Central Kansas Podiatry Associates

Have high-heel hangover? Here's help

2012-02-01T12:03:00.000-06:00

High heels push the pelvis forward, shifting body weight and loading the small bones and tissues of the forefoot. Hello bunions, fasciitis and hammer toes.

Photograph by: Wayne Cuddington, PNG Merlin Files, Vancouver Sun

We often talk about the post-holiday hangover: the sluggish feeling we get from all the food and drink consumed. But there is another hangover many women experience. It starts in the feet and works it's way up. We're talking about the high-heel hangover.

We all know that high heels are bad for our feet, but there are so many fabulous heels out there and they sure can dress up an outfit and make our legs look great. So we often ignore the obvious and pretend that a well made, well fitting pair of heels is the answer.

Maybe we don't wear them every day, but during the holiday season, with parties every other day, we donned them more often than usual.

And now we are suffering the high-heel hangover.

"Foot health is a really big issue for people over the age of 40, to the point where one in four can't really walk without foot pain," says U.S.-based bio-mechanics expert Katy Bowman, author of Every Woman's Guide to Foot Pain Relief.

According to Bowman, who is also the director of the Restorative Exercise Institute in California, foot pain is the canary in the coal mine of human health. Jimmy Choos and Manolo Blahniks are the poison.

"Your foot pain is like an early indicator of the state of everything," she says. "Every other ailment of the body, from your body composition to even something like depression, all of those ailments are affected by physical mobility. But more than that, foot pain tells us that our knees, hips and back are at risk.

Most of us totally ignore our feet. We may exercise all the other parts of our bodies, but do nothing south of the ankle. Many of us can't spread our toes, fewer still can lift each toe individually.

That is where the problem begins, says Bowman. "The feet are just breaking down under the weight of the body because there is no muscle to resist it."

Then we mess with our posture by wearing high heels.

If we are standing with perfect posture, our pelvis is in the middle of a vertical line from our head to our heels, which as the densest structure of the foot are the best equipped to take our weight, says Bowman.

But when we wear heels, we push the pelvis forward positioning our weight over the front of the feet and loading the small bones and tissues of the forefoot. Hello bunions, fasciitis and hammer toes.

Wearing heels also causes the calf muscle to shorten, which in turn causes a cascade of problems, including knee and hip osteo arthritis. Research has shown people who have worn high heels regularly for more than 20 years have calves 13-per-cent shorter than everyone else.

"That is what causes the knee osteo arthritis, because the calf muscle attaches above the knee joint so the tighter the muscle the less joint space your knee has."

Even low heels can do the damage, says Bowman, adding there is no such thing as a sensible heel, except "in same way as there is a sensible cigarette." If we must wear heels, we should treat them like we treat dessert, she says.

"There is a consequence that comes with eating a lot of desserts and there are steps you can take to mitigate the effects. The same thing goes with high heels.

"If you are going to wear them, instead of trying to come up with a healthier way to do so, you want to come up with another daily habit or habit you cultivate every time you wear them that undoes some of the permanent tissue changes so that you don't have to deal with the full effects of wearing them."

These habits should include stretching, strengthening and wearing flat, flexible footwear or bare feet the rest of the time. Fifteen minutes of exercise a day is enough to protect your feet, says Bowman, and no fancy equipment is needed.

So avoid the hangover. Limit your time in heels and mitigate the damage they do. Here are four basic exercises that anyone can do, even as they watch TV or work at their desk.

Calf Stretch: Put your hands on a wall, place one foot in front of the other and keeping both heels on the ground, bend the front knee until you can feel the stretch in your back calf. Hold 30 seconds. A second calf stretch can be done on stairs; hang one heel off the stair until you can feel the stretch. Hold 30 seconds. Switch.

"A calf stretch is what anyone who wears any shoes should do, because even your general athletic shoe is technically 1½-2 inches (3.8-5 cm) in the heel, so that is a high heel, too," says Bowman. "So calf stretch, calf stretch, calf stretch."

Toe spread: Sit in a chair and rest your feet on an ottoman or low table. Spread your toes so that there is a space between each one. Repeat. (if you can't do this, start with wearing pedicure spacers).

Toe lift: Standing straight, lift your big toes off the ground while keeping all the other toes on the ground. Then lift the other toes one by one.

Tennis ball massage: While seated, roll a tennis ball under your feet to stretch your plantar fascia. If your feet are inflamed or tired, roll your foot over a bottle of water that has been frozen.

Stretching out plantar fasciitis

2012-01-31T12:01:00.000-06:00

Tight hamstrings play an important role in plantar fasciitis, according to a study published in the June issue of Foot and Ankle Specialist.

“These findings show that while we always consider the tightness of the gastrocnemius/soleus complex and the subsequent restricted ankle motion from this equinus, we also need to consider the role of the hamstrings,” said Jonathan Labovitz, DPM, lead author and associate professor at Western University of Health Sciences, Pomona, CA.

The prospective cohort study included 105 participants (210 feet); 79 had plantar fasciitis, which researchers assessed with palpation, who measured popliteal angle with a tractograph and diagnosed hamstring tightness when the popliteal angle ≤160°.

Without controlling for covariates, body mass index (BMI), tightness in the hamstring, gastrocnemius/soleus, and gastrocnemius, and the presence of a calcaneal spur all had statistically significant associations with plantar fasciitis.

After controlling for covariates, participants (86 of 210 feet) with hamstring tightness were 8.7 times as likely to experience plantar fasciitis (p < .0001) as participants without hamstring tightness. Patients with a BMI >35 were 2.4 times as likely as those with a BMI <35 to have plantar fasciitis.

Researchers at Cappagh Orthopedic Hospital in Dublin, Ireland, first linked hamstring tightness with plantar fasciitis in a study published in the December 2005 issue of Foot & Ankle International. The Western University researchers now suggest that an increase in hamstring tightness may induce prolonged forefoot loading and, through the windlass mechanism, may be a factor that increases repetitive plantar fascia injury.

Triceps surae tightness was not included in the Western University covariate analysis, raising the possibility that hamstring tightness was not actually the cause of plantar fasciitis in patients wth tightness in both areas.

“People who have tight hamstrings are more than likely going to have a tight triceps surae,” said Michael T. Gross, PT, PhD, a professor in the Division of Physical Therapy at the University of North Carolina in Chapel Hill. “The investigators of this study admitted that 96% of subjects who had tight hamstrings also had tight triceps surae. Now there’s a cause and effect. If you can’t get dorsiflexion at your talo-crural joint, this often drives dorsiflexion at other joints and that is going to cause collapse of the longitudinal arch of the foot, loading the plantar fascia with increased tensile stress.”

In people with hamstring and triceps surae tightness and plantar fasciitis it’s not known whether the ankle equinus from a tight triceps surae causes hamstring tightness or vice versa, Labovitz said.

“There is no question that the tightness of the triceps surae will cause flattening of the arch and increase tensile stress on the plantar fascia,” Labovitz said. “The question becomes, are the hamstrings involved in this and, if so, to what effect?”

The timing of plantar fascia loading and hip kinematics during gait raise additional questions about possible hamstring involvement, Gross said.

“When loading is taking place at the plantar fascia, it’s mid to late stance. At mid to late stance, the hip is in extension and even hyperextension. Even though the knee is extended, extension/hyperextension at the hip will limit the amount of passive tension that could be developed in the hamstrings, so it is a mystery to me how tight hamstrings would cause trouble for the plantar fascia,“ he said.

Labovitz suggested, however, that a little hamstring tightness might go a long way in influencing the plantar fascia.

“The practical application is that since the hamstrings have been shown to be involved and possibly have more influence than equinus due to the longer lever arm, showing greater effect on the flattening of the foot and plantar fasciitis, less restriction is necessary to have the same effect as equinus,” he said.

The researchers suggest that treatment of plantar fasciitis should address hamstring tightness along with equinus and obesity. Night splints, orthoses, and gait retraining have been shown to be effective for managing plantar fasciitis pain but will not address hamstring flexibility, Labovitz noted.

“The hamstrings should be examined and treated,” Labovitz said. “Stretching is the best treatment for increasing flexibility.”

Shoe stiffness and pressure patterns

2012-01-30T11:57:00.000-06:00

Pressure measurement technology can differentiate between the impact forces of a stability shoe and a flexible shoe during gait, according to a preliminary study presented in August at the annual meeting of the American Society of Biomechanics in Long Beach, CA.

Researchers from Indiana’s Valparaiso University found that walking in a flexible shoe was associated with increased duration of contact at the heel compared with a stability shoe.

“Shoes that are overly flexible in the midfoot region may delay the off-weighting or dorsiflexion of the calcaneus. This can have potential detrimental effects on foot and lower extremity function,” said Bruce Williams, DPM, one of the researchers and a podiatrist in private practice in Merrillville, IN.

The preliminary study of one 21-year-old man compared the impact force profiles produced throughout gait with two different running shoes from the same shoe company.

The flexible shoe featured flexion near the midfoot region of the shoe, while the stability shoe flexed closer to the ball of the shoe. An in-shoe pressure measurement system was used to map the force versus time profile for each shoe type as the participant walked 30 feet.

“In-shoe pressure had not been used to differentiate potential differences in function from shoes of these types and their potential effects on foot function,” Williams said.

In order to evaluate the transition between the heel and ball of the foot, force measurements were recorded for the heel, the ball, and the entire sole of the foot. Three trials for each shoe type were undertaken. To compare force profiles across trials, heel strike to toe off (one period) was truncated and normalized to the time associated with that period.

Force versus time was analyzed for the heel and the ball in order to observe slope variation and compare periods in which impact force was constant. This dwell in the gait cycle represents prolonged ground contact.

The results indicate a significantly longer dwell period in the heel region for the flexible shoe compared with the stability shoe (p < 0.05), at 0.1663 seconds compared with 0.0959 seconds. There were no significant dwell periods in the ball region for either shoe.

Prolonged pronation associated with a lack of midfoot support in the flexible shoe explains this dwell period, according to the researchers. They suggest this may be compensatory pronation in response to a lack of ankle joint dorsiflexion. Although no dwell period was evident for the ball of the foot, the researchers suggested this may not be the case in future studies with additional participants.

There is a definite clinical usage for the pressure measurement technology used in this study, said Williams. The technology holds potential for identifying effects of different shoe construction features on lower extremity mechanics and how those changes can result in pain and impaired function, he said.

The researchers plan to collect further data from a variety of subjects with varying foot types, gender, age, and weight.

“These studies may help design better shoes and help match the shoe construction to activity or foot type,” said Smita Rao, PhD, PT, assistant professor of physical therapy at New York University.

There are a number of questions that remain unanswered with regard to shoe stiffness and pressure patterns.

“Stability and flexible shoes may alter load distribution patterns. This may contribute to the user’s perceived comfort,” Rao said. “Differences in magnitude of regional loading are not discussed [in the pilot study]. It would be helpful if the authors related their findings to specific features of the shoes.”

Further trial data are being examined, said Williams. “Such data have the potential to clarify unanswered questions, such as ‘What other sporting shoe types potentially have an impact like this?’” he said.

Diabetic shoes: Fashion and function

2012-01-28T13:53:00.000-06:00

Every day, people willingly trade good foot health for stylish shoes—think stilettos, platforms, and pointy toeboxes. For some time, however, patients who wore diabetic footwear didn’t have the option of worrying about style versus substance.

“When I began practicing years ago there was only one style of [diabetic] shoe and you could tell from across the room it was an orthopedic shoe,” said Crystal Holmes, DPM, CWS, assistant professor in the Department of Internal Medicine at the University of Michigan in Ann Arbor.

Fortunately, diabetic shoes have come a long way, shedding, to some degree, their designation as clunky and unattractive, and are now available in a variety of styles and a rainbow of hues.

With diabetic shoes, the trade-off between fashion and function gets complicated. Holmes and Hillary Brenner, DPM, of Tribeca Private Medical Group in New York City, shared advice for balancing patients’ desire for fashion with clinical concerns.

Sources said women tend to be more focused on style than men. As a result, the Mary Jane has become a staple of diabetic footwear lines, and serves as an example of how aesthetic needs must be weighed against patients’ pathology and lifestyle.

On the whole, experts approve of this shoe style. Holmes said many of her patients like its versatility for everyday, special occasion, and professional looks.

The style can make extra depth look relatively attractive and is compatible with foot orthoses when they are needed. Mary Janes come in cloth or leather, which can accommodate foot deformities.

This style does have drawbacks: The strap across the front may not be suitable for patients with edema or bony prominences, Holmes said.

Brenner isn’t keen on the opening at the top of the shoe and insists patients wear the shoes with socks, stockings, or tights.

In addition, Holmes noted, the toebox can be very wide while the heel tends to be narrow, so foot slippage inside the shoe can be an issue, Holmes said.

Experts who talked with LER said they make a priority of discussing the clinical objectives of diabetic footwear with patients first, then move on to lifestyle issues.

“I certainly would not prescribe the same shoe for a 90-year-old diabetic patient who is a community ambulator who just goes to the market or walks around her home as for a 60-year-old farmer who still works daily on his farm,” Holmes said.

But it’s a safe bet the 90-year-old will be more concerned about fashion than the farmer.

Matching the shoes to the activity is also important, Brenner said. For example, a three-hour sit-down dinner may be a chance for the patient to don a less clinically appropriate, but more attractive, diabetic shoe. In contrast, a full day of walking at a museum calls for wearing prescribed footwear.

“You want to avoid completely taking away options from a patient,” Brenner said.

Options are key when negotiating fashion and fit with patients. Often, patients get their diagnosis and assume it means diabetic shoes are their only choice.

“Just because a person has diabetes doesn’t necessarily mean she’ll need the shoe with the extra depth or the rocker bottom,” Brenner explained. “A younger person with diabetes whose blood sugar is under control may not need that diabetic shoe. On the other hand, an older patient with some balance issues will need a shoe that offers stability and support. It’s not one-style-fits-all for diabetic patients.”

If a patient is determined to wear a certain style, Holmes tenders a compromise.
“I say to them, ‘I’ll let you wear this shoe for six months. During that time, we’ll check your feet regularly. If we see any problems—a spot of irritation—then you have to agree that you’ll stop wearing that shoe and wear the shoe that I prescribe for you,’” she said.

CDC: Big Drop in Diabetes Amputations

2012-01-27T11:49:00.000-06:00

65% Lower Rate of Foot, Leg Amputations in Just Over a Decade

Jan. 24, 2012 -- There has been a dramatic drop in the rate of diabetes-related amputations in the U.S., and experts attribute the improvement to better management of risk factors that lead to the loss of feet and legs.

The amputation rate declined by 65% among adults with diabetes in a little over a decade, the CDC reports.

Foot and leg amputations occurred in 4 out of every 1,000 adults with diabetes in 2008, compared to 11 out of every 1,00 in 1996, the CDC reports.

Non-injury-related amputation rates were still eight times higher among those with diabetes than adults without the disease.

Nevertheless, the decline shows that efforts to reduce the complications of diabetes are having a major impact, says American Diabetes Association President of Medicine and Science Vivian Fonseca, MD.

“This is very encouraging and important news for people with diabetes,” he says. “The decline confirms the tremendous progress we have made in translating research into practice."

