Lower extremity focus helps cut risk of falls

Falls are common, disabling and costly. Causes are multifactorial but include foot disorders, ill-fitting footwear, and poor bal­ance. Recent research supports a multi­dis­ci­plinary approach to falls prevention and indicates that lower extremity practi­tioners can play an important role. Falls in older people are a major public health problem, with one in three people aged 65 years and older falling each year.1 Falls most frequently result in minor injuries such as superficial cuts and abrasions, bruises, and sprains. However, up to 15% of falls result in more serious injury such as head trauma, fractures, dislocations, and lacerations, making falls the leading cause of hospitalization in older people.2 Furthermore, in the US, falls are responsible for two-thirds of deaths from unintentional injury, making falls a larger contributor to mortality in older people than motor vehicle accidents.3 Management of fall-related injury makes a substantial contribution to healthcare expenditure. In the US, it has been estimated that each injurious fall costs an average of $10,749 in treatment costs—a figure that increases to $26,483 if hospitalization is required.4 In 2000, the total cost of treating nonfatal injurious falls in the US was an estimated $19 billion.5 Although substantial, these figures are likely to be an underestimate of the true economic impact of falls, as they focus on direct treatment costs and do not consider loss of productivity, personal costs, and the financial impact on spouses, other family members, and caregivers. What causes falls? Falls are complex multifactorial events that result from both intrinsic (physiological) and extrinsic (environmental) risk factors. Prospective studies have identified major intrinsic risk factors for falls in older people; these include muscle weakness, a previous history of falls, gait disorders, visual impairment, use of psychoactive medications, and cognitive impairment. Extrinsic risk factors include hazards such as stairs, slippery surfaces, throw rugs, and cracked pavements.6 It is now well accepted that environmental hazards alone are not the major cause of most falls. Rather, the interaction between environmental hazards and an older person’s physical abilities plays a key role. For example, an older person with high level of physical functioning may be able to cope in a hazardous environment without falling, while an older person with significant physical impairment may fall in a relatively safe environment. Furthermore, an older person’s perceptions of their own abilities and risk of falling, particularly fear of falling, influences their level of exposure to hazardous situations and subsequent incidence of falls.7 Foot disorders, balance, and falls The foot provides the only source of direct contact with the ground during walking, and contributes to both the absorption of impact after heel contact and the generation of power required for forward momentum. Each of these functions requires the complex interaction of joint motions at specific times to achieve smooth transfer of body weight. It is therefore reasonable to expect that foot dysfunction may interfere with normal progression of the body during walking and may therefore be a contributing factor to falling in older people.8 The first literature reference to the potential link between foot problems and falls, a paper published by De Largy9 in 1958, suggested that structural foot disorders may lead to inactivity and subsequent lower extremity muscle weakness, thereby increasing the risk of falls. In 1966, Helfand suggested a more direct link, arguing that foot disorders impair balance by modifying the base of support during standing and walking.10 In the past decade, a growing body of evidence has emerged to support these early observations. In addition to foot pain, structural factors such as hallux valgus, lesser-toe deformity, limited ankle joint range of motion, and reduced strength of foot and ankle muscles have been shown to impair performance in tests of walking speed, balance, and functional tasks, such as rising from a chair.11-13 Two prospective studies have confirmed that many of these characteristics are also independently associated with falls after established risk factors are considered. Menz et al14 prospectively followed 176 retirement village residents for 12 months to track the incidence of falls and found that, compared with those who did not fall, fallers were more likely to have foot pain and exhibit decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantar flexor strength. After adjusting for physiological falls risk and age, decreased toe plantar flexor strength and disabling foot pain remained significantly and independently associated with falls. More recently, a 12-month prospective study of 312 com­munity-dwelling older people by Mickle et al15 concluded that, compared with nonfallers, fallers demonstrated significantly less plantar flexion strength of the hallux and lesser toes and were more likely to have hallux valgus and lesser-toe deformity. Footwear, balance and falls By modifying the interface between the body and the environment during weightbearing, footwear has the potential to influence postural stability, either beneficially or detrimentally. Several studies have reported that many older people wear suboptimal footwear that could potentially increase the risk of falling. Barbieri16 conducted interviews with older people who had fallen while hospitalized, and found that poorly fitting shoes played a role in 51% of cases. Similarly, Finlay17 evaluated footwear in 274 patients admitted to a geriatric outpatient unit, and reported that only 53% were wearing adequate footwear. Finally, Hourihan et al18 reported that 33% of 147 subjects hospitalized for fall-related hip fracture were wearing slippers when they fell. Laboratory-based biomechanical studies have since confirmed that that high heels, narrow heels, and excessively thick and soft soles are detrimental to balance in all adults, while shoes with a low, broad heel and thin, firm midsoles are beneficial.19 However, extrapolating the laboratory findings to falls studies is difficult due to the wide range of other risk factors that need to be considered and the range of different shoes and walking surfaces encountered during normal daily activities. Although prospective studies have shown that shoes with high, narrow heels increase the risk of falls,20 there is also evidence that the role of footwear varies depending on whether the fall takes place outdoors or inside the home, with the risk of indoor falls being increased when older people are barefoot or wearing socks compared with wearing shoes.21,22 Nevertheless, despite the inherent difficulties in identifying the role of footwear in falls, general recommendations regarding footwear have