptoms related to these areas.

The tilting back of the talus in the ankle joint would deplete most of the available dorsiflexion of the ankle joint and lead to ankle equinus, which would lead to gastrocnemius-soleus contracture. The extensor muscles would compensate in stance and swing for the gastrocnemius contracture, producing extensor substitution, which is present in most cavus feet. The higher arch would decrease the contact area, increasing pressure on the metatarsal heads, and limited ankle dorsiflexion would cause that pressure to be experienced over a longer period of time as the tibia moves forward in gait. This would all eventually result in a patient suffering from metatarsalgia, ankle joint pain, heel pain, and antalgic gait changes, all classic signs and symptoms of cavus foot.9

Would early evaluation and intervention with orthotic therapy improve midlife clinical outcomes in these patients? Could early intervention slow down the progression of the deformities that result from a lifetime of compensation and metatarsalgia? Forward-looking studies may prove this true, as more investigators recognize that cavus foot is a mirror image of posterior dysfunction in the child and adult.

Evidence for orthotic therapy

A 1997 paper analyzed gait patterns in nine patients with painful pes cavus.14 The Italian researchers noted the presence of two different types: compensated pes cavus (greater ankle joint laxity) and noncompensated pes cavus. These are now considered functional variations. The compensated pes cavus foot had enough laxity to allow the metatarsal depression to be compensated by ankle joint and midtarsal joint dorsiflexion, reducing pain at the forefoot. Some individuals, because of heredity and genetics, are born with greater hip or ankle range of motion, while others have less than normal range of motion. The same must be true for the range of motion of the midtarsal joint—this is obvious to anyone who has examined a large number of feet. Individuals born with or developing cavus feet are not excused from this inevitability, and, therefore, some have a large range of motion of the midtarsal joint and will compensate for the unusual contact forces of a cavus foot. Those without much midtarsal motion will not be able to compensate.

In the Italian study, gait analysis revealed that the compensated group had increased knee flexion and increased ankle joint dorsiflexion, coupled with prolonged firing of the anterior tibialis muscle into late stance. This finding partially validates a portion of the proposed hypothesis. The noncompensated group, which was more symptomatic, had hyperextension of the knee during stance and an inability of the anterior tibialis muscle to overcome the plantigrade position of the forefoot.14

The researchers also reported that gait patterns were improved with custom orthoses, which distributed loads over a wider plantar surface area, unloading the metatarsal area. The uncompensated group was more likely to require surgical correction, since mechanical intervention was less successful. This may have been because it is difficult to change mechanics when there is little or no motion. Two factors were identified in reducing pain: first, the wider contact surface area of the orthoses; second, the ability to control the compensatory motion and unloading of the metatarsal heads.14

A 2001 study took a different approach, dealing with differences in foot types and related sports injuries.15 Researchers from the University of Delaware, Newark, studied two groups of runners with flat or high-arched feet to determine the differences in their injury patterns. They screened patients based on an arch ratio system.16 Although the FPI was not utilized, the individuals had either a high arch or a flat foot, but none had a normal arch height.

The low-arched runners had more medial and soft-tissue injuries, while the high-arch runners had more lateral and bony injuries. The most common injuries in high-arched runners were plantar fasciitis, iliotibial band friction syndrome, and lateral ankle sprains. The most common type of bony injury observed in the high-arch group was stress fracture; all stress fractures occurred at the fifth metatarsal. This group had increased lateral loading compared with the low-arched individuals, and the center of pressure of the foot remained more lateral than the normal medial shift in normal gait throughout stance. This study has been one of the few to differentiate a true set of injuries experienced by people with cavus feet. Although runners are a unique population, the speed and increased contact forces compared with walkers help exaggerate the differences in injury distribution between the two types of foot morphologies.

Remarkably, only since 2000 have studies begun to focus on orthotic therapy and symptoms related to pes cavus, specifically metatarsalgia. Considering that metatarsalgia is the most common symptom in patients with pes cavus,2 a review of studies on the effect of orthoses on metatarsalgia is relevant.

Researchers from the Washington University School of Medicine in St. Louis measured peak pressure and pressure-time integrals in a study of patients with diabetic neuropathy and a history of plantar ulcers.17 An ulcer or pre-ulcer lesion are clear clinical signs of excessive metatarsal head pressure. We can, therefore, look at this study’s attempts to reduce metatarsal head pressure in patients with diabetes and extrapolate the results to efforts to reduce metatarsal head pressure in cavus feet.