What Your Feet Say About Your Health

Diabetes-Related Amputations Down

Nerve damage or neuropathy is a common complication of diabetes, especially among people who have had the disease for many years.

Poor control of diabetes, such as prolonged high blood sugar, low insulin levels, and high blood pressure, are believed to be major contributors to diabetes-related nerve damage.

According to this new study, foot and leg amputation rates serve as an important gauge of the effectiveness of efforts to reduce diabetes complications by controlling these risk factors.

Researchers analyzed data from two national surveys to determine the prevalence of diabetes-related leg and foot amputations in adults aged 40 and over.

Among the major findings:

· Between 1996 and 2008, the rate of leg and foot amputations among adults with diabetes declined by 65%, with men having three times the rate of amputations as women (6 per 1,000 vs. 2 per 1,000).

· Amputation rates were higher among blacks than whites (5 per 1,000 vs. 3 per 1,000).

· Those over the age of 75 had the highest rate of amputations.

The study will appear in the February issue of the journal Diabetes Care.

Keep a Close Eye on Your Feet

While the decline is encouraging, CDC epidemiologist Nilka Rios Burrows, MPH, says much more could be done to reduce amputation rates among diabetic people.

“The message to patients and their doctors is that addressing the modifiable risk factors for diabetes complications can have a huge impact,” she says.

That means aggressive medical management of blood pressure, blood sugar, and cholesterol, maintaining a healthy lifestyle, and keeping a close eye on your feet.

“A foot exam should be part of every medical visit,” Burrows says. “If the doctor doesn’t mention it, the patient should. And people with diabetes should check their own feet every day to look for sores or injury.”

Other recommendations for diabetic people from the CDC’s National Diabetes Education Program include:

· Wash your feet every day, keep feet soft with lotion or petroleum jelly, smooth corns and calluses gently, and trim toenails frequently.

· Wear shoes and socks at all times to minimize the risk of injury.

· Protect feet from extreme heat and cold.

· Remain active and do other things to promote blood flow to feet.

· Discuss foot care with your doctor.

Stem Cell Therapy May Reverse Diabetes

2012-01-26T09:48:00.000-06:00

An immune regulator from healthy cord blood stem cells (CB-SCs) can "educate" the T cells of a person with type 1 diabetes (T1D), enabling the pancreas to produce insulin....

Yong Zhao, MD, PhD, from the University of Illinois at Chicago, and colleagues base their "stem cell educator therapy" on observations that multipotent stem cells from human cord blood can alter regulatory T cells (Tregs) and islet B cell–specific T-cell clones. The new approach alters autoimmunity both in non-obese diabetic mice and in islet B cells from patients with diabetes.

In a small, open-label trial, a single treatment reduced the median daily dose of required insulin by 38% at 12 weeks for patients with moderate T1D and some B-cell function (36 ± 13.2 U/day at baseline vs 22 ± 1.8 U/day 12 weeks post-treatment), and by 25% in patients with severe T1D and no residual function (48 ± 7.4 U/day at baseline vs 36 ± 4.4 U/day 12 weeks post-treatment). The investigators saw no change in insulin requirements among the control group.

The researchers circulated lymphocytes from patients' blood in a closed-loop "stem cell educator," co-culturing the cells for 2 to 3 hours with adherent CB-SCs from healthy donors. The device sandwiches CB-SCs between 9 discs of a hydrophobic material, with a top cover plate and a lower collecting plate through which the lymphocytes exit. The investigators infused the "educated" lymphocytes into the patients and measured both levels of C-peptide and glycated hemoglobin and indicators of immune function at 4, 12, 24, and 40 weeks.

Investigators conducted this open-label, phase 1/2 clinical trial at the General Hospital of Jinan Military Command in China from October 2010 until January 2011, 15 patients (median age, 29 years [range, 15 - 41 years]; median diabetic history, 8 years [range, 1 - 21 years]) received a single treatment. Three control patients received a sham treatment lacking cells.

Primary endpoints were feasibility (change in C-peptide secretion), safety by 12 weeks, and preliminary evidence of improved B cell function by 24 weeks. Immune modulation was a secondary end point.

Overall, the treated individuals displayed better C-peptide and glycated hemoglobin A1c values, lower daily requirement for insulin, and decreased autoimmunity.

Patients with moderate T1D had improved fasting C-peptide levels at 12 and 24 weeks. Those with severe T1D showed successive improvement in fasting C-peptide levels.

A1c levels for patients with moderate T1D fell from 8.73% ± 2.49% at baseline to 7.67% ± 1.03% at 4 weeks (P = .036), and to 6.82% ± 0.49% at 12 weeks post-treatment. For those with severe T1D, A1c levels fell 1.68% ± 0.42% at 12 weeks post-treatment, with no change seen in the control group.

Stem cell education significantly increased the percentage of Tregs in peripheral blood, as well as levels of CD28 and inducible co-stimulator. Cytokine balance improved. The CB-SCs produce an autoimmune regulator which may eliminate autoreactive T cells.

"This innovative approach may provide CB-SC-mediated immune modulation therapy for multiple autoimmune diseases while mitigating the safety and ethical concerns associated with other approaches," conclude the researchers.

BMC Med. Published online January 10, 2012.

Bariatric Surgery Not a Cure for Diabetes

2012-01-25T11:41:00.000-06:00

According to Dimitrios Pournaras, MD as reported in the BMJ, "Bariatric surgery (gastric bypass, sleeve gastrectomy, or gastric banding) leads to complete remission in only about one third of patients with type 2 diabetes, and should be viewed as a means for improving glycemic control, not as a cure."...

Using the recently updated American Diabetes Association (ADA) standard, which defined diabetes remission as hemoglobin (Hb) A1c levels below 6% and fasting glucose levels less than 100mg/dL.(5.6 mmol/L ) at least 1 year after bariatric surgery without hypoglycemic medication, the researchers found remission to be substantially lower than had been reported with earlier criteria.

Using data from 1006 patients, 209 of whom had type 2 diabetes at the time of gastric surgery, and a median follow-up of 23 months postsurgery, complete remission rates, using the new ADA standard, were 40.6% after gastric bypass (65/160 patients), 26% after sleeve gastrectomy (5/19 patients), and 7% after gastric banding (2/30 patients). However, the authors explain, "The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40.6 versus 57.5 per cent; P = 0.003)." Remission rates for the other 2 procedures were not significantly different according to the new vs the old criteria.

The data, which were collected prospectively in 2 bariatric surgery centers in the United Kingdom and 1 center in Norway, also showed that on average, patients remained obese after surgery (preoperative body mass index [BMI], 48 kg/m2 vs postoperative BMI, 35 kg/m2). After surgery, oral hypoglycemic medications were still used by 29.4% of gastric bypass patients, 63% of sleeve gastrectomy patients, and 83% of gastric banding patients.

HbA1c levels were significantly lower after surgery in all 3 surgical groups, with mean levels of 6.2% (compared with 8.1% before gastric bypass), 6.8% (compared with 7.5% before sleeve gastrectomy), and 6.3% (compared with 7.7% before gastric banding; P < .001 for each comparison).

The authors note that these findings are important for "establishing realistic expectations among patients, clinicians, and policy-makers" regarding bariatric surgery in the management of type 2 diabetes. They suggest that emphasis should shift to bariatric surgery as an aid in achieving glycemic control, rather than as a tool for achieving remission.

The authors conclude, "The principal benefit of surgery, however, would not be to improve glycemic control per se but rather to reduce microvascular and macrovascular complications associated with diabetes. The findings of this study emphasize the need for intensive follow-up of patients with type II diabetes following bariatric surgery, in order to review pharmacological treatment, monitor for complications of diabetes, and ensure that adequate glycemic control is achieved."

Br J Surg. 2012:88:100-103.

Assessing PTTD: Linking the kinetic chain

2012-01-24T11:33:00.002-06:00

Many studies of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot disorder, have focused on foot kinematics and benefits of bracing for pain relief and increased ambulation. But new findings from the University of Southern California in Los Angeles suggest clinicians also look higher along the kinetic chain when determining an effective treatment.

A September 2011 Journal of Orthopedic & Sports Physical Therapy study by USC researchers revealed women with PTTD performed significantly fewer single leg heel raises and repeated sagittal and frontal plane nonweight-bearing leg lifts; had at least 27% less hip abduction endurance; showed nearly 40% less hip extensor endurance; and reported a 50% increase in pain after a six minute walk test when compared with age-matched controls. Hip torque and calf muscle strength were also dramatically inferior, and, most interestingly, weakness was apparent in the involved and uninvolved limbs of participants with PTTD.

“The hip deficits that appeared bilaterally were surprising, as our hypothesis was that the hip deficits would be on the same side as the PTTD,” said Lisa M. Noceti-DeWit, DPT, ATC, adjunct instructor of clinical physical therapy at USC. Noceti-DeWit coauthored the study with university colleagues, including Kornelia Kulig, PhD, PT, a Catherine Worthingham fellow. “At this point, our research team is not yet able to speculate why the hip deficits are bilateral. We do feel that clinicians should assess hip strength in women with PTTD and provide appropriate intervention if deficits are found.”

Hip weakness may not be specific to women with PTTD, but reflective of general deconditioning or changes in motor control for a variety of reasons, explained Jeff Houck, PT, PhD, associate professor of physical therapy at New York’s Ithaca College, where he specializes in clinical biomechanics and orthopedics.

“One might ask about knee strength in these patients. If it is also lower, it would indicate more general deconditioning,” Houck said.

General strengthening approaches combined with functional exercises may be helpful, especially from a general health perspective, Houck suggested.

“However, the impact on clinical management of tendinopathy is not determined, therefore the weakness may not be specific to PTTD, but rather a secondary effect,” he said.

Women are three times as likely as men to be diagnosed with PTTD, and the disorder is most frequently found in women in their 50s. PTTD appears to peak during perimenopause, prompting research into female hormonal indicators, including estrogen receptors. A Pennsylvania State College of Medicine study, published in the December 2010 Foot & Ankle International, found no significant gender-related differences in estrogen expression in diseased posterior tibial tendons and no differences in estrogen receptors in diseased tibial tendons versus controls of healthy posterior tibial or flexor digitorum longus tendons. Larger studies may yet explain the role of estrogen in the overall health of tendons and connective tissues.

Houck suggested clinicians be cautious when employing ankle foot orthoses in women with PTTD unless the devices allow some ankle plantar flexion. His studies have shown more restrictive devices may lead to compensatory gait alterations that further weaken the ankle plantar flexors.

“The hip compensation to adapt to a decreased push off may be a stronger hip flexor contraction, resulting in a pull off rather than a push off. The further weakening of the ankle plantar flexors may aggravate the overall condition,” Houck said.

This overemphasis on hip flexion could help explain the reduced hip extensor endurance associated with PTTD in the USC study.

Changes in subtalar motion may also affect hip mechanics in patients with PTTD, Houck added.

“Subtalar inversion/eversion fine-tunes standing balance, and the hip abductors and adductors are major players in maintaining balance. Therefore, losing control at the subtalar joint as a result of PTTD may require some compensations at the hip. This may manifest as lower single leg stance time or increased trunk movements during single leg stance,” he said.

Future targeted studies exploring connections beyond the foot and ankle may elucidate whether existing hip weakness predisposes women to PTTD, or whether PTTD through its various stages complicates movement affecting both hips.

By Christina Hall Nettles

Weight Loss Is Not The Answer for Preventing Diabetes

2012-01-19T12:56:00.000-06:00

Richard Kahn, PhD, who was the chief scientific and medical officer of the ADA for nearly 25 years stated at a conference that, "Community-based weight-loss programs have not been shown to be effective at reducing the incidence of diabetes, so implementing a national program would likely be money down the drain."...

He stated that, "Community programs are ineffective at achieving weight loss."

Kahn -- who now teaches medicine at the University of North Carolina at Chapel Hill -- said that just sustaining significant weight loss, even with intensive dieting, exercise, and coaching, "requires near-heroic measures" in the face of a "very hostile food environment."

He outlined his views in a published paper, in which he wrote that there are two ways to dramatically reduce the toll of diabetes: One is to detect diabetes early and then treat it so effectively that complications from the disease are practically zero. The other is to prevent diabetes before it even happens.

Thousands of public health campaigns are aimed at prevention, and for diabetes, that generally means losing weight. But people have the "fundamental problem" of not being able to maintain weight loss, so preventing diabetes in a person at high risk for the disease is extremely difficult, Kahn said.

His paper looked at diabetes prevention studies, including the large Diabetes Prevention Program, in which patients lost an average of between 4% and 6% of their body weight (but gained about 40% back by the end of the nearly three-year trial). It also looked at the government-funded Look AHEAD trial, which found that intensive lifestyle changes resulted in a major reduction in cardiovascular risk factors, but the effects greatly diminished after four years when many participants gained weight and lost their improved fitness.

Kahn said those studies, along with the Finnish Diabetes Prevention Study -- in which the greatest diabetes prevention benefit occurred in people who lost at least 5% of their body weight -- suggest that "without substantial, sustained weight loss, progression to diabetes will probably resume." Progression to diabetes may be delayed for a few years, but the long-term effects are uncertain, he said.

(However, a preliminary study presented at the American Diabetes Association meeting last year found that a short-term lifestyle modification program for overweight diabetic patients showed long-term benefits for many of the participants.)

"In sum, to date, we have not seen a demonstration of any program that results in a clinically meaningful weight loss that can be maintained for more than two to three years in the great majority of participants and at a low cost," Kahn wrote.

Kahn's remarks preceded those of Kenneth Thorpe, of Emory University, who outlined how the healthcare reform law laid the groundwork for a national, community-based diabetes prevention strategy modeled on the Diabetes Prevention Program.

Kahn said that would be a waste of money. "The main argument is that implementing a nationwide community intervention program is not going to do anything, I believe, except waste resources." He also stated that there are too many unanswered questions about how weight loss works that must be answered before a national program would ever succeed in preventing diabetes in the long term.

"We really need to know what is going on with this complex system we have," he said. "What is going on in our physiology that precludes us from losing weight and keeping it off?" Another issue that prevents people from keeping weight off is the ubiquity of the "cheap, widely available, delicious food that we eat again and again."

He suggested "painful policies" as the solution -- such as raising the price of all food except for fruits and vegetables, and offering financial incentives to people who can keep weight off, while penalizing overweight people with higher insurance premiums.

He acknowledged those aggressive policies likely would be unpopular among members of Congress and doctors. "While we wait for the time when lifestyle modification becomes practical, we might be better served by focusing more attention on improving our understanding of the processes that affect energy intake and expenditure and improving the medical management of diabetes," Kahn wrote.

Those medical management strategies include making an early diagnosis and administering "proven treatments that have been shown to reduce complications of diabetes and extend life," he said.

He added that the best doctors can offer right now is to suggest to overweight patients that losing 4% body weight and keeping it off can reduce the risk for serious complications of diabetes by 15% to 20%.
Health Affairs, Jan. 2012

Paula Deen Announces She Has Diabetes

2012-01-18T12:51:00.002-06:00

TV chef Paula Deen—the queen of deep-fried Southern cooking—joins Halle Berry, Randy Jackson, Dick Clark and 28.5 million other Americans in battling diabetes.