been developed for older people at risk of falling (see Figure 1). Falls prevention interventions Over the past three decades, there has been a sustained research effort to evaluate the effectiveness of a wide range of interventions to prevent falls in older people, resulting in hundreds of trials. This vast body of research has been collated recently into a systematic review published by the Cochrane Collaboration,23 and this provides the best available evidence of what works for falls prevention. For older people living in the community, this review of 111 trials indicates that exercise (including multiple-component group exercise, Tai Chi, and individually prescribed multiple-component home-based exercise), gradual withdrawal of psychoactive medication, the prescription of vitamin D (in people with low vitamin D levels), prescription modification by primary care physicians, the use of pacemakers (in people with carotid sinus hypersensitivity), and first eye cataract surgery are effective for reducing the incidence of falls. The review found that home safety modification was not effective for reducing falls overall, but was effective in people with severe visual impairment and older people at high risk of falling. Foot specialists and falls prevention In response to the emerging evidence that foot problems and inappropriate footwear increase the risk of falls, two recent falls prevention guidelines recommend that older people at risk of falling should have their feet and footwear assessed, and that appropriate treatment should be provided as part of a multifactorial intervention strategy.24,25 Furthermore, several multidisciplinary “falls clinics” have been established in the US, the UK, and Australia that employ podiatrists alongside physical therapists, geriatricians, and occupational therapists.26 However, there is very little guidance in the literature on what type of interventions should be used by lower extremity practitioners to prevent falls. Furthermore, a recent evaluation of podiatry involvement in falls prevention clinics in Australia revealed a high level of variability of podiatry service provision relative to eligibility criteria, assessments undertaken, and interventions provided.26 Based on these observations, it would appear that despite significant potential, lower extremity healthcare currently has a limited and poorly defined role in falls prevention, largely because of a lack of evidence from randomized trials to guide treatment. A multifaceted podiatry intervention To address this substantial gap in the literature, our research group recently conducted, to our knowledge, the first randomized controlled trial of a podiatry intervention specifically designed to improve balance and prevent falls.27 In this study, 305 community dwelling older men and women with disabling foot pain and an increased risk of falling were allocated to either a routine podiatry care control group or a multifaceted podiatry intervention, and were tracked for falls over a 12-month period. The routine podiatry care group received ongoing maintenance treatment only, which typically involved nail care and scalpel debridement of hyperkeratotic lesions (corns and calluses). The multifaceted podiatry intervention group also received routine care in addition to prefabricated foot orthoses (Figure 2), advice on footwear, a cost subsidy to assist in the purchase of new footwear if current footwear was deemed inappropriate, a home-based program of foot and ankle exercises (Table 1), and a falls prevention education booklet. At the completion of the study, researchers had documented 264 falls. Participants in the intervention group experienced 36% fewer falls than participants in the control group. In addition, the intervention group demonstrated significant improvements relative to the control group with regard to strength (ankle eversion), range of motion (ankle dorsiflexion and inversion/eversion), and balance (postural sway on the floor when barefoot and maximum balance range wearing shoes). Adherence to the interventions was good, with 52% of the participants completing 75% or more of the requested three exercise sessions weekly, and 55% of those issued orthoses reporting that they wore them most of the time.28 Given that the interventions are inexpensive and relatively simple to implement, we believe that program could be incorporated into routine podiatry practice or multidisciplinary falls prevention clinics with minimal training. Future directions The findings of our trial suggest that podiatry has an important role to play in preventing falls in older people living in the community. However, whether the same intervention would be effective in residential aged-care settings or in older people without foot pain requires further investigation. Given that older people in residential care are generally older, more frail, and more likely to have cognitive impairment than those living in the community, the intervention may need to be modified to address the needs of this population. Furthermore, the intervention did not target all relevant foot and ankle risk factors for falls. Both hallux valgus and deformity of the lesser toes have been shown to be risk factors for falls, but these conditions generally require surgical treatment. It is likely that surgical treatment of toe deformities is beneficial for balance, but this has yet to be formally evaluated. Finally, we used only a simple prefabricated orthosis in our intervention; future investigations could evaluate the effectiveness of other types of orthoses and braces in improving balance and preventing falls. Conclusion Falls in older people are common, disabling, and costly to the healthcare system. Foot disorders and inappropriate footwear increase the risk of falling. Recent research indicates that a multifaceted podiatry intervention improves foot and ankle strength, range of motion, and balance and reduces the rate of falls by 36%. These findings make a strong case for lower extremity healthcare to play an important role in the multidisciplinary effort to prevent falls in the older population. Hylton B. Menz, PhD, is professor and deputy director of the Musculoskeletal Research Centre at La Trobe University in Melbourne, Australia. Martin J Spink, BPod(Hons), is a podiatrist and PhD candidate in the Department of Podiatry and Musculoskeletal Research Centre at La Trobe University. Disclosure: The trial reported in this article was funded by the National Health and Medical Research Council of Australia and the La Trobe University Central Large Grants Scheme. The foot orthoses were provided by Foot Science International. Professor Menz is funded by a National Health and Medical Research Council of Australia Career Development Award. Neither of the authors has a competing interest to declare. By Hylton B. Menz, PhD, and Martin J. Spink, BPod(Hons)