The researchers looked at the use of shoes alone, shoes with custom-molded total contact inserts, and shoes with total contact inserts and metatarsal pads. Both devices used in this study were designed to have a minimum fill or total contact design. The study followed 20 patients, 12 men and eight women, with a mean age of 57 years. When patients were given orthoses, peak plantar pressure and pressure-time integrals were reduced by 16% to 24%, respectively, compared with a shoe-only condition. When patients wore metatarsal pads with the total contact orthoses, the peak plantar pressure and pressure-time integral were reduced by 29% to 47% relative to the shoe-only condition.

This study has applications in many patient groups, but is especially important for patients with pes cavus feet; almost 60% of this population suffer from metatarsalgia.2 Burns demonstrated in 20052 that patients with symptomatic cavus feet and metatarsalgia not only had greater pressure under the metatarsal head region but also that the pressure in that region was maintained for a longer time compared with individuals with noncavus feet.

Some research has addressed whether padding the metatarsal area with soft materials or controlling motion with more rigid materials would reduce symptoms. Canadian researchers assessed patients with rheumatoid arthritis and metatarsalgia. Twenty-four individuals completed three 12-week interventions in random order: shoes alone, soft custom orthoses, and semirigid custom orthoses. The data demonstrated that semirigid devices had a highly statistically significant effect on pain, whereas neither soft orthoses nor supportive shoes alone had a statistically significant effect.

Most recently, an Australian group published three relevant studies on the symptoms and mechanical treatment of cavus foot. Burns et al,2 as previously described, attempted to determine the relationship among pes cavus, pain, and foot deformity. Sixty percent of pes cavus patients complained of pain compared with 23% of patients without the deformity. Pressure-time integrals in all three areas of the foot (rearfoot, midfoot, and forefoot) were higher in the pes cavus group than in normal patients. There was also a significant correlation between higher pressure-time integrals and pain.

In a later study of 130 individuals with painful idiopathic pes cavus,19 the Australian researchers also found that those patients demonstrated a more cautious gait pattern than individuals with normal feet. Peak plantar pressure and mean plantar pressure values were also lower than normal, particularly in the forefoot and rearfoot. Patients with pain limited to the rearfoot were more likely to demonstrate an antalgic gait pattern, lower plantar pressures, and higher pressure-time integrals than those with pain limited to the forefoot.

The same research group also published the first randomized controlled trial20 to investigate the effectiveness of custom orthoses for the treatment of painful pes cavus deformity. One hundred fifty four patients with chronic idiopathic foot pain and bilateral cavus feet received either custom-molded orthoses made of 3-mm polypropylene with a Poron top cover or sham insoles of 3-mm foam. Researchers evaluated patients after three months for changes in quality of life, using the Foot Health Status Questionnaire21 and changes in plantar pressure measurements.

The foot pain scores after three months of insole use improved by 43% with sham insoles and 74% with custom-molded orthoses. The peak pressure was 9% less than at baseline for the sham insole but 26% less than baseline for the custom-molded orthoses. Overall, the custom orthoses had a greater effect on quality of life, including statistically significant increases in activity and decreases in pain. One cannot overlook the value of improvement in both physical and mental health for patients with chronic pain and disability.

Although the clinical studies concerning pes cavus are limited, the information is applicable to clinical scenarios. Cavus gait is specific and often limited by the amount of compensation available at the midtarsal and ankle joint. The runner study revealed that the injury pattern is somewhat predictable and can help guide orthotic fabrication details. The studies by the Australian group revealed that custom orthoses can relieve pain and decrease pressure-time integrals. The positive information gained from this research confirms the value of biomechanical intervention for patients with pes cavus.

Orthotic goals for pes cavus foot

The typical complaints associated with pes cavus are pain, issues with shoe fit, and lateral ankle sprains. By focusing on the pathomechanics of cavus foot issues and applying the evidence in the literature, we can compile a list of prescription components for the ideal custom orthosis.

The overload on the metatarsal heads is due to the limited contact area on the plantar surface of the foot created by the high arch. According to the proposed theory detailed earlier, there is also a domino effect from a weak anterior tibialis muscle, tight gastroc-soleus complex, overactive extensors for ground clearance, and extensor substitution or claw toe contractures that result in metatarsalgia.