The Daily reported last week that the Food Network star--famed for artery-clogging fare as deep-fried macaroni and cheese—wrapped in bacon—would soon come clean about a “big fat secret," her type 2 diabetes diagnosis. Deen just announced the diabetes news with Today’s Al Roker.

Rumors about Deen’s diabetes first surfaced in April when both the National Enquirer and The Daily Mail reported that the bestselling cookbook author was keeping her disorder hidden due to concerns that it would harm her career. However, learning that she has a disease strongly linked to obesity and unhealthy eating would hardly shock fans who have watched her prepare such belly-busters as egg-and-bacon-topped burgers served between two glazed donuts.

Deen, who has described butter as “a little stick of smiles and happiness,” has already come under fire for the lavish amounts of fat and sugar in her cooking. Now that the diva of the deep fryer has confirmed a diabetes diagnosis, what might be ahead for her? Here’s a look at a disease that’s predicted to affect in one in three Americans in coming years if current trends continue.

Use these 7 diabetes tips to manage your condition

What triggers type 2 diabetes?

While the cause isn’t fully understood, type 2 diabetes starts when the body becomes insensitive to insulin, a hormone that acts like a key to let sugar—the body’s main source of fuel—into cells. This forces the pancreas to pump out higher and higher amounts of insulin, to try to keep up with demand. Ultimately, the pancreas becomes exhausted and blood sugar rises, leading to diabetes. A diet that’s high in saturated fats—such as the deep-fried dishes that figure prominently in Deen’s cooking—also increase insulin resistance.

Who’s at risk?

Like Paula Deen, about 90 percent of people who develop type 2 diabetes are overweight. And the more belly fat you have, the more likely you are to develop insulin resistance. A particular danger zone is a waist circumference of more than 35 inches for a woman and 40 inches for a man.

Other risk factors include family history, a couch potato lifestyle, age (risk rises significantly after age 45), and ethnicity, with African-Americans and Hispanics, Native Americans and Asian Americans facing a greater threat of the disease. Women who have had gestational diabetes during pregnancy or who have given birth to babies weighing over 9 pounds are also at higher risk.

Learn which foods can help diabetes patients manage their blood sugar

What are the symptoms?

One-third of the 28.5 million Americans with diabetes and the 87 million with pre-diabetes (an earlier stage) don’t know it because the disease may not cause symptoms until serious complications set in.

Warning signs include increased thirst, frequent urination, extreme hunger, blurred vision, slow-healing wounds, and frequent infections, such as gum infections, bladder infections, or yeast infections.

How dangerous is diabetes?

The disease triples the danger of heart attacks and strokes. Other complications, particularly if diabetes goes undiagnosed and untreated, include kidney damage, nerve damage, blindness, foot infections and lower leg amputation.

Recent research suggests that high blood sugar may also boost for Alzheimer’s disease in diabetes with a certain gene. A 2011 study linked high blood sugar to increased risk for colon cancer.

Read about how diet affects your children's risk of diabetes

What’s the best test to check for diabetes?

The American Diabetes Association (ADA) considers the oral glucose tolerance test the “gold standard” for diabetes detection. After an overnight fast, you’ll drink a sugary liquid, with blood samples taken at timed intervals to measure sugar levels. The ADA also recommends the A1C blood test, which measures your average blood sugar level for the past two to three months. Have your blood sugar checked every three years, starting at age 45, or at a younger age if you are overweight with at least one other risk factor.

Is there a diabetes diet?

There’s no specific diet advised for everyone with the disease. However, large studies show that focusing on low-fat, high-fiber foods—such as fruits, vegetables and whole grains—is the healthiest plan for diabetes.

Figuring out the what to eat can be complex for people who are newly diagnosed, so doctors advise working with a registered dietician to develop a meal plan that takes health goals, food preferences and lifestyle into account.

Find out about the top 5 diabetes-healing supplements

What’s the treatment?

Along with a healthy diet, therapies for type 2 typically include medication—which can include both diabetes drugs and statins to reduce heart disease risk--exercising at least 150 minutes per week, and weight loss. Deen may want to take cooking lessons from such chefs as Art Smith, who shed a whopping 85 pounds after getting a diabetes diagnosis.

And if you have pre-diabetes, a review of 28 previous studies, published in Health Affairs this month, finds losing 5 to 7 percent of your body weight (10 to 12 pounds if you weight 200), coupled with stepping up exercise and improving your eating habits, cuts the risk of progressing to full-blown diabetes by 50 percent.

Will Deen now revamp her famously fatty recipes to trim down calories? And if so, will her fans be willing to give up deep-fried Twinkies and eat more veggies? Stay tuned to see what the TV chef dishes up next.

Start Good Habits Early

2011-12-24T10:58:00.000-06:00

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?

2011-12-23T11:46:00.000-06:00

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

2011-12-22T10:42:00.000-06:00

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

2011-12-21T15:15:00.000-06:00

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?

2011-12-19T12:28:00.000-06:00

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

2011-12-18T12:20:00.002-06:00

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

2011-12-16T12:07:00.000-06:00

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?

2011-12-15T11:43:00.000-06:00

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?

2011-12-14T08:37:00.000-06:00

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

2011-12-12T16:37:00.000-06:00

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

2011-12-11T11:16:00.001-06:00

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?

2011-12-09T13:13:00.000-06:00

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

2011-12-08T10:10:00.000-06:00

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

2011-12-07T11:07:00.002-06:00

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

2011-12-02T09:20:00.000-06:00

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

2011-12-01T15:15:00.002-06:00

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

2011-11-17T16:42:00.001-06:00

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

2011-11-17T11:38:00.001-06:00

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

2011-11-08T09:00:00.000-06:00

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

2011-11-06T08:55:00.000-06:00

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.

Regular trips to a podiatrist will help keep you on your toes

2011-11-04T10:47:00.000-05:00

It's all too easy to take healthy feet for granted — they take you where you want to go without complaint and don't ask for much in return. But, over time, those puppies can really start barking due to corns, calluses, bunions and other assorted ailments.

Many people are surprised to learn that the normal aging process affects feet as much as any other body part. Feet become wider and flatter, the protective fat pads on the soles thin out and circulation throughout the feet can decrease, all of which can lead to foot pain and damage. But you don't have to suffer alone. You — and your feet — need an ally. That's where a podiatrist comes in.

Doctors of podiatric medicine focus their practices entirely on the foot, ankle and lower leg. Their medical education and training includes four years of undergraduate education, four years of graduate education at an accredited podiatric medical college and two or three years of hospital residency training. Each state requires podiatrists to be licensed to practice there.

"We're primary physicians and specialists for the foot and ankle," says Dr. Marlene Reid, president of the Illinois Podiatric Medical Association. "That's all we do, which means it's best to go to a podiatrist for any foot or ankle condition, large or small."

Unlike many familiar screening guidelines, like getting your first mammogram at age 40 or your first colonoscopy at age 50, there is no definite rule about when to start seeing a podiatrist. "I always suggest coming in for an initial look once you're past your 30s," says Dr. Kirk Contento of Contento Foot & Ankle Center in Palos Heights and Chicago. "We're all about preventing little problems from developing into something major later."

Here are three common foot conditions that become all the more common as we age, and here's what to do about them.

1. Toenail fungus - Podiatrists suggest seeing a podiatrist whenever a nail thickens or becomes discolored. "The doctor can thin the nail, then medicate topically or orally and get the patient started on a good home treatment regimen," Contento says. "Fungal infections often thicken the nail, which can lead to a secondary problem of an ingrown nail." Lasers are also an emerging new treatment for this common problem.

2.Arch strain and heel pain - One word here: Orthotics. Either custom or over-the-counter are fine, as long as you receive adequate arch support. "The tendon that supports the foot's arches weakens over time due to decreased blood flow, which means your arch drops," says Reid. "It usually starts as a vague feeling of weakness or muscle strain and is often misdiagnosed as plantar fasciitis. People tend to ignore it but it can cause the tendon to rupture, which may require surgical repair."

3. Arthritis - People tend to think about big-toe bunions when they think about arthritis in the foot, as arthritis often follows when bunions develop. But Reid, who practices in Naperville, says arthritis can develop in any joint. "Older people often develop arthritis across the top of the foot or in the instep, and it's quite painful," she says. "This is another instance where proper orthotics early on can make a big difference."

One last caveat: If you have diabetes, put your podiatrist on speed-dial because you'll be seeing a lot of each other. "Diabetes is a multi-organ disease that requires constant vigilance because decreased blood flow and neuropathy magnifies everything that happens in the feet," says Contento. "I want to see all my diabetic patients twice a year if they are not having problems and every 2 to 3 months if they are. Diabetics literally should not even be cutting their own toenails due to the risk of infection."

Fortunately, Medicare should cover nail trims every 60 days for people with diabetes. "That's a good interval," Contento says. "It lets me check the feet's skin, neurological status and circulation on a regular basis."

According to Reid, at a certain point, even people 55+ without diabetes should plan on leaving the regular foot care to a pro: "Once reaching or seeing your toes becomes a problem, plan on coming in every few months. An office visit charge of $40-$60 is well worth the peace of mind."

Copyright © 2011, Chicago Tribune

Lymphedema presents therapeutic challenges

2011-11-03T11:43:00.000-05:00

Although lymphedema in the past has often been overlooked or misdiagnosed, a growing number of certified practitioners are using the conservative treatment techniques of manual lymph drainage and complete decongestive therapy to effectively treat lymphedema patients.

By Harold Merriman, PT, PhD, CLT

The clinical importance of lymphatic system disorders is becoming better known among members of the medical community, including physicians and therapists. Most prominent of these disorders is lymphedema, which involves a buildup of protein-rich lymph fluid in the interstitium.

Some of the most common known causes of lower extremity lymphedema include pelvic or lower extremity cancer and cancer treatment (e.g, lymph node resection or radiation) that can damage the lymphatic system. Other causes of lymphedema may be much more subtle, such as an insect bite or sunburn that could irreversibly damage an already compromised and susceptible lymphatic system. Though lymphedema can be found in all types of individuals, active and fit individuals are less likely than obese individuals to develop lymphedema.

Once the diagnosis of lymphedema has been made, appropriate conservative treatment should be administered. Currently, a certified lymphedema therapist (CLT) is the provider of choice to administer the recommended conservative treatment. Before the 1980s, most of the research and treatment of lymphedema and related disorders occurred in Europe. Now there are also many opportunities for practitioners to obtain advanced training in lymphedema in North America. For example, in North America a number of lymphedema schools teach certification courses that allow practicing clinicians to become certified lymphedema therapists. The Lymphology Association of North America (LANA) administers a nationally recognized lymphedema certification exam to qualified and experienced lymphedema clinicians.1

Though the topic of lymphedema and related disorders is becoming better understood, patients with these disorders may still be ignored, misdiagnosed, or simply unable to find proper treatment. Unfortunately, in many areas of the United States there is a currently a shortage or absence of qualified clinicians who can successfully treat these conditions. This article will briefly review the anatomy and physiology of the lymphatic system and discuss the conservative treatment options for the lymphedema patient.2-5
Lymphatic anatomy and physiology

Lymph originates from blood plasma that leaves the blood capillaries and enters into the interstitum. A percentage of that interstitial fluid then enters the lymphatic system, where it is then called lymph. Lymph matter consists of proteins, water, fatty acids, and cellular components. The typical lymphatic system vessel has a three-layer wall structure and presence of valves, similar to the vessels of the venous system. The inner layer (intima) consists of endothelial cells, the middle layer (media) is made up of smooth muscle, and the outer layer (adventitia) is formed by collagen fibers that are loosely anchored to the extravascular connective tissue.4

The functional unit of the lymph vessel is the lymphangion, which consists of a lymph vessel bordered by two valves. As the lymphangion contracts due to the presence of smooth muscle in the middle layer, the valves provide directionality so that the lymph flows in only one direction. It should be stressed that the lymphatic vessel, unlike the vein, regularly contracts (under the control of the autonomic nervous system) and that this contraction rate can change depending on a number of factors. For example, the lymphangion contraction rate can be stimulated to increase during the hands-on portion of conservative treatment.

While the lymphangions have a distinct three-layer wall construction with valves, not all lymphatic vessels are that well organized. The first type of vessel that collects what will later become lymph fluid is called the initial lymph vessel or lymph capillary. These vessels are blind or dead-end sacs (tubes) consisting of a single layer of endothelium with junctions that can open and close to let in interstitial fluid. The initial lymph vessels lack valves and are located near the blood capillaries. As this fluid flows unidirectionally toward the heart, the lymphatic vessels become larger in diameter and more organized. The lymph collectors and the even larger lymph trunks have the distinct three-layer wall construction with valves. The diameter of the lymph collectors can be as large as 0.6 mm, and the lymph collectors’ valves are spaced 0.6 cm to 2.0 cm apart.3,5 Lymph then flows into the larger lymphatic trunks. The most important lymphatic trunks are the right lymphatic duct and the thoracic duct, which drain the lymph into the venous system near the heart at the right and left venous angles, respectively. The right lymphatic duct drains the right arm, right side of the head, and right upper trunk; meanwhile, the body’s largest lymphatic trunk, the thoracic duct, drains the left arm, left side of the head, both legs, and the rest of the trunk. 2-5

As the lymph moves unidirectionally in the lymphatic vessels, lymph nodes filter and concentrate the lymph and also provide immune surveillance using T & B lymphocytes. The 600 to 700 lymph nodes found in the human body are concentrated in the neck, axilla, chest, abdomen and—most importantly for the lower extremity practitioner—in the groin. In addition to immune defense, the lymphatic system plays a critical role in fluid homeostasis as well as transport and drainage of excess fluids, proteins, and cellular debris from the interstitial spaces that are not reabsorbed by the venous system. One can think of the lymphatic system as the body’s “sanitation system,” whose purpose is to dispose the body’s “waste material.”2-5

Lymphedema results from mechanical failure of the lymphatic system, which leads to an accumulation of protein-rich edema in the interstitium. Mechanical failure means that the “lymphatic load” (amount of lymph transported in a given time period) exceeds what an impaired lymphatic system can handle (transport capacity). In most cases, lymphedema will present itself in a single extremity, or in bilateral cases one extremity will often be more involved than the other (asymmetry). Though one might picture lymphedema occurring mostly in the upper extremity, often lymphedema (especially primary lymphedema) occurs in the lower extremity as well. 2-5

Diagnosis of lymphedema

Lymphedema is the most common disease of the lymphatic system. It is estimated that lymphedema affects 140 million to 250 million people worldwide and at least 3 million Americans.5 Lymphedema exists in two different forms, primary and secondary. Primary lymphedema is believed to result from an abnormally developed lymphatic system that can present either at birth or later in life. In many cases there is no known cause of primary lymphedema. However, in some cases heat, puberty, pregnancy or minor trauma such as insect bites, infections, sprains or strains may be identified. 2-5

In contrast, secondary lymphedema results from a known insult to the lymphatic system that causes a reduced transport capacity. Specific insults to the lymphatic system include surgery, radiation, trauma, tumor growth, infection, and chronic venous insufficiency. 2-5 The two worldwide most common causes of secondary lymphedema are breast cancer surgery and lymphatic filariasis. It should be stressed that even with the advent of less invasive modern surgical techniques such as sentinel lymph node biopsy and lumpectomy, lymphedema may still occur after breast cancer surgery and treatment. 2-5