Division 11 player bitten by a shark

Of all the injuries college basketball players have sustained this year, Chad Renfro's may have been the scariest. Renfro, the leading returning scorer at Division II Barry University in Miami Shores, Fla., was paddling out on his surfboard to catch a wave at a beach near his parents home in Jacksonville when he felt sharp pain in his left foot. A shark bit him with enough force to slice most of a tendon, damage a bone and require 85 stitches to close the wound. "Immediately I knew what it was, so I just paddled back in as fast as I could — caught the next wave in," Renfro told WJXT-TV in Jacksonville. "I was sitting there and people kept looking at me. I was trying to get someone to help me, and then one girl had walked over and I told her to call 911, and then I saw the lifeguards drive by, and so I just hollered for them and they came over." The silver lining to the shark attack is Renfro's injuries could have been far worse. The 6-foot-4 guard expects to return to the basketball court in time for the start of next season and even hopes to get back on a surfboard as soon as possible. Experts have said what bit Renfro was likely either a four-to-five-foot bull or lemon shark, both of which are common off the coast of Florida. Renfro's mom joked with WJXT-TV that her son would be more likely to win the lottery than get bit by a shark while surfing. Hopefully he buys a winning ticket when he leaves the hospital because he's due for some good luck.

Suddenly All the Kids Have Diabetes

From the way diabetes gets talked about in the news, you'd think that everyone and their brother had it. Well, now it's looking more like everyone and their daughter has it. A new study has just been released which shows a pretty terrifying increase in the rate of diabetes and pre-diabetes among young people. In 2000, only 9 percent of teens were diabetic or pre-diabetic. By 2008, a whopping 23 percent of adolescents are. Jesus H. Christ on a cracker. That is a huge increase in just eight years. One small ray of hope is that the test they used, a fasting blood glucose test, doesn't give as accurate a picture of a person's health because it's a single snapshot of blood sugar rather than an average over time. So that number could be somewhat artificially high. Still, even considering that, this news is not good. The author of the study, Ashleigh May, who is an epidemiologist for the CDC, calls the findings "very concerning." Pediatric endocrinologist Larry Deeb, who is also a former president of medicine and science for the American Diabetes Association, says other research shows there could be "a 64% increase in diabetes in the next decade. [...] We are truly in deep trouble. Diabetes threatens to destroy the health care system." As if that wasn't bad enough, this study also found something else that's equally scary: [H]alf of overweight teens and almost two-thirds of obese adolescents have one or more risk factors for heart disease, such as diabetes, high blood pressure or high levels of bad cholesterol. By comparison, about one-third of normal-weight adolescents have at least one risk factor. While it was already clear that we needed to do something to protect the health of our kids, this data suggests we'd better do something quickly. Not that there's any easy way to fix this problem, especially among modern teens who already have so many other things to worry about, like being bullied and not getting caught in a sexting scandal. Perhaps it's time to call upon some kind of health superhero. Will Mr. Metabolic Syndrome save the day and defeat evil Dr. Diabetes? Blood Sugar Man to the rescue? Can we even just get Jack Black in a spandex suit doing PSAs? Someone? Anyone? Help. By Cassie Murdoch