Figure 2. Semirigid orthoses with a very minimum arch fill, rearfoot post, 4-mm heel lift, and a forefoot valgus wedge or forefoot padding are recommended for pes cavus.

Increasing the plantar surface contact area with a total contact orthosis ensures that more of the plantar pressure is being borne in the arch area and that the metatarsal heads are bearing less weight for shorter periods. One can accomplish this by using a minimal fill cast correction technique, which raises the arch of the orthosis (total contact), and prescribing a semirigid or rigid device.

Adding a metatarsal bar or a metatarsal pad will shift plantar pressures more proximally, away from the metatarsal heads. Leaving the anterior edge of the orthosis at full thickness (instead of beveled) produces a rocker-type effect, which shortens the time the metatarsal heads bear weight. A forefoot extension of soft durable material attenuates the pressure peaks under the metatarsal heads.

Lateral ankle instability and a laterally deviated subtalar joint (STJ) axis are frequently associated with high-arched feet.22 The STJ axis lies more laterally and exits the foot at a different angle in the pes cavus foot than in the average STJ axis.

This axis deviation leaves the pes cavus foot with more inversion as well as more plantar surface medial to the STJ axis, which increases the likelihood of supinatory moments across the STJ axis. Because the peroneus brevis has a shorter and less efficient moment arm to oppose these supinatory moments, this situation can increase the risk of lateral ankle sprain. The muscle imbalance inherent in the cavus foot leads to a plantar flexed first ray, subsequent rearfoot inversion, and lateral ankle instability by leaving the foot in an inverted position, as described in the theory of cavus pathomechanics.

Leaving the lateral side of the rearfoot post unbeveled increases the surface area and effectiveness of the post by providing a more stable platform to resist inversion of the device. Adding a reverse Morton’s extension or a slight valgus forefoot extension creates a pronatory moment on the forefoot that counteracts the excessive supinatory moment. This makes the cavus foot less laterally unstable.

Rearfoot instability is an extension of the laterally deviated subtalar axis. However, in flexible pes cavus feet, midtarsal flexibility compensates for this later in stance. The forefoot pathology produces midtarsal joint supination, which leads to excessive pronation of the rearfoot.23 Some pes cavus feet suffer from both lateral ankle instability at midstance and rearfoot pronation at late midstance. Adding a flat rearfoot post and a deep (>16 mm) heel cup helps stabilize the rearfoot by limiting rearfoot motion in relation to the supporting surface.

Multiple problems contribute to the apropulsive antalgic gait of the pes cavus foot. Pain in the metatarsal heads or rearfoot can cause shortened strides, which can lead to excessive use of extensor tendons and eventually result in tendinitis, tendon fatigue, and even shin splints.19 Limited ankle joint motion also leads to shorter strides and limited propulsion and is often associated with pes cavus.

Adding a 4-mm heel lift to the rearfoot post actually increases available ankle joint dorsiflexion by plantar flexing the talus. Also bear in mind that a wide orthosis will increase the surface area that contacts the arch of the foot and distribute more pressure to the midfoot and away from the forefoot and rearfoot.

One must understand that, early in treatment, the morphology and pathomechanics of cavus feet are likely to be progressive, especially in the developmental form. Neurologic disorders, such as Charcot-Marie-Tooth disease and muscular dystrophy, create a progressive muscle imbalance.24 Orthotic and shoe interventions are likely to change on a regular basis. Frequent reevaluation and recasting are essential to follow the continually rising arch and shifting of symptoms.

The true etiology of pes cavus remains one of our unsolved mysteries. The proposed pathomechanical model described above is one that future trials can test. Recent research is both enlightening and encouraging. However, it is apparent that more studies are needed. There are congenital and familial components to these feet, but there is much more to be studied about the progression. We need to recognize patients with cavus feet early in life, and studies need to document the effectiveness of orthoses and other early interventions for affecting midlife outcomes and avoiding symptoms.

Paul R. Scherer, DPM, is a clinical professor in the College of Podiatric Sciences at the Western University of Health Sciences in Pomona, CA. A version of this article appears in his book, Recent Advances in Orthotic Therapy, published by Lower Extremity Review. For more information, call 518/452-6898.