Since lymphedema usually begins distally, it will first be noticed in the lower extremity in the toes, feet, and ankles before progressing proximally up into the thighs. Lower extremity lymphedema would typically be caused by a lymphatic insult in the lower extremity and/or pelvic region, but not by an upper-body lymphatic insult such as breast cancer surgery. The classic sign of lymphedema is a positive Stemmer skin fold sign, which can be defined as a thickened skin fold at the base of the second toe such that the tissue cannot be lifted away from the bone.6 A summary of lymphedema clinical features are listed in Table 1. Since there is no pain associated with lymphedema, the classic symptom that brings a patient to a lower extremity practitioner is edema or infection (cellulitis), which becomes more prevalent as lymphedema severity increases.2,4

It should also be mentioned that combination forms such as lipo-lymphedema are not uncommon. Lipo-lymphedema is a condition in which individuals with lipedema (symmetrical accumulation of fat rather than edema in the subcutaneous tissue) later develop lymphedema in addition to the underlying and ongoing lipedema. Unfortunately, many lipedema patients develop lymphedema since the accumulation of fatty tissue from lipedema causes compression of the superficial lymph vessels.2

Table 1. Lymphedema characteristics

Clinical Feature
Lymphedema

Gender
Women > men

Distribution
Unilateral, or bilateral with one leg usually affected more severely (asymmetric)

Pain on pressure
Absent

Easy bruising of affected area (hematoma)
Absent

Distal edema in the foot
Present

Stemmer sign
Present (positive)

Treatment

It is well documented that lymphedema is best treated using conservative methods administered by the certified lymphedema therapist.7-12 Unfortunately at times, lymphedema is still treated with diuretics, which is contrary to treatment guidelines set forth by the International Society of Lymphology and by other lymphedema physician specialists.2,4,12 Perhaps the best known conservative method is manual lymph drainage (MLD) which is a component of complete decongestive therapy (CDT). MLD is a gentle manual treatment technique originally developed in the 1930s by the Danish couple Emil and Estrid Vodder.2,5

CDT consists of two phases; phase I is the treatment phase, and phase II is the self-management phase. CDT and MLD should only be performed after the CLT has determined that no contraindications (e.g., acute infections or cardiac edema) are present. Phase I treatment consists of MLD, compression bandages, exercise (in bandages), and meticulous skin care (to cure/prevent bacterial and fungal infections). Once the reduction in lymphedema begins to plateau, the CLT will transition the patient to the self-management phase II. Phase II consists of compression (typically achieved by a customized garment during the day and bandages at night), exercise (with the limb in either a compression garment or bandages), meticulous skin care, and MLD as needed. Patient compliance with all treatment components (especially during phase II) is the key to a successful long-term outcome, and it is crucial that the patient, therapist, and other caregivers work together as a team.5

One of the most important skills the CLT performs is to provide MLD in the proper sequence. Since MLD increases lymph flow, the therapist does not want this increased lymph flow to overload and further damage an already impaired lymphatic system. For this reason, the CLT may need to initially limit the area to be treated by MLD. For example, if a patient has lymphedema in both legs, then the CLT may elect to initially focus on only one leg. Typically, the lymphedema therapist should first perform MLD on central and uninvolved areas, followed by performing MLD on the involved areas (e.g., the leg). This MLD strategy prepares the uninvolved areas to receive the additional lymph flow from the affected extremity. Again, it is very important that the lymphedema therapist administers MLD in a proper manner and sequence in order to obtain optimal outcomes.5

Proper compression during both phases of CDT is the key to the successful management of the lymphedema patient. If the affected areas do not receive constant and appropriate compression, the improvements achieved by MLD will be temporary (may last only a few hours).5 Therefore, the lymphedema therapist should have a frank discussion with the patient during the initial evaluation outlining the extreme importance of continuous compression of the affected extremity. This discussion should include the reasons why compression is so important, determining the method by which the patient (or other caregiver/family member) can don/doff the compression bandages or garment at home, and alerting the patient to the financial implications of proper compression since two compression garments per affected extremity will need to be purchased about every six months.

In order to achieve appropriate compression during phase I, the lymphedema therapist should use textile-elastic short-stretch bandages that provide a high working pressure when the muscles contract (in contrast with long-stretch Ace bandages, which have a low working pressure). These compression bandages should be applied in such a way that there is more compression distally than proximally. This compression gradient can be achieved by applying more layers of bandage distally and fewer layers proximally.

The lymphedema patient is ready to be fitted for a garment (used for phase II) when the improvements in limb circumference measurements begin to “plateau”. Although ready-made lymphedema garments are available, custom garments are usually made for patients with advanced stages of lymphedema. Compression for lower extremities is often in the range of 40 mmHg to 50 mmHg, and values less than 20 mmHg are not suitable for successful lymphedema management.5

Any exercise or activity that contracts the muscles in the affected area will likely benefit the patient, as activity can promote lymphatic system function. However, the patient should be reminded that during both phase I and phase II, exercises of any type or any strenuous activity should only be performed when the affected extremity is compressed by either a bandage or garment. One helpful strategy when developing an exercise program for a lymphedema patient is to start gradually, and to first start with core muscle and breathing exercises, then proceed to more distal exercises, and finally return to the core muscles and breathing exercises. Examples of distal exercises include toe clenches, ankle curls, heel slides and bike riding.5 It is also very important to carefully monitor the affected extremity of the lymphedema patient during and after the exercise and/or activity to determine if the lymphedema has increased, stayed the same or decreased. Of course, if the lymphedema increases, the intensity and frequency of the exercise should be reduced. 5,12

Lymphedema treatment implications

Only a properly trained lymphedema therapist should treat and educate patients with lymphedema. Unfortunately in North America, extensive instruction during physical therapy schooling is not yet standard. The American Physical Therapy Association APTA), among other groups, is looking for ways to increase the level of expertise among its members. However, with the proliferation of lymphedema certification courses available in North America, many physical therapists and other healthcare professionals are becoming CLTs. These certification courses are 135 hours or more in length and include both didactic and laboratory portions. A number of accelerated certification programs include an extensive pre-course component, allowing the practitioner to take less time off from work. Other important lymphedema resources include the National Lymphedema Network (NLN) and the International Society of Lymphology (ISL).12,13

While lymphedema in the past has often been overlooked or misdiagnosed, a growing number of CLTs are using the conservative treatment techniques of manual lymph drainage and complete decongestive therapy to effectively treat lymphedema patients. An understanding of the pathophysiology of lymphedema on the part of lower extremity practitioners and an ability to recognize the symptoms will enable more patients to get the treatment they need.

New frontiers in PTTD

2011-11-02T13:29:00.000-05:00

Focus is on ultrasound, hip strength

Research presented in February at the Combined Sections Meeting of the American Physical Therapy Association highlighted underappreciated clinical characteristics of posterior tibial tendon disorder that could influence patient management.

Tendon thickness as measured using high-frequency ultrasound may help determine which patients with Stage II PTTD are most likely to benefit from conservative interventions and which might be better candidates for surgery, according to research from Upstate Medical University in Syracuse, NY.

Ultrasound imaging identified 12 Stage II patients with abnormal tendon thickening, seven with tendon enlargement and five with tendon atrophy. Mean tendon cross sectional area was 39.7 mm2; those with tendon enlargement averaged 53.4 mm2 while those with atrophy averaged 24.6 mm2.

Tendon thickness was not visibly evident prior to imaging, nor were there apparent functional differences between subjects at presentation. However, the researchers did observe significant kinematic differences between the two groups. Patients with tendon enlargement demonstrated significantly greater range of motion for hindfoot inversion/eversion, forefoot plantar/dorsiflexion, and total excursion; forefoot abduction/adduction did not differ significantly between groups.

Although PTTD is typically thought to be associated with tendon enlargement as the result of degeneration, the Syracuse findings show that tendon atrophy also occurs. The kinematic differences related to relative tendon thickness could help explain inconsistencies in patient response to exercise interventions, and knowing the cross sectional area of an individual patient’s tendon could facilitate more effective patient management.

“Targeted exercises to move the foot may be possible in the tendon enlargement group, and conservative or alternative treatments may be indicated,” said Christopher Neville, PT, PhD, an assistant professor of physical therapy at Upstate Medical University, who presented the results at the Combined Sections Meeting. “The tendon atrophy group may be surgical candidates, or if they don’t have surgery, the goal of treatment may be to protect the secondary structures that maintain foot posture and stability.”

A second study from the University of Southern California suggests that practitioners may also want to consider proximal joint kinetics in their patients with PTTD.

After anecdotally noting increased frontal plane motion at the hip in patients being seen for PTTD, researchers compared hip and calf muscle performance in 17 female patients with Stage I PTTD and 17 healthy matched controls. Patients reported a history of symptoms lasting from six months to one year.

They found that the PTTD patients demonstrated significantly lower levels of strength and endurance across the board, with 33.8% less hip extensor torque, 38.5% less hip extensor endurance, 28.5% less hip abduction torque, 27% less hip abduction endurance, and 62.9% less calf muscle strength. Interestingly, these effects were seen in the uninvolved limb as well as the involved limb. The PTTD patients also covered significantly less distance on the six minute walk test (497 m vs 571 m) and reported as much as a 50% increase in pain following the test.

These two sets of findings may be related, said Lisa M. Noceti-DeWit, DPT, ATC, adjunct instructor of clinical physical therapy at USC, who presented her group’s findings at the Combined Sections Meeting. The researchers theorize that because the PTTD patients walk more slowly, their muscles—all the way up the lower extremity—are being underutilized and over time lose their strength and endurance capacity.

“Walking does not depend solely on the actions of the foot and ankle,” Noceti-DeWit said.

The researchers are unable to tell from this study whether the decreased walking velocity occurred as a result of the pain of PTTD or whether other mechanisms may have been involved. Nevertheless, the findings suggest that practitioners treating patients with PTTD should not limit their focus to the most distal aspects of the lower extremity.

By Jordana Bieze Foster

The epidemiology of plantar fasciitis

2011-10-31T09:16:00.002-05:00

Up to 10% of the population may present with heel pain over the course of their lives, which underscores the importance of practitioner familiarity with the diagnosis of plantar fasciitis and the associated risk factors, both intrinsic and extrinsic.

Plantar fasciitis is the most common cause of heel pain presenting to the outpatient clinic.1 Although thought of as an inflammatory process, plantar fasciitis is a disorder of degenerative changes in the fascia, and may be more accurately termed plantar fasciosis.2 Plantar fasciitis is diagnosed on the basis of a history of pain on taking the first few steps in the morning, worsening pain with weightbearing, and pain and tenderness to palpation over the medial calcaneal tubercle.1-5 Patients may have decreased ankle dorsiflexion secondary to a tight Achilles tendon, which may lead to a compensatory pronation of the foot.4 Up to one third of patients with plantar fasciitis will present with bilateral symptoms.6

On examination, plantar fasciitis must be distinguished from other causes of plantar heel pain. For example, fat-pad atrophy occurs in elderly patients with pain in the central heel. These patients usually do not complain of pain upon first weight bearing in the morning.7 Tarsal tunnel syndrome is described as burning pain along the area of the posterior tibial nerve inferior to the medial malleolus. Finally, a calcaneal stress fracture is confirmed on examination with use of the squeeze test, tenderness on mediolateral compression of the calcaneus.7

Etiology

Plantar fasciitis is multifactorial in etiology. Intrinsic factors include age, excessive foot pronation, obesity and limited ankle dorsiflexion;1,6,8-12 extrinsic factors include occupational prolonged weightbearing, inappropriate shoe wear, and rapid increases in activity level.1,8,12 These factors combine to create a pathologic overload of the plantar fascia at the calcaneal insertion, causing microtears in the fascia that subsequently lead to perifascial edema and increasing heel pad thickness.2,13,14 As microtears within the fascia increase in size, they may coalesce to form a large symptomatic mass that causes the increase in heel pad thickness and can be identified during surgery. These changes in fascial thickening, particularly in the proximal portion of the plantar fascia extending to the calcaneal insertion, and edema of the adjacent fat pad and underlying soft tissues can typically be seen on magnetic resonance imaging studies.15 Inflexibility of the posterior structures of the foot, combined with weakness of the plantar flexors during pushoff, alters the normal biomechanics of the foot, creating an environment of decreased efficiency of force absorption and production.14 The decrease in force absorption contributes to the overload of the plantar fascia and increasing degenerative changes, which include collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia and matrix calcification.2 Plantar fasciitis can also be associated with various seronegative spondyloarthropathies, but in approximately 85% of cases there are no known systemic factors.1,15,16

In runners, plantar fasciitis is primarily believed to be an overuse injury combined with training errors, training surfaces, biomechanical alignment and muscle dysfunction and inflexibility. For example, excessive pronation of the foot leads to increased tension on the plantar fascia during the stance phase of running.18 In athletes who are just beginning their training programs, the lower limb muscles may have yet to develop the necessary strength and flexibility, and shock absorption can be negatively affected.17

Epidemiology

Plantar fasciitis is an important public health disorder as it is the most common cause of heel pain in the outpatient setting.1 Ten percent of people in the United States may present with heel pain over the course of their lives, with 83% of these patients being active working adults between the ages of 25 and 65 years old.3,4 Two large national data sets of ambulatory care data (excluding visits to podiatrists or federal, military, or Veterans Administrations facilities) from the Centers for Disease Control and Prevention’s National Center for Health Statistics found that plantar fasciitis accounts for an average of one million patient visits per year to medical doctors.4 Sixty-two percent of these visits were made to general medicine clinics, while 31% of patients were evaluated by orthopaedic or general surgeons. Additionally, a recent survey of members of the American Podiatric Medical Association revealed that plantar fasciitis/heel pain was the most prevalent condition being treated in podiatric clinics.19 Within the current literature, prevalence rates of plantar fasciitis among a population of runners have been shown to be between 4% and 22%.20,21

Rano et al11 found that the average age of the patients presenting to their facility with heel pain was almost 10 years higher than controls who presented for other reasons. Matheson et al’s retrospective review of 1407 patients from an outpatient sports medicine clinic, found that younger athletes had a lower prevalence of plantar fasciitis (2.5%) than older athletes (6.6%).17 The association of plantar fasciitis with increasing age is consistent with the histopathological findings of degenerative, rather than inflammatory, changes within the plantar fascia.2 These degenerative findings support the hypothesis that plantar fasciitis is secondary to repetitive microtrauma caused by prolonged weightbearing activities.13 The constant overload inhibits the normal repair process, resulting in collagen degeneration, which causes both structural changes and perifascial edema.15,22 These changes in turn lead to a thicker heel pad, which has been shown to be associated with pain in individuals with plantar fasciitis.12,13 Increasing heel pad thickness leads to a loss of heel pad elasticity; both of these factors are associated with increasing age and increasing BMI.23 The decrease in elasticity of the fascia seen with increasing age is associated with a decrease in shock absorbing capabilities,23 which may be a result of the degenerative fascia’s inability to resist normal tensile loads.22 It is this decrease in shock absorbing capability that is believed to cause the pain associated with plantar fasciitis.