Born to run barefoot? Some end up getting injured

LOS ANGELES (AP) — Swept by the barefoot running craze, ultramarathoner Ryan Carter ditched his sneakers for footwear that mimics the experience of striding unshod. The first time he tried it two years ago, he ran a third of a mile on grass. Within three weeks of switching over, he was clocking six miles on the road. During a training run with a friend along a picturesque bike path near downtown Minneapolis, Carter suddenly stopped, unable to take another step. His right foot seared in pain. "It was as though someone had taken a hammer and hit me with it," he recalled. Carter convinced his friend to run on without him. He hobbled home and rested his foot. When the throbbing became unbearable days later, he went to the doctor. The diagnosis: a stress fracture. As more avid runners and casual athletes experiment with barefoot running, doctors say they are treating injuries ranging from pulled calf muscles to Achilles tendinitis to metatarsal stress fractures, mainly in people who ramped up too fast. In serious cases, they are laid up for several months. Many converts were inspired by Christopher McDougall's 2009 best-seller "Born To Run," widely credited with sparking the barefoot running trend in the Western world. The book focuses on an Indian tribe in Mexico whose members run long distances without pain in little more than sandals. While the ranks of people running barefoot or in "barefoot running shoes" have grown in recent years, they still represent the minority of runners. Some devotees swear they are less prone to injuries after kicking off their athletic shoes though there's no evidence that barefoot runners suffer fewer problems. In some cases, foot specialists are noticing injuries arising from the switch to barefoot, which uses different muscles. Shod runners tend to have a longer stride and land on their heel compared with barefoot runners, who are more likely to have a shorter stride and land on the midfoot or forefoot. Injuries can occur when people transition too fast and put too much pressure on their calf and foot muscles, or don't shorten their stride and end up landing on their heel with no padding. Podiatrist Paul Langer used to see one or two barefoot running injuries a month at his Twin Cities Orthopedics practice in Minneapolis. Now he treats between three and four a week. "Most just jumped in a little too enthusiastically," said Langer, an experienced runner and triathlete who trains in his barefoot running shoes part of the week. Bob Baravarian, chief of podiatry at the UCLA Medical Center in Santa Monica, Calif., said he's seen "a fair number" of heel injuries and stress fractures among first-timers who are not used to the different forces of a forefoot strike. "All of a sudden, the strain going through your foot is multiplied manifold" and problems occur when people don't ease into it, he said. Running injuries are quite common. Between 30 to 70 percent of runners suffer from repetitive stress injuries every year and experts can't agree on how to prevent them. Some runners with chronic problems have seized on barefoot running as an antidote, claiming it's more natural. Others have gone so far as to demonize sneakers for their injuries. Pre-human ancestors have walked and run in bare feet for millions of years often on rough surfaces, yet researchers surprisingly know very little about the science of barefoot running. The modern running shoe with its cushioned heel and stiff sole was not invented until the 1970s. And in parts of Africa and other places today, running barefoot is still a lifestyle. The surging interest has researchers racing for answers. Does barefoot running result in fewer injuries? What kinds of runners will benefit most from switching over? What types of injuries do transitioning barefoot runners suffer and how to prevent them? While some runners completely lose the shoes, others opt for minimal coverage. The oxymoron "barefoot running shoes" is like a glove for the feet designed to protect from glass and other hazards on the ground. Superlight minimalist shoes are a cross between barefoot shoes and traditional sneakers — there's little to no arch support and they're lower profile. Greg Farris decided to try barefoot running to ease the pain on the outside of his knee, a problem commonly known as runner's knee. He was initially shoeless — running minutes at a time and gently building up. After three months, he switched to barefoot running shoes after developing calluses. Halfway through a 5K run in January, he felt his right foot go numb, but he pushed on and finished the race. He saw a doctor and got a steroid shot, but the pain would not quit. He went to see another doctor, who took an X-ray and told him he had a stress fracture. Farris was in a foot cast for three months. He recently started running again — in sneakers. "I don't think my body is made to do it," he said, referring to barefoot running. Experts say people can successfully lose the laces. The key is to break in slowly. Start by walking around barefoot. Run no more than a quarter mile to a mile every other day in the first week. Gradually increase the distance. Stop if bones or joints hurt. It can take months to make the change. "Don't go helter skelter at the beginning," said Dr. Jeffrey Ross, an associate clinical professor of medicine at Baylor College of Medicine and chief of the Diabetic Foot Clinic at Ben Taub General Hospital in Houston. A year and a half ago, Ross saw a steady stream — between three and six barefoot runners a week — with various aches and pain. It has since leveled off to about one a month. Ross doesn't know why. It's possible that fewer people are trying it or those baring their feet are doing a better job adapting to the new running style. There's one group foot experts say should avoid barefoot running: People with decreased sensation in their feet, a problem common among diabetics, since they won't be able to know when they get injured. Harvard evolutionary biologist Daniel Lieberman runs a lab devoted to studying the effects of running form on injury rates. He thinks form matters more than footwear or lack of — don't overstride, have good posture and land gently. In a 2010 study examining different running gaits, Lieberman and colleagues found that striking the ground heel first sends a shock up through the body while barefoot runners tend to have a more springy step. Even so, more research is needed into whether barefoot running helps avoid injury. "The long and the short of it is that we know very little about how to help all runners — barefoot and shod — prevent getting injured. Barefoot running is no panacea. Shoes aren't either," said Lieberman, who runs barefoot except during the New England winters. Carter, the ultramarathoner, blames himself for his injury. Before he shed his shoes, he never had a problem that kept him off his feet for two months. In April, he ran his fourth 100-mile race — with shoes. Meanwhile, his pair of barefoot running shoes is collecting dust in the closet.