The current literature is inconsistent regarding the association between sex and plantar fasciitis, with some studies showing an increased prevalence in men,18,24 while others show an increased prevalence in women.11,25 In a retrospective case-control study of running athletes, Taunton et al found a significant sex difference within their study population, as 54% of those affected were male and 46% were female. In contrast, a prospective study including athletes of varying skill levels by Rano et al11 found a higher percentage of women in the heel pain group than in the control group (66.1% compared with 42.6%; p = 0.015). There are no theories within the current literature hypothesizing the reason for a difference in the prevalence of plantar fasciitis between the two sexes, whether it be a function of different hormones or structural differences caused by genetic variations, as is suggested by the increased incidence of anterior cruciate ligament tears in women compared with men.

Increased body weight10 and increased body mass index (BMI)6,8,9,11 have been shown to be significant risk factors for plantar fasciitis, with a BMI of more than 30 kg/m2 having an odds ratio of 5.6 (95% confidence interval, 1.9 to 16.6; p < 0.01) compared with a BMI of less than 25 kg/m2. Frey and Zamora9 demonstrated a 1.4-fold increased probability of plantar fasciitis being diagnosed in an overweight or obese patient. Rome et al13 suggested that BMI is not related to plantar fasciitis pain in the athletic population, but other factors such as a low estrogen levels in female athletes leading to a reduction in the elasticity of collagen may predispose these patients to plantar fasciitis. Riddle et al8 hypothesized that reduced ankle dorsiflexion is the most important risk factor for the development of plantar fasciitis, as the greater the limitation in ankle dorsiflexion, the greater the amount of compensatory foot pronation and therefore the higher level of loading on the plantar fascia. A study by Scott et al26 found that older patients (mean age 80.2) had reduced ankle range of motion compared with younger patients (mean age 20.9). An exponential relationship between decreasing ankle dorsiflexion and the risk of developing plantar fasciitis has been found, with individuals who have 0o of dorsiflexion or less having an odds ratio of 23.3 (95% confidence interval, 4.3 to 124.4).8 Foot pronation alone, as measured by the Foot Posture Index,27 has also been shown to be significantly greater in patients with chronic plantar heel pain.6

In addition to these intrinsic factors, various extrinsic factors have been related to the development of plantar fasciitis. Several studies have shown an association between work-related prolonged weightbearing and plantar fasciitis.8,24,28,29 In their case series, Lapidus and Guidotti’s patient population included a predominance of occupations that necessitate continual standing or walking, such as waiters, maids, and kitchen workers. In addition, each heel strike during running causes compression of the heel pad up to 200% of body weight.30 Therefore, in individuals who may not have adequate muscle strength or flexibility, and therefore have decreased shock-absorbing capabilities, the initiation of a new training program can exacerbate overloading of the plantar fascia.30 Increases in tensile loading, seen with new increases in running intensity or frequency and changes in general footwear have been associated with overloads of the plantar fascia leading to microtears.14 In particular, firm footwear may exacerbate the developing plantar fasciitis in these patients.28 Additionally, plantar fasciitis has also been associated with young individuals engaging in sports involving jumping.15

In order to determine epidemiological risk factors and the current incidence of plantar fasciitis within a population of individuals with a high level of physical activity, Scher et al31 accessed a database from the United States Armed Forces. The United States Armed Forces represent a physically active population of ethnically diverse male and female service members with generally high occupational demands. They participate in daily, organized physical fitness training programs and are subject to the physical rigors of repeated combat deployments. The inability to meet these physical requirements secondary to a medical condition, such as plantar fasciitis, may necessitate a medical discharge from military service. In this population, the authors chose to look at various epidemiological risk factors in order to identify groups at high risk of developing plantar fasciitis. The authors used the Defense Medical Epidemiology Database, which compiles ICD-9 coding information for every patient encounter in a military treatment facility.

The overall incidence of plantar fasciitis in the military population was 10.55 per 1,000 person-years. Female sex; black race; junior enlisted, senior enlisted and senior officer rank groups; military service in the Army or Marines; and age greater than 24 years old were found to be significant risk factors for the development of incident plantar fasciitis when compared to male sex, white race, junior officers rank, service in the Air Force, and age 20 to 24, respectively. Female subjects, when compared with male subjects, had a significantly increased incidence rate ratio for plantar fasciitis of 1.95 (95% CI 1.93-1.98). These findings are based on incidence rates, but tend to correlate with prevalence data seen within the existing literature.

Summary

As 10% of the population may present with heel pain over the course of their lives, a familiarity with the diagnosis and risk factors for plantar fasciitis is important for both primary care and specialty practitioners. Obesity, decreased ankle dorsiflexion, a pronated foot, and increasing age are important intrinsic risk factors that have been associated with plantar fasciitis. The extrinsic risk factors include prolonged occupational weightbearing, increasing activity levels, and inappropriate shoe wear. With the knowledge of specific risk factors for the development of plantar fasciitis, the next step is to develop preventive measures, such as plantar-specific stretching programs and changes in footwear, to decrease the current incidence of this disorder.

by Capt. Danielle L. Scher, MD; Lt. Col. Philip J. Belmont, Jr., MD; and Maj. Brett D. Owens, MD

Sleeping Difficulties Increase Risk of Eye Disease in People with Diabetes

2011-10-30T13:01:00.000-05:00

People with Type 2 diabetes who have obstructive sleep apnea (OSA) are more at risk of losing their sight due to severe retinopathy, as well as foot problems and possible amputation because of neuropathy....

Researchers from the University of Birmingham looked at 231 people with Type 2 diabetes of whom 149 had OSA, a sleep disorder caused by disturbed breathing. They found there were twice as many people with severe retinopathy (48 percent) in the group with OSA compared to the group without OSA (20 percent).

In a separate study, the researchers found that OSA was also linked to neuropathy. They looked at 230 people with Type 2 diabetes of whom 148 had OSA. They found that 60 percent of the group with OSA had neuropathy compared to 22 percent in the group without OSA.

According to Dr. Iain Frame, Director of Research at Diabetes UK, said, "We already know that there is a high prevalence of OSA in people with Type 2 diabetes. However, this is the first time that the link between OSA and retinopathy, and neuropathy in people with Type 2 diabetes has been examined. This research suggests that if someone with Type 2 diabetes also has this sleeping disorder they are more at risk of developing these serious complications compared to someone with the condition who does not have OSA."

"As being overweight is a risk factor for both OSA and Type 2 diabetes, this is yet another reason to highlight the importance of good weight management through a healthy diet and regular physical activity. In people with Type 2 diabetes, the increasing severity of OSA is associated with poorer blood glucose control and the treatment of sleep disorders (in this case by losing weight) has the potential to improve diabetes control and energy levels."

In both studies, the association between OSA and the two diabetes complications in people with Type 2 diabetes was independent of age, gender, ethnicity, blood pressure, blood glucose levels, smoking and cholesterol.

"Our work highlights several important issues," stated Dr. Abd Tahrani, who led the research. "Our results emphasized what is already known -- that OSA is very common in patients with Type 2 diabetes, much higher than OSA prevalence in the general population. Furthermore, our results suggest that OSA is not an innocent bystander in patients with Type 2 diabetes and might contribute to morbidities associated with this condition. Whether OSA treatment has any impact on these complications will need to be determined."

Killer pumps: Dangers of high heel shoes

2011-10-28T08:45:00.000-05:00

Think you need a new pair of high-heeled bejeweled Louboutins? Think again. Many women are obsessed with high heels even if they are painful. Many of them think that high heels indicate higher status. However, this status is worthless if old age is filled with leg and back pain. Experts and doctors have been discussing the reasons why women should stop wearing heels and replace them with comfortable shoes.

Wearing heels brings your whole outfit together and makes your legs look taller and slimmer, but it also can make your ankle ache, says Dr. Nadia Saleh, an orthopedic doctor at Takhasusi Hospital in Riyadh. “Sprained ankles, hammertoes, nerve damage and even knee arthritis are other common problems linked to wearing high heels regularly,” she said.

Saleh says high heels are bad for the body, as they put pressure on one part of the body, requiring the rest of the body to adjust. “Wearing high-heeled shoes positions the foot downward, thus placing more pressure on the forefoot. This position lowers half of the body and makes it extend forward towards the toes. The chest also has to stretch backward to maintain balance, thus affecting the standard posture. As a result, many women who wear high heels often complain about back pain,” she explained.

In fact, wearing high heels can lead to the flattening of the lumbar vertebra (one of 5 vertebrae in the human vertebral column), adds Saleh. “The area in the lower back receives the most stress when wearing heels, especially since it gets pulled backward. This can cause a displacement of the thoracic spine, which is the area in the mid and upper back. Since the upper part of the body leans forward, the body tries to maintain its balance by decreasing the forward curve of the lower back. This position is unhealthy and it leads to lower back pain,” she said.

Wearing heels also affect your walk, she added. “Women tend to think that when it comes to heels, the higher they are, the better they look. This thought is completely wrong for high heels affect the walk. The whole body puts pressure on the forefoot, making legs unable to apply balanced strength on the ground when walking. This in turn puts pressure on the hips and muscles in the legs, making these muscles work harder to move the body forward. Also, since the knees remain bent, it affects the knee muscles as well.”

A British study published in the Journal of Experimental Biology stated that women who wear high heels on a daily basis had a 13% shortening of calf muscles and a noticeable thickening of the Achilles tendon, making it painful to stand on the ground barefoot.

Another study, which was presented in the annual meeting of the American Society of Biomechanics in 2010, stated that high heels increased the compression inside the knee, creating additional joint pain and strain.

“Wearing heels also altered the women's posture, forcing their ankles, knees and hips into unnatural positions that increased their risk for joint degeneration and osteoarthritis,” stated the study.

Arab News asked a number of women if they would switch shoes to save their feet. Eight out of 10 women said they would never give up their stilettos and switch to flats while two said they would go for stylish ballerinas and spare the heels for special occasions.

“We women know that heels are bad for our spine and bones, but it’s just like our bad eating habits and addiction to sugar; we can’t seem to kick the habit of high heels,” said 23-year-old graphic designer, Hawazen Jazzar. “I believe that heels make our outfits look complete and give it this feminine and girly touch even if we’re just wearing jeans and a T-Shirt.”

Knowing the effects of high heels by heart will not make women give up high heels, says Saleh. “I will not ask women to completely give up the idea of wearing high heels, I just ask them to wear them during special occasions. Wearing high heels repeatedly can cause chronic ailments, so I only recommend a heel with a height of 1.5 inches for daily purposes,” she added.

Michael Lohan Arrested Again, Tries to Flee Cops by Jumping Off Balcony

2011-10-27T16:34:00.000-05:00

Michael Lohan’s in trouble with the law for the second time this week.

According to ABC affiliate WFTS, Tampa, Fla. police took the father of “Mean Girls” star Lindsay Lohan into custody early Thursday for violating the terms of his release. He was arrested Tuesday on a domestic abuse complaint.

Kate Major, Michael Lohan’s girlfriend who filed the original complaint, notified Tampa police to say that he had contacted her by phone. When they showed up at Major’s home, Lohan allegedly called Major again. Upon contacting the Hillsborough County State Attorney’s office, police were given the okay to arrest him.

Then things got hairy. Cops said Lohan tried to flee the scene by jumping off of a third floor balcony. He didn’t escape and was apprehended shortly thereafter. Paramedics initially determined that Lohan was not hurt from the jump, whereupon he was transported to the Hillsborough County Jail for booking. But once he arrived at the jail, deputies suspected Lohan might have broken his foot. Early this morning he headed to Tampa General Hospital for evaluation and is expected to go back to jail for processing after.

Killing the pain of killer heels

2011-10-27T10:42:00.000-05:00

ECCENTRIC superstar Lady Gaga’s recent interview with TV’s Paul O’Grady may have drawn gasps from audiences for many different reasons.

Perhaps her bald head, bold lyrics or bright green wig might have been startling to some but, for me, it was the towering heels in which she tottered across the stage which caused the biggest surprise.

For many decades now celebrities have been setting the trend in the fashion for “killer heels” and a quick trip to high street shoe shops will prove the point that new shoe styles seem to becoming higher and more daring than ever before.

Iconic French designer Christian Louboutin even hit the headlines this week for creating a pair of his famous red-soled eight inch stilettos which will now be auctioned off to raise funds for the English National Ballet.

And although these shoes would probably only ever be attempted by a ballet dancer at best, a visit to most UK town centres on a Friday or Saturday night will prove that young women are still opting for killer heels which can leave them hobbling and limping home after a long evening out.

But what impact does the wearing of high heels really have on a person’s feet?

Podiatrist Kerri Money, who works at PhysioPlus in Kingsthorpe, said she believed only a section of 18 to 23-year-olds really attempt to wear super high heels, but those who wear them routinely should be aware of their biomechanical impact on the body.

She said: “When you are in a high heeled shoe, your body has been made unstable so the shoe will affect the way you stand and walk. Your back will be more arched, your pelvis pushed forward and your calf muscles will shorten so your muscles will not be working as they should be.

“If your calves are often flexed they will stay like that, if you are in them all the time and go to a lower heeled shoe you are asking them to be in a position they are not used to.

“In low heeled shoes you can absorb the shock from the ground. If you are not doing that you are pushing the foot forward to absorb the shock, which isn’t what it has been designed to do. In high heels the centre of gravity is pushed forward and the balls of the foot are absorbing the hit of the ground and you are pushing off with them. That is a lot of work and can make the balls of your foot hurt.”

She continued: “We all like to wear heels sometimes but my advice would be to wear them only for short periods. I call them ‘car to bar’ shoes. If you are going out, you should go for thicker soles, the thicker the better. The more sole, the more cushioning there will be to help with shock absorption.”

Other tips from Kerri include trying to vary the types of shoes worn and opting for footwear with more straps, which offer more support.

She said: “Rotate between different shoes. If you are rotating different heels your muscles will work in lots of different positions.

“With more straps you will have more stability.

“With narrow, pointed shoes and high heels that is two negatives. If someone has a bunion and they are in a high heel their centre of gravity will have been pushed forward and they will be putting weight on a problem area.”

According to the NHS, the occasional wearing of high heels will not be harmful but damage can be caused if they are worn often during a working week, particularly when a person has to do a lot of walking or standing.

And poor footwear can have an impact later in life.

Helen Harman, falls practitioner for NHS Northamptonshire, said: “The impact of falling later in life is probably not foremost in the mind of fashion conscious young ladies. However, one of the highest risk factors for falling in later life is related to feet. Poor balance which can lead to severe falls can be a result of poor feet, possibly caused by footwear in earlier years.

“The Northamptonshire Falls Service routinely assesses feet and footwear as part of identifying the possible causes of a fall and aim to minimise falls risks. Advice is given regarding wearing well fitting supportive shoes.

“The effect of poor footwear can cause problems such as a corn, ingrown toenails, a callus or bunions.

“Frequently money is spent on appearance such as facials/makeup/hair styles but, despite our feet walking many miles over the years and being vital to wellbeing, they are often neglected.”

Restaurant Calorie Counts Not Always Accurate

2011-10-26T10:38:00.001-05:00

About 20% of meals tested by scientists pack at least 100 more calories than indicated on the menu, a study finds. Some foods are off by as much as 225 calories....

Dieters beware: offerings at popular restaurants may have more calories than what's stated on menus or company websites.

A team of scientists purchased items from 42 fast-food and sit-down eateries in Indiana, Arkansas and Massachusetts, and then measured the calories they contained. The list of stops on their calorie-busting tour included Burger King, Olive Garden, Outback Steakhouse, McDonald's, Taco Bell and Chuck E. Cheese's.

Susan Roberts, lead study author at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, stated that, only 7% of the 269 foods tested were within 10 calories of what the restaurants stated, the scientists found. And almost 20% packed at least 100 more calories than what was indicated. Over the course of a year, an extra 100 calories daily can add up to 10 to 15 pounds.

The biggest discrepancies occurred at sit-down restaurants, where the stated calorie information and what the researchers measured, was off by an average of 225 calories, according to the study. At fast-food restaurants, the average discrepancy was 134 calories per menu item.

The most variable foods included those that dieters are more likely to choose, such as an order of three pieces of dark chicken meat at Boston Market — listed as 358 calories but packing more than 500 in the study — and the cranberry pecan chicken salad at the Midwestern restaurant chain Bob Evans, listed as 841 calories but weighing in at over 1,100 calories — more than half of what an average adult should eat in a day.

The researchers later repurchased and retested 13 of the 17 menu selections with the greatest calorie discrepancies, and found that the items were often repeat offenders. For example, Chipotle Mexican Grill's burrito bowl, which is supposed to be 454 calories, was 703 calories on one occasion and 567 on the second. The 17 foods had more than 250 extra calories on average than what was stated.

It's too early to tell whether calorie information affects what types of foods people purchase, let alone obesity rates, experts said. A 2010 study showed that parents used calorie information to choose more healthful foods for their children -- but not themselves.

In New York City, Starbucks customers ordered 6% fewer calories after menu labeling laws went into effect in 2008, according to another 2010 study.

Restaurant food accounts for 35% of the calories Americans eat today, the authors noted.

6 Emergency Complications of Type 2 Diabetes

2011-10-20T07:30:00.003-05:00

Uncontrolled diabetes can control your health. Help prevent these serious diabetes complications by learning the warning signs.

People with type 2 diabetes are at increased risk of many serious health problems, including heart attack, stroke, vision loss, and amputation. But by keeping your diabetes in check — that means maintaining good blood sugar control — and knowing how to recognize a problem and what to do about it should one occur, you can prevent many of these serious complications of diabetes.

Heart Attack
Heart disease and stroke are the top causes of death and disability in people with diabetes. If you experience any of the following heart attack warning signs, call 911 immediately:
-Chest discomfort that feels like pressure, squeezing, fullness, or pain in the center of your chest, lasting for a short time or going away and returning
-Pain elsewhere, including the back, jaw, stomach, or neck; or pain in one or both arms
•Shortness of breath
•Nausea or lightheadedness
Heart attack symptoms may appear suddenly or be subtle, with only mild pain and discomfort.

Stroke
Stroke warning signs may include:
Sudden numbness or weakness in the face, arm, or leg, especially if it occurs on one side of the body
-Feeling confused
-Difficulty walking and talking and lacking coordination
-Developing a severe headache for no apparent reason
If you suddenly experience any of these stroke symptoms, call 911 immediately. As with a heart attack, immediate treatment can be the difference between life and death.

Nerve Damage
People with diabetes are at increased risk of nerve damage, or diabetic neuropathy, due to uncontrolled high blood sugar. As a result, various foot and skin problems can occur, including:
•Foot problems. Nerve damage associated with type 2 diabetes can cause a loss of feeling in your feet, which makes you more vulnerable to injury and infection. You may get a blister or cut on your foot that you don't feel and, unless you check your feet regularly, an infection can develop. Untreated infections can result in gangrene (death of tissue) and ultimately amputation of the affected limb.
•Skin problems. Diabetes can make it more difficult for your body to fight infections, causing skin problems. Various skin conditions are linked to diabetes, and even the most minor cuts or sores can turn serious fast. Any bumps, cuts, or scrapes should be cleaned and treated with an antibiotic cream and monitored carefully.
If you notice any of the following symptoms, see your doctor:
•Inflammation and tenderness anywhere on your body
•Red, itchy rash surrounded by small blisters or scales
•Cuts, sores, or blisters on your feet that are slow to heal and are not as painful as you would expect
•Numbness, tingling, or burning sensations in your hands or feet, including your fingers and toes
•Sharp pain that gets worse at night
•Muscle weakness that makes walking difficult
•Bladder infections and problems with bladder control
•Bloating, stomach pain, constipation, nausea, vomiting, or diarrhea
•Erectile dysfunction in men and vaginal dryness in women

Kidney Disease
Type 2 diabetes increases your risk of kidney disease, or diabetic nephropathy, a condition in which the blood vessels in your kidneys are damaged to the point that they cannot filter out waste properly. If left untreated, dialysis (a treatment to filter out waste products from the blood) and ultimately a kidney transplant may be needed.
Typically, you won’t notice symptoms of kidney disease until it has advanced. However, if you experience any of the following symptoms, tell your doctor:
•Swelling in your ankles and legs
•Leg cramps
•A need to go to the bathroom more often at night
•A reduction in your need for insulin
•Nausea and vomiting
•Weakness and paleness
•Itching
The best way to prevent type 2 diabetes-related kidney problems is to have your urine, blood, and blood pressure monitored regularly and to keep your blood sugar and blood pressure under control.

Eye Problems
People with type 2 diabetes are at risk of several eye conditions, including diabetic retinopathy (which affects the blood vessels in the eye), glaucoma, and cataracts. If left untreated, these conditions can cause vision loss.
Call your doctor if you notice any of these warning signs:
•Blurry vision that lasts for more than two days
•Sudden loss of vision in one or both eyes
•Floaters, black or gray spots, cobwebs, or strings that move when you move your eyes
•A sensation of seeing "flashing lights"
•Pain or pressure in one or both eyes

Hyperglycemia
Hyperglycemia means you have too much sugar in your blood. High blood sugar doesn't always produce symptoms; therefore, it is important to check your blood sugar regularly, as indicated by your doctor. When symptoms of hyperglycemia occur, they may include:
•Frequent urination
•Extreme thirst
•Feeling tired and weak
•Blurry vision Feeling hungry even after eating
If you frequently have high blood sugar, tell your doctor. He or she may need to make changes to your medication and suggest diet and lifestyle modifications to help you gain and maintain better blood sugar control.
The key to preventing many of the complications of diabetes is to keep your blood sugar at a healthy level. To do this, eat right, exercise, monitor your blood sugar as recommended by your doctor, and don't smoke.
Report any unusual signs or symptoms to your doctor. Together you can work to prevent these diabetes-related health complications.

By Hedy Marks, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

Heel pain revisited: New guidelines emphasize evidence

2011-10-18T13:11:00.000-05:00

The American College of Foot and Ankle Surgeons’ revised guidelines for heel pain treatment reflect lower extremity healthcare’s increasing focus on evidence-based medicine, including hundreds of references as well as helpful diagrams. But evidence has its limitations, and clinical experience is still essential to the therapeutic process.

New practice guidelines for the diagnosis and treatment of heel pain, published on April 30 by the American College of Foot and Ankle Surgeons (ACFAS), continued the trend of basing treatment recommendations on evidence-based medicine.1 But the guidelines also provoked controversy among those most likely to rely on them for clinical decision making.

Heel pain—most commonly plantar fasciitis—is a serious matter for podiatrists, physical therapists, and other lower extremity clinicians. Roughly two million Americans are affected by it each year, and 10% of people experience chronic heel pain at some point in their lives.2

Despite the condition’s prevalence, practitioners disagree about the best treatments for it. Some of this has to do with scope of practice; physical therapists can’t give cortisone injections or perform surgery, of course, and podiatrists are usually less familiar with physical therapy approaches than with the techniques in which they’ve been trained. Some clinicians dismiss the relevance of orthoses, while others consider them the most crucial aspect of treatment. Certain practitioners feel that surgery is inappropriate for fasciitis, while others rely on it to an extent that their colleagues sometimes consider troubling.

Of course, the whole point of guidelines is to delineate the evidence for different approaches and help all practitioners make better decisions. And although there is significant confluence of ideas about best practices, the differences can be telling. The American Physical Therapy Association (APTA) published its own set of heel pain guidelines in 2008 and provided significant evidence for its recommendations.3 And although the APTA recommendations agree in many respects with the ACFAS guidelines, the two documents also diverge in important ways.

Both organizations rank evidence and make recommendations based on the same template, though they differ in the details. Evidence is graded from Level I (the highest, based on randomized controlled trials) to Level IV or V (expert opinion). Grades of recommendation range from grade A (strong evidence, based on Level I or II studies) to grade F (in the case of the APTA guidelines) or grade I (in the ACFAS guidelines, “I” signifies “insufficient evidence to make a recommendation”).

The Word from ACFAS

The new ACFAS guidelines, which evolved from a previous version in 2001,4 classify heel pain in several categories and provide both text and graphic pathways for diagnosing, evaluating, and treating it. The clinician’s first step is to determine the cause of the problem, whether it be neurologic, arthritic, traumatic, or mechanical. This last etiology, which typically presents as plantar heel pain, is the most common.

“What’s really new in these guidelines is they are not just opinion-based; we’ve tried to look at evidence-based medicine and give treatment recommendations based on that,” said James Thomas, DPM, FACFAS, the lead author of the ACFAS guidelines.

Thomas, an associate professor in the department of orthopedics at West Virginia University in Morgantown, noted other improvements over the previous version.

“Newer technology and treatments are available now, such as radiofrequency coblation of the plantar fascia, though at this point it rates only a ‘C’ because it’s so new we don’t have the numbers to support it,” he said. “We will probably see that [literature] grow over the next few years.”

The new guidelines also note a shift in terminology.

“While ‘fasciitis’ describes the most common cause of heel pain, MRI studies are showing us that it is not just a matter of inflammation,” Thomas said. “There are degenerative changes in the fascia which are better described as ‘fasciosis.’ Practitioners recognize this and are starting to use the new term.”

Thomas also pointed out the document’s flowcharts, which provide a succinct visual presentation of the decision trees in the text. In Pathway 2, “Plantar Heel Pain,” for example, clinicians are guided through taking the history (e.g., pain in the morning or after periods of rest); through significant findings (radiographs, pain on palpation, obesity, pronated foot architecture, and the like); through initial treatment options (e.g. stretching, over the counter insoles, cortisone injection, activity limitation, padding, and strapping); and finally to second and third-tier treatments that include night splints, prescription orthoses, repeated injections, and surgery.

Controversy

Some of these recommendations have stirred the pot of controversy, however. For example, corticosteroid injections are given an evidence grade of B in the guidelines’ text and listed as an initial treatment option; by contrast, physical therapy is not listed in any of the protocol’s three tiers (physical therapy received a grade of “I”—insufficient evidence to recommend—from ACFAS).

“I am strongly against cortisone shots as a first intervention,” said Michael Gross, PT, PhD, a professor of physical therapy at the University of North Carolina at Chapel Hill. “They don’t address a single issue that gave the person the problem. Fasciitis is caused by tensile stress from the foot undergoing three-point bending, exacerbated by factors such as weight gain or increases in activity. An injection compromises tissue that is already weak, and it reduces pain that is the only thing telling the patient that something’s wrong. As a result, they’re likely to go out and hurt the tissue more, but they won’t know that until the analgesic wears off, at which point they’re in worse condition than they were originally.”

It’s not only physical therapists who object to this treatment approach.

“I would take exception to corticosteroids being in Tier 1, for a first visit,” said James Clough, DPM, who practices in Great Falls, MT. “There are people who come in with such severe pain that they can’t walk, and maybe there I would occasionally give an injection. But 95% of patients never need that. You’re running the risk of injuring Baxter’s nerve and creating a neuritis, and corticosteroids delay the healing process. Also, some studies have suggested the method of injection is more important than what is actually injected.”

Thomas acknowledged that clinical judgment should be a key factor in such decisions.

“With clinical practice guidelines you have to be inclusive and consider all the different types of presentation you may see,” he responded. “The panel agreed that corticosteroid injections have to be used judiciously, and by no means do we use them now as we did ten years ago, when patients would get a series of three weekly injections. By the same token, we don’t have evidence-based medicine that says, ‘What is the proper time for that?’ An injection in the first appointment would be for the patient who has had problems for a long time and is acutely symptomatic.”

Reprinted with permission from Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S2.

Although Thomas emphasized the importance of examining the guidelines’ text rather than going just by the flowcharts, in fact the text provides no further clarification of the authors’ intent in this matter. It simply reads, “Initial treatment options may include…a corticosteroid injection localized to the area of maximum tenderness.” The guidelines from nine years ago read, “Initial treatment options may include…corticosteroid injections for appropriate patients.”4 It’s difficult to discern the change in approach.

Some research supports concern. For example, a 2005 paper in the Clinical Journal of Sports Medicine found that “existing medical literature does not provide precise estimates for complication rates….Tendon and fascial ruptures are often reported complications of injected corticosteroids.”5

Necessary Surgery?

Clough also expressed concern that the guidelines did not clarify which aspects of orthotic intervention were most likely to affect fasciitis.

“Fasciitis is primarily a mechanical malfunction of the foot, and the orthotic, along with stretching and gait training, is very important in establishing normal function,” he said. “But the ACFAS guidelines don’t expound on what an orthotic approach should be. Almost 100% of my plantar fasciitis patients are not walking correctly, and a lot of that has to do with dysfunction of the first ray. Correcting that with an orthotic modification, then doing the appropriate gait training to get them to use their first ray and engage the windlass mechanism, is a very effective way to treat fasciitis.”

Clough has not had to resort to plantar fascia surgery for fasciitis in his past 15 years of practice, and he is troubled at how often some of his colleagues do.

“I worry that we are going too fast from Tier 1 to Tier 2, then to Tier 3,” he said. “Not all doctors adhere to these tiers. They don’t understand the proper use of orthotics, stretching, and gait training; they view them as just another stepping stone to surgery. This is a mechanically induced problem, and if patients are not responding to mechanical control of the foot, we need to reevaluate and make changes. Watching your patients walk can be very instructive. Perhaps surgery is appropriate for hallux limitus or an extremely unstable flatfoot deformity, but I fail to see the indication for a plantar fasciotomy, no matter how many ways you can think of to do it.”

Thomas agreed that roughly 95% of patients get better without surgery.

“In the algorithms we recommend exhaustive nonoperative care for a minimum of six months,” he said. “Surgery is really the end stage, only if you’ve failed nonoperative approaches. But it is very worthwhile for folks who have gotten to that point and has a high success rate, approaching 90%.”

However, Clough noted a scarcity of studies assessing long-term outcomes following plantar fasciotomy.

“Is there an increase in bunion deformities, in hammer toes, in shin splints? Is there a flattening of the foot?,” he asked. “You look at them after a year and you say, ‘they got better.’ But five years down the line are they still better, or are they coming in with other problems?”