Autism Linked to Mom's Diabetes

Mothers who are obese or who have diabetes appear to be more likely to have children with neurodevelopmental disorders, including autism.... According to Paula Krakowiak, MS, a PhD candidate at the MIND Institute at the University of California Davis, and colleagues, maternal obesity was associated with greater odds of the offspring receiving a diagnosis of an autism spectrum disorder (OR 1.67, 95% CI 1.10 to 2.56) or a developmental delay (OR 2.08, 95% CI 1.20 to 3.61) by age 5. A combination of maternal metabolic conditions was associated with a range of impairments in the children's development, the researchers reported. Susan Hyman, MD, of the University of Rochester in Rochester, N.Y., who is the chair of the American Academy of Pediatrics' autism subcommittee, called the findings provocative. Although the observational study could not prove causal relationships, Hyman said the findings suggest that maternal metabolic disorders are contributing causes to autism and other developmental disorders. Roughly one in every 88 children has an autism spectrum disorder (ASD), according to a recent estimate from the CDC, and one in every 83 has another developmental delay. Hyman also said that if maternal metabolic conditions are adding to the burden of autism, it is likely a small contribution. She noted that other factors related to obesity that were not captured in the database could be involved in the relationships. She added that mothers of children with disabilities often scrutinize everything they did, ate, and were exposed to during their pregnancy to try to find an explanation. But, she said, "At the time of your child's diagnosis, that's all ancient history. What you have to concentrate on is what you can do, what are effective interventions ... being proactive and changing what you can change is really what research is all about. It's not about pointing fingers." Krakowiak agreed, noting that the study is preliminary and cannot prove cause and effect; it is possible there are other factors involved that independently affect obesity and autism. "So I would definitely not want moms to feel guilty for having any one of these conditions, and that being a cause of their child's disorder," she said. The exact cause of autism has not been identified, but both genetics and environmental factors are believed to be involved. Previous studies have identified an association between diabetes during pregnancy and general developmental impairments in the offspring, although research examining the relationship with autism has yielded mixed results. To further explore issue, Krakowiak and colleagues turned to the CHARGE (Childhood Autism Risks from Genetics and the Environment) study, an ongoing case-control study of children born in California. The current analysis included 1,004 children ages 2 to 5 -- 517 with an autism spectrum disorder, 172 with other developmental delays, and 315 with typical development. All of the children were evaluated using the Mullen Scales of Early Learning (MSEL) and the Vineland Adaptive Behavior Scales (VABS), which assessed cognitive and adaptive development, respectively. The specific metabolic conditions assessed among the mothers were obesity, hypertension, and diabetes (either gestational diabetes or type 2 diabetes) during pregnancy. All three of the metabolic conditions were more frequent among the mothers of children with an ASD or other developmental delay. Combined, the rates were 28.6% for mothers of children with an ASD, 34.9% for mothers of children with a developmental delay, and 19.4% for mothers of typically developing children. After adjustment for sociodemographics and other factors, mothers who had one of the three conditions were more likely to have a child diagnosed with an ASD (OR 1.61) or developmental delay (OR 2.35). Maternal hypertension alone was not related to either outcome, and maternal diabetes was associated with greater odds of having a child with a developmental delay (OR 2.33), but not autism. Maternal obesity was associated both with ASD and developmental delay among the children. Among the children with an ASD, maternal diabetes was associated with "relatively small" impairments in expressive language. Among the children without an ASD, the combination of maternal conditions was associated with a wide range of deficits in cognition and adaptive development. Although a case-control study cannot prove cause and effect, there are some possible mechanisms to explain a relationship between maternal metabolic conditions and a child's neurodevelopment, according to Hyman. Maternal glucose, but not insulin, can cross the placenta. If the mother has elevated levels of glucose, the fetus will have to produce more insulin. The increased oxygen demand that results can induce intrauterine tissue hypoxia. Poorly regulated maternal glucose could also result in iron deficiency in the fetus. Both hypoxia and iron deficiency can harm the developing brain. An alternate explanation is that the proinflammatory cytokines present in mothers with metabolic conditions may impair fetal neurodevelopment. Hyman said all of these explanations are hypothetical and need to be studied further. "I think that we have to look at this as a call to our society that there are multiple implications of the obesity epidemic that we need to consider, and that we need to be proactive in what we can do," she said. "What we can do is we can eat healthy and exercise, and this is a positive suggestion for change. There are so many things we can't change. We can change this."