Some research supports Clough’s concerns, including at least one long-term study. In 2009, researchers reviewed 22 years’ worth of studies, then reported in the Journal of the American Podiatric Medical Association that research in cadaver feet suggested that plantar fasciotomy led to loss of integrity of the medial longitudinal arch. They also reviewed in vivo studies, which found satisfactory clinical outcomes but a decrease in medial longitudial arch height and a medial deviation of the center of pressure of the weightbearing foot.6 One long-term study of fasciotomy (4.5- to 15-year follow-up) reported that it was successful (i.e., with good or excellent results) 71% of the time, but that problems included slower recovery and abnormalities of foot function.7

The PT’s Perspective

The authors of the APTA guidelines, not surprisingly, found significant evidence to support the use of physical therapy in treating heel pain and fasciitis (though it should be noted that an MD was among the authors).

Recommendations for the physical exam include palpation, talocural joint dorsiflexion range of motion, the tarsal tunnel syndrome test, the windlass test, and longitudinal arch angle. Interventions include activity limitation, dexamethasone delivered via iontophoresis, manual therapy, stretching of the calf and plantar fascia, night splints, and prefabricated or custom foot orthoses.

“We wanted to review the best current evidence for how one should go about the exam, and also look at interventions that fall within the realm of physical therapy,” said Thomas McPoil, PT, PhD, lead author of the guidelines. McPoil, who is the regents professor of physical therapy and co-director of the Laboratory for Foot and Ankle Research at Northern Arizona University in Flagstaff, added that the authors had hoped to include exercise but ultimately opted not to.

“Most physical therapists feel that exercise is important, for both the muscles of the lower leg and the intrinsic muscles of the foot, but we didn’t have the evidence to substantiate including that,” he said.

A recent randomized clinical trial further bolstered the efficacy of manual therapy, however;2 and Michael Gross explained why stretching the calf actually works.

“When you get a lot of tension in the Achilles, it grabs onto the calcaneus and pulls it slightly posterior, which stretches the plantar fascia,” he said. “And if you have tightness in the calf muscles, it will restrict the motion of the ankle joint and drive it to the other joints of the foot. That, in turn, can cause the arch to collapse and put even more stress on the plantar fascia.”

“What is preventing our patients from doing what they want to do is edema, inflammation of periarticular tissues, muscle weakness, and pain,” McPoil added. “In physical therapy, we have to look more at impairment, functional limitation, and disability rather than trying to come up with a specific diagnosis.”

McPoil’s colleague and coauthor, Mark Cornwall, PT, PhD, CPed, agreed. “Plantar fasciitis is a medical diagnosis, not a physical therapy diagnosis,” Cornwall said. “The physical therapist would say, ‘I know you have fasciitis, but what can you do? What can’t you do? Why can’t you do it?’”

According to McPoil, the feedback from therapists has been positive.

“It’s having an impact,” he said. “Physical therapists like the guidelines because it provides a consensus of the available literature. They can say, here is what we’re doing, and here’s the evidence to support that.”

New studies make it important to update the guidelines every four or five years if possible, McPoil said; the 2008 guidelines are the first set issued by the APTA. He is also more struck by the similarities between the various guidelines than by their differences.

“If you allow for the differences in scope of practice, the new guidelines from ACFAS are very similar to what we published,” he said. “I was glad to see that, because I thought, good—we are pretty much right on.”

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

References

1. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-19.

2. Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther 2009;39(8):573–585.

3. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther 2008;4(38):A1–18.

4. Thomas JL, Christensen JC, Kravitz SR, et al.The diagnosis and treatment of heel pain. J Foot & Ankle Surg 2001;40(5):329–340.

5. Nichols A. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med 2005;15(5):370–375.

6. Tweed JL, Barnes MR, Allen MJ, Campbell JA. Biomechanical consequences of total plantar fasciotomy: a review of the literature. J Am Podiatr Med Assoc 2009;99(5):422–430.

7. Daly P, Kitaoka H, Chao E. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13(4):188–195.

Socks: Getting in shape with new technologies

2011-10-17T12:23:00.003-05:00

Socks are often an afterthought for patients with diabetes, but they shouldn’t be. Advances in materials science and new twists on old favorites mean that modern socks conform to feet without the bunching, chafing, slipping, and irritation of the past. Some even promote healing.

Socks have come a long way since the days of the long white tube with the colored bands around the top. A visit to any sporting goods store will offer a rock climbing wall’s worth of “performance socks,” tricked out with high-tech properties such as moisture wicking, temperature control, and arch support.

No doubt that these sock manufacturers have taken more than a few cues from diabetic socks, which have always combined fibers to maximize support, cushioning, and comfort. But do diabetic socks offer advantages to patients beyond these performance socks? Yes and no, according to the experts. Proper fit and sizing play a big part in ensuring that diabetic socks do their job.

Materials

One hundred percent cotton or wool socks have been criticized for not maintaining the sock’s shape on the foot, which can be problematic for diabetic patients on two fronts. The increased friction between the skin and the fibers can lead to ulcerations. In addition, 100% cotton or wool socks may start out quite tight, possibly reducing circulation in patients who already have compromised blood flow. As the socks are worn over time, the fibers loosen, resulting in a sock that slides between the foot and the shoe, again leaving diabetic patients vulnerable to shear, blisters, and potential ulcerations.

On the other hand, purely synthetic socks may not allow sweat to evaporate properly; sweaty feet can lead to fungal infections, which in and of itself is more complicated in a patient with diabetes than an otherwise healthy subject and can also be another gateway to ulceration. Synthetics blended with natural fibers would seem to be the best bet, offering support and—most importantly—breathing room, according to Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner of Foot and Ankle Associates of North Texas in Grapevine.

“I’m not one that really likes totally cotton socks,” she said. “I find that socks with a little bit of Lycra in them are better. They also offer some compression to address swelling.”

Crane also advocates seamless socks because seams, constantly rubbing against the skin, may cause blisters, calluses, or ulcerations. For a patient with neuropathy, a skin irritation caused by the seam will not be felt immediately, increasing the risk of calluses and other pre-ulcerative conditions.

Moisture wicking can be achieved with a variety of materials: Wool, synthetics, cotton, silk, and renewable materials. Each has its pros and cons.

The biggest advantage of wool, and merino wool in particular, is that it is thermostatic so that feet stay comfortable in a range of temperatures. Wool also can absorb 30% of its own weight in water so feet are more likely to stay dry. Cushioning is another benefit, because diabetic patients have an increased risk for pressure ulcers and because focused areas of high plantar pressure are most likely to become sites of ulceration. On the downside, wool dries out slowly, and wool socks generally carry a higher price-tag than other materials. Both factors could prove problematic for a diabetic patient who cannot afford multiple pairs of socks.

Synthetics, such as nylon and Lycra spandex, help socks retain their shape. Some synthetics may provide arch support, which can help lateralize plantar pressures and provide a bit of extra stability for diabetic patients who have problems with balance. Socks with polypropylene, polyester, or acrylic fibers will offer moisture wicking. Synthetic socks are durable but may be unsuitable for warmer climates. In addition, the socks’ insulation properties may be reduced if the socks get too wet.

Silk is a natural insulator that is often blended with wool for extra softness. The lightweight material offers reliable wicking and a smooth texture; however, it is less durable than other materials. This is important not only with regard to the cost and inconvenience of replacing socks, but also because areas of wear in a sock’s fabric fail to protect the diabetic foot and leave skin vulnerable. In addition, the very “silkiness” of a silk-based material could cause the foot to slip within the shoe, leading to abnormal skin shear and friction-induced skin issues.

A full cotton sock is not advisable for the diabetic foot. The material is easily saturated with sweat and dries slowly, both of which leave the foot vulnerable to blisters. Cotton is less expensive than other materials and, when blended in small quantities with synthetics, it can offer softness.

Eco-friendly materials, such as bamboo, corn-based polylactic acid (PLA), hemp, and charcoal, offer moisture wicking and odor control properties. Combining these materials with synthetic fabrics ups their durability.

Finally, socks made of fabrics embedded with copper, silver, or charcoal fibers offer protection against bacteria. Patients with diabetes are less resistant than healthy individuals to infection, which can lead to complications such as cellulitis (diffuse inflammation of the connective tissue) or osteomyelitis (bone infection, which almost always occurs in the presence of an ulcer). However, a sock billed as resisting bacterial growth does not automatically reduce the chance of infections on the surface of the foot, nor will this type of fabric necessarily protect an open wound from becoming infected. Visual inspection of the feet, along with daily washing, is still needed to avoid infection.

Socks come in sizes

While it’s obvious to patients with diabetes that their shoes come in sizes, the same cannot always be said for socks.

“A lot of patients don’t realize that their socks need to be the correct size,” Crane said. “If the sock is too tight, it can cause ingrown toenails, it can cause problem with compression in between the toes, it can cause ulceration between the toes.”

Crane said she advices her patients with diabetes to “size up” when it comes to socks.

“For instance, I wear a size 6-6.5 (in shoes) and most size small socks go to 6. I’ll go to a medium sock instead of a small because they will shrink once they are washed,” she said.

Socks that are too tight can reduce flow, which is particularly problematic in patients whose diabetes is complicated by vascular disorders. Poor blood flow impairs healing of existing ulcers and other wounds; it can exacerbate loss of sensation in neuropathic patients, increasing the risk of neuropathic ulcers; and it can also increase the risk of ischemic ulcers, which are even more difficult to heal. However, socks that are too big can wrinkle or bunch inside the shoe, putting excess pressure on the feet. For patients with neuropathy, a bunched sock can easily lead to blisters or ulcerations.

But as with shoes, neuropathic patients often need a sock to feel snug against their leg. A sock with binding elastic at the top may feel right to these patients, but can negatively impact blood flow.

If possible, socks and shoes should be fit simultaneously, Crane added.

“One of my pet peeves is that the socks and shoes are not fit at the same time,” she said. “I have a patient who has a beautiful pair of diabetic shoes, but she wears them with pantyhose that she buys at the drug store. The hose have a seam in them and that causes an ulceration on the tip of her toe.”

Another argument for fitting shoes and socks simultaneously is that once a sock size has been determined, the shoe size may change. For instance, a neuropathic patient who is prescribed a therapeutic sock with silicone padding to reduce plantar pressure may have to go with a shoe that is a half-size larger or convert to extra-depth shoes.

OTS socks

Crane pointed out that socks are not covered under the Therapeutic Shoe Bill (see HEADLINE, PAGE XX) so they are an out-of-pocket expense for the patient.

“Good socks are expensive,” she said. “You can’t buy a good pair of socks for $4. You are looking at as much as $20.”

As a result, off-the-shelf (OTS) socks are not always out of the question.

“In terms of the OTS, performance socks, I like the ones that have a bit of Lycra and a bit of either DryWeave or CoolMax to wick the sweat away from the foot. That’s necessary whether the person is a diabetic or not,” she said.

But these performance socks don’t necessarily offer the kind of support that a diabetic foot requires, pointed out Roy H. Lidtke DPM, CPed, FACFAOM, associate professor of podiatric medicine and surgery at Des Moines University and director of the Center for Clinical Biomechanics at

St. Luke’s Hospital, Cedar Rapids, IA. Socks made especially for patients with diabetes provide that support, along with added benefits.

“They offer extra padding and compression that can produce a form of neuromuscular feedback,” Lidtke said. “An example would be when you wear a pair of padded socks with areas of elastic compression and you feel a tightness around your arch. This provides greater proprioceptive feedback on the position and neuromuscular control of the foot.”

Diabetes is often complicated by a loss of postural control, which research suggests is a product of more than just the loss of sensation that accompanies neuropathy. Any intervention that can improve proprioception could potentially also help to improve postural control and, in turn, reduce patients’ risk of falling.

Shedding light on neuropathic pain

Advances in materials technology have seen the introduction of socks with optically modified properties.

Both near infrared light and far infrared light have shown efficacy in addressing diabetic foot problems by influencing the transmission of electromagnetic energy into the underlying tissue and skin. When incorporated into socks, near and far infrared light are credited with improving blood flow, delivering more oxygen to the tissues, and reducing swelling.

A recent study done at the University of California, Irvine looked at the effect of polyethylene terephthalate fiber socks on foot pain in patients with diabetic neuropathy and other disorders. In this double-blinded, randomized trial, 55 patients (29 with diabetic neuropathy) wore socks made from polyethylene terephthalate (PET) incorporating optically active particles (Celliant). The latter scatters and reflects visible light and near infrared light, according to the study authors.

Overall, patients reported a certain level of pain reduction. In the neuropathic patients, there was some some pain reduction but it was not as significant as it was in the patients with other foot disorders. The authors postulated that in the neuropathic foot, only a portion of the diseased neuron fibers are in close proximity to the sock. The findings were published in April 2009 by the online journal BMC Complementary and Alternative Medicine.

Far infrared and negative ion technology, which also can be incorporated in sock fibers, has been shown to reduce some of the foot discomfort associated with neuropathy. Although no studies of far-infrared socks have been published in the medical literature to date, a recent randomized clinical trial did evaluate the effects of photon stimulation with far infrared light on pain intensity and pain relief in patients with diabetic peripheral neuropathy.

Patients who underwent a series of photon therapy treatments reported significant decreases in the intensity and quality of their pain, with a 30% to 50% reduction in pain immediately following treatment, compared to those who received a placebo treatment. The findings were published in the January 2010 issue of the Journal of Pain and Symptom Management.

By Shalmali Pal

Do Bariatric Surgery Patients Fare Better?

2011-10-14T12:04:00.000-05:00

A new study in VA patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care, at least out to seven years....

Dr. Matthew L. Maciejewski, who presented the findings, stated that doctors "should counsel their patients that there are numerous significant benefits to bariatric surgery -- including the fact that it's the most effective weight-loss treatment, and it improves the control of chronic conditions and quality of life -- but there doesn't appear to be a survival benefit at nearly seven years." It is possible that there will be a survival benefit longer term, he says, and his group is continuing to follow these patients and add in others who have had surgery more recently.

The new findings contrast with those of prior studies, many of which have shown survival benefits with bariatric surgery, but most of which have examined outcomes in younger, primarily white, and female populations, said Maciejewski. But obesity-related mortality is highest in men and minority patients, who have high rates of comorbid diseases, and this is the first study that has looked at long-term survival in such high-risk patients, he points out.

In addition, in this work, statistical analyses were employed, which "represent an advance over prior work. The VA has really rich data sets, and we had body-mass-index [BMI] information on all patients, including the nonsurgical controls," information that provides for more robust results, Maciejewski explains.

Maciejewski et al conducted a retrospective, cohort study of bariatric-surgery programs in VA medical centers, including 850 veterans who underwent Roux-en-Y gastric bypass from January 2000 to December 2006. The population was 74% male, the mean age was 49.5 years, and the mean BMI was 47.4. Race/ethnicity was 78% white, 16% nonwhite, and the remainder "unknown." Mortality for these patients was compared with that of 41,244 nonsurgical controls (mean age 54.7 years, mean BMI 42, 74% male, and 77% white) from the same 12 Veteran Integrated Services Networks.

In unadjusted analyses, bariatric surgery was significantly associated with reduced mortality (hazard ratio 0.64), but in an analysis of 1694 propensity-matched patients, bariatric surgery was no longer significantly associated with reduced mortality in both unadjusted (hazard ratio 0.83) and time-adjusted (HR 0.94) Cox regressions.

Previous studies have mostly identified control patients via the use of a diagnosis code of morbid obesity, says Maciejewski, which "means they were probably not random samples of all patients eligible for surgery, and they were probably a sicker group [than those who underwent bypass], which might overstate the benefits of surgery."