Banish Shin Splints Forever With One Magical Exercise

The sun is out, the weather's warm, and in a month or so you're going to be parading around the beach nearly naked. Time to shed that winter weight. So you start running. But lo! Just as you start getting results, you also get pain. In your shins. It's bad. Shin splints are one of the most common running and sports injuries, and they can really knock you off your routine. Luckily, with one simple exercise, you can kill your shin splints. Here's how to send them to hell, where they belong. Welcome to Fitmodo, Gizmodo's gym for your brain and backbone. Don't suffer through life as a sniveling, sickly weakling—brace up, man, get the blood pumping! Check back on Wednesdays for the latest in fitness science, workout gear, exercise techniques, and enough vim and vigor to whip you into shape. First off, what are shin splints? The medical name for them is tibial stress syndrome. They're a result of fatigue and inflammation in the muscle tissue in the front of your leg and the posterior peroneal tendon. Pain usually occurs around the front, outer side of your tibia (shin bone). It's generally considered to be an overuse injury, and it's incredibly common. What most people don't realize is just how insanely easy it is to treat. Back when I first started fixing my knees, my physical therapist had me do some very light running on a treadmill. After just a few sessions, I started getting shin splints, and they sucked. I thought it meant I had to stop. Nope. My doc said, "I'm going to give you one exercise routine that you're going to do once a day, and the shin splints will be gone within the week." Sounded like bullshit to me. But, to my amazement, he was absolutely right. Here's how you do it. Instructions: § 1. Find some stairs. Actually, just one stair or a curb will do. § 2. Turn so you're facing down the stairs. Scoot forward until just your heels are on the stair, with the rest of your foot hanging off (you can hold a wall or railing for balance). § 3. With your legs straight, point your toes downward as far as you can, then lift them up as far as you can. Repeat. § 4. Use a timer. Do as many as you can in 30 seconds. Do them rapidly, but with full extension and flexion. § 5. After 30 seconds, bend your knees at a 45-degree angle (about half way). Without pausing to rest, do another 30 seconds of flexing in that position. That's one complete set. If it burns like hell, then you're doing it correctly. § 6. Rest for a minute or two, then do another set—30 seconds with the legs straight, immediately followed by 30 seconds with the knees bent. Rest for a another minute, and repeat the two-part set. § 7. Each day, do three of these two-part sets. The total daily routine includes 6 30-second sessions. That's it. Toe raises. You think I'm crazy. That's fine. Try it. I've been spreading this wisdom for the past ten years like some kind of Johnny Shin Splint-seed and it has worked for literally everyone. I'm eager to hear the results from a larger sample size (that's you, dear readers). The usual disclaimer applies: Everyone's body is different, and if you feel like you're injuring yourself, stop and see a doctor or physical therapist. You may have something else that could require calf stretching, calf raises, shin stretching, or standing on tennis balls to do mid-foot stretching. Some people are told to walk around on their heels, but it seems that this would cause impact and stress on the knees. Really, I've never seen the toe raising exercise fail when performed properly, daily. Have you had shin splint issues? If you've fixed them, how? If you haven't yet, try this and tell us if it works. And tune in next Wednesday for more Fitmodo.