The results highlight the importance of statistical adjustment and careful selection of surgical and nonsurgical cohorts, particularly during evaluation of bariatric surgery according to administrative data. The survival benefits between the bariatric surgery and control group were modest in most previous studies and so may have been attenuated if adjustment for confounders had been possible, they explain.

It will be important to continue to track this cohort to see whether any survival advantages for surgery emerge in the longer term. The fact that no survival advantage has been seen so far is perhaps "not surprising." In the only other trial to have compared bariatric surgery with "high-quality clinical data," the Swedish Obese Subjects (SOS) study, the survival benefit was not observed until a median of 13 years of follow-up.

It will also be necessary to incorporate other patients who have undergone more contemporary laparoscopic gastric banding or gastric-sleeve resections -- procedures that are being performed more and more in the VA system. "It will be important to update the results to account for those procedures," Maciejewski observes.

But, in the meantime, even though bariatric surgery is not associated with reduced mortality, many patients may still choose to undergo such procedures, "given the strong evidence for significant reductions in body weight and comorbidities and improved quality of life," the researchers conclude.

Diabetes Doubles Alzheimer's Risk

2011-10-12T10:34:00.000-05:00

People with diabetes are at increased risk of having a heart attack or stroke at an early age. But that’s not the only worry: Diabetes appears to dramatically increase a person’s risk of developing Alzheimer’s disease or other types of dementia later in life, according to a new study conducted in Japan.

In the study, which included more than 1,000 men and women over age 60, researchers found that people with diabetes were twice as likely as the other study participants to develop Alzheimer’s disease within 15 years. They were also 1.75 times more likely to develop dementia of any kind.

“It’s really important for the public health to understand that diabetes is a significant risk factor for all of these types of dementia,”says Rachel Whitmer, PhD, an epidemiologist in the research division of Kaiser Permanente Northern California, a nonprofit health-care organization based in Oakland, Calif.

Whitmer, who studies risk factors for Alzheimer’s but wasn’t involved in the new research, stresses that many questions remain about the link between diabetes and dementia. The new study was “well done” and provides“really good evidence that people with diabetes are at greater risk,” she says,“but we really need to look at other studies to find out why.”

What Factors Increase the Risk?

Diabetes could contribute to dementia in several ways, which researchers are still sorting out. Insulin resistance, which causes high blood sugar and in some cases leads to type 2 diabetes, may interfere with the body’s ability to break down a protein (amyloid) that forms brain plaques that have been linked to Alzheimer’s. High blood sugar (glucose) also produces certain oxygen-containing molecules that can damage cells, in a process known as oxidative stress.

In addition, high blood sugar—along with high cholesterol—plays a role in the hardening and narrowing of arteries in the brain. This condition, known as atherosclerosis, can bring about vascular dementia, which occurs when artery blockages (including strokes) kill brain tissue.

“Having high glucose is a stressor to the nervous system and to the blood vessels,” says David Geldmacher, MD, a professor of neurology at the University of Alabama at Birmingham. “The emerging information on Alzheimer’s disease and glucose shows us that we do need to remain vigilant on blood sugar levels as we get older.”

New and Improved Research

Studies dating back to the late 1990s have suggested that people with diabetes are more likely to develop Alzheimer’s disease and other types of dementia, but the research has been marred by inconsistent definitions of both diabetes and dementia.

The authors of the new study, led by Yutaka Kiyohara, MD, an environmental medicine researcher at Kyushu University, in Fukuoka, sought to address this weakness by using the gold standard of diabetes diagnosis, an oral glucose tolerance test. This involves giving a person a sugar-loaded drink after they have fasted for at least 12 hours, and then measuring how much glucose remains in their blood two hours later.

At the beginning of the study, the tests showed that 15% of the participants had full-fledged diabetes, while 23% had prediabetes, also known as impaired glucose tolerance.

During the next 15 years, 23% of the participants received a dementia diagnosis. Slightly less than half of those cases were deemed to be Alzheimer’s disease, with the remainder roughly split between vascular dementia and dementia due to other causes. (The diagnoses were confirmed with brain scans of living patients and brain autopsies in deceased patients.)

The link between diabetes and dementia risk persisted even after the researchers took into account several factors associated with both diabetes and dementia risk, such as age, sex, blood pressure, and body mass index.

The next step in the research, Whitmer says, will be to understand whether controlling blood sugar and reducing risk factors for type 2 diabetes also reduces dementia risk. She and her colleagues have several studies underway investigating these questions.

Maggot Debridement Promotes Healing of Long-Standing Wounds

2011-10-11T08:30:00.002-05:00

Maggots are an effective, low-cost salvage option to debride poorly vascularized, infected wounds in patients with diabetes, especially when vascular remediation is not possible....

Lawrence Eron, MD, infectious disease consultant at Kaiser Moanalua Medical Center and associate professor of medicine at the John A. Burns School of Medicine of the University of Hawaii in Honolulu, stated that, in addition to debriding nonviable tissue, maggots secrete bacteriostatic substances that help eradicate infections in conjunction with antibiotics. He said his talk involved a medical device, "and the device is the maggot."

Dr. Eron said that diabetic limb infections are difficult to treat with antibiotics in part because of vascular insufficiency. Maggot debridement therapy (MDT), using the larvae of the green blowfly (Lucilia sericata), not only removes necrotic tissue without affecting viable tissue but also stimulates the formation of granulation tissue.

Dr. Eron and colleagues used MDT to treat 37 patients with diabetes with complex wounds complicated by diabetic comorbidities. "In some cases, these wounds had been present for as long as 5 years and had failed multiple attempts at treatment," he said. The original wounds were abscesses, infected ulcers, and osteomyelitis with very narrow fistula tracts.

MDT consisted of applying 50 to 100 maggots to a wound, which were covered with nylon mesh fabric (similar to pantyhose) and then removed after 2 days. Clinicians then reapplied more maggots, and the cycles were repeated as necessary (median, 5 cycles; range, 1 - 30 cycles). Maggots were commercially obtained from Monarch Labs at a cost of just under $100 per treatment with 200 maggots.

The researchers defined a successful outcome as elimination of the infection, complete debridement of devitalized tissue, formation of robust granulation tissue, and greater than 50% closure of the wound. "The maggots will not totally heal the wound," Dr. Eron said. "We need other, further methods to heal the wound."

Of the 37 patients, "three quarters, roughly, achieved successful outcomes. The majority had Gram-positive infections. The Gram-positive infections seemed to do better than the Gram-negative anaerobic infections," Dr. Eron reported. The numbers were quite small, however, and a few wounds were culture-negative.

Representative Gram-positive organisms were methicillin-resistant Staphylococcus aureus, methicillin-sensitive S aureus, and group B streptococci. Patients were treated with appropriate, commonly used antibiotics, depending on the infecting organisms.

Failures occurred in patients with severe peripheral vascular disease with narrow fistulae that were not mechanically accessible after they healed after a single treatment in 3 patients with osteomyelitis, with bleeding from wounds (n = 2), or with excessive inflammation around the wound (n = 1). Pain limited treatment for 1 patient, but Dr. Eron said 5 or 6 patients responded well to acetaminophen for discomfort.

"The rest of the patients seemed to acquire, even with their peripheral neuropathy and numbness, some degree of sensation and would feel a creepy, crawly sensation, which they didn't object to," he said. "In fact, they appreciated [it] when they were dealing with anesthetic feet prior to [MDT]. It's an interesting phenomenon, and probably is worthy of investigation."

He warned that MDT is contraindicated in patients with coagulopathies and in patients with large blood vessels near their wounds.

Diabetic wound healing is hampered by a number of factors, not the least of which is vascular disease. Dr. Eron told the audience that MDT "allowed many of these patients -- three quarters of them -- to be ready for a second phase" of wound treatment, "and in many cases it averts amputation." He compared the median cost of about $500 for MDT to the cost of an amputation, which can be $65,000.

He noted that patients with peripheral vascular disease also have generalized vascular disease, so averting an amputation may allow a patient to live out his or her life with limbs intact. In the study, 5 patients died, usually from heart disease, during follow-up after successful MDT.

These investigators saw, as have others, an apparent antimicrobial effect from the maggot therapy. "It may stimulate defensins, which are part of our innate immune system," Dr. Eron said. "There seems also to be an angiogenesis type of effect because in many cases it converted dry wounds into moist, healthy wounds ... and finally it seemed to stimulate granulation tissue."

51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC): Abstract L-967. Presented on September 18, 2011

Hypermobile Flatfoot And Pediatric Obesity: What You Should Know

2011-10-07T15:11:00.000-05:00

Given the increasing prevalence of childhood obesity, this author examines the emerging connection with pediatric flatfoot via a thorough review of the current research and discusses the need for further research to support treatment of flatfoot in this population.

Almost daily, you can turn on your TV or open your favorite newspaper and learn about the “national health crisis” that is obesity. There is also a tremendous amount of literature concerning the long-term health pitfalls of morbid obesity and how it can affect the heart, liver, kidney and lymphatic system. Obviously, obesity can also lead to diabetes and a whole host of other health-related issues.

We are also starting to realize that these poor habits begin in our youth and translate to our overall health as adults. This is very apparent if you’ve ever watched The Jamie Oliver Experiment. In this show, the titular young chef travels the United States and tries to revamp cafeterias in public schools to have a menu that is generally healthier, and convince our nation’s youth to modify their lifestyles and help them attain health into adulthood.

As a parent, I am very concerned about my children’s health but does their health translate to their feet as well? Are obese children more prone to a certain foot type? If that is the case, how does that relate to their general health?

A Closer Look At How Researchers Are Identifying Flatfoot In Study Populations
Before starting the discussion of flatfoot studies and their outcomes, I would like to discuss the methodologies of many of these authors with respect to how they determined a flatfoot condition. Many of the studies that I will discuss employed modern methods of determining foot type. We use many of these methods (such as weightbearing radiographic measurements and evaluation of patients in stance and ambulation) in the day-to-day practice of podiatry.

Study authors used these and other more sophisticated methods of determining flatfoot. The other methods included: electronic footprint capture during gait; ultrasonography to measure fat pad thickness; dynamic plantar pressure analysis; and three dimensional laser surface measures. It is important to point out the use of these additional measurement techniques as they lend credence to the outcomes and conclusions of the studies. Without these modalities, one might be tempted to pass off many of the conclusions derived from these studies as “user bias.” However, most of these studies also combined sophisticated measurement techniques with hard data and statistical analysis. This was one the reasons I selected these studies for this review.

Other studies throughout the world’s medical communities have found similar results when studying the relationship with childhood obesity and flatfoot. In doing the research for this article, it became evident that every corner of the world is struggling with this problem of obesity and flatfoot, given the type of research that is occurring with the pediatric population.

What The Research Says About The Effect Of Weight On Pediatric Feet
As we know, infants do not have much of an arch. Even new walkers do not display much of an arch height. Up until approximately the age of 2, when the arch becomes recognizable, it is virtually impossible to assess foot type unless significant pathology is present.

One study attempted to correlate obesity and low arch height in adults.1 The authors found, using footprint-based estimates, that study patients who were obese displayed lower arch heights than their non-obese adult counterparts. Although this study did not focus on the pediatric population, it served as a springboard for others to investigate this topic in obese children as well.

Another study in Australia measured the same basic premise of arch height in obese children.2 The authors found that “obese children had fatter and flatter feet compared to normal weight children.” They did caution, however, that more studies needed to be completed to assess “… the functional and clinical relevance of the increase [sic] … .”2

A similar study out of Spain found similar results when researchers compared the arch height of obese and non-obese children.3 The authors concluded that obese children had lower medial longitudinal arch heights. They did not, however, relate whether lower arch heights were due to a more pronounced fat pad or whether they were due to a more structurally related etiology.

Another study based in Australia also found that obese children had flatter feet.4 Researchers then postulated that this flatter foot morphology could be caused by structural changes in the anatomy of these children’s feet and the morphology can affect function as these children mature into adulthood.

Interestingly, another group of Australian researchers studied the effects of medial midfoot fat pad thickness and how it correlates to plantar pressures in school age children.5 Although the authors did find some correlation between the two factors, they also admitted that this correlation was rather low and more intense study was needed to solidify a more meaningful conclusion.

The last but potentially most telling of the research published in Australia on this topic is a study that took this concept into a more biomechanical realm than the others and examined the kinematics of gait.6 The study patients underwent analyses that measured certain aspects of their gait while they were being filmed walking. What the authors found was that obese children had more “gait asymmetry … a greater stride width … pointing to a slower, more tentative normal speed.” They also found that the obese children were more unstable at a slower walking speed and that they had trouble walking at a faster pace. Additionally, they found that obese children had a more flat-footed and abducted gait at all phases of the gait cycle.

In a study of 835 preschool age children in Austria, the authors found that the most common study group that displayed a flat-footed morphology was the obese male children.7 Researchers went so far to say they observed “a highly significant prevalence of flatfoot” in the overweight child. A study based in Italy found similar results.8 In a study of 243 children between the ages of 8 to 10 years of age, the authors found those who were obese had a higher incidence of moderate and very marked flat-footedness in comparison to their non-obese classmates.

A group in Germany chose a slightly different route to identify the feet of their patients.9 They chose to classify the feet by how they looked and found that overweight children were much more likely to have flat feet or what they called “robust” feet. They did not quantify exactly what “robust” referred to but the description of flat feet was more descriptive of the morphology of the overweight children in any case.

The Taiwanese were so interested in this phenomenon that they generated three separate studies concerning the prevalence of flexible flatfoot in obese school age children. Within these three research articles, researchers evaluated a total of over 4,700 children. This comprises the largest cumulative sample size ever seen with this topic.

The first study was comprised of 1,598 children and its conclusion was that obesity was one of the risk factors of developing this foot type.10 A study concluded one year earlier with a sample size of over 2,000 children showed that male children who were obese were 2.66 times more likely to have a flatfoot morphology than their non-obese classmates.11 The study also noted that female children who were obese were 1.39 times more likely to have this foot morphology than females who were not obese. In addition, researchers noted that obese children of either sex showed this foot morphology between the ages of 7 and 8.

The last of the Taiwanese studies published recently evaluated flatfoot in children between the ages of 5 and 13.12 Researchers found that when combining the children they considered “overweight” and “obese,” there was a very large percentage who had flat feet. Fifty-six percent of children they classified as “obese” had flat feet and 31 percent of those who were “overweight” had flat feet. The one observation with this study that one should note is that the “normal” children had a 27 percent prevalence of obesity. This calls the statistical analysis of the authors’ data into question but we cannot overlook their conclusion.

In Search Of EBM For Flatfoot Treatment In Obese Pediatric Patients
Much of the research shows that to some degree or another, obesity in childhood can lead to flatfoot. Now how do we transfer this knowledge to the care of this pediatric population?

Much of the studies talk about the foot type but few refer to the consequences of this foot type. One journal article that talks about obesity as a potential cause of flatfoot also expresses concern that one should treat this carefully and consider patient adherence and parental involvement in following the treatment plan.13

There are only two papers relating the factors of pediatric obesity, flatfoot and pain. The relationship of the three factors in these articles is not direct but the authors talk of the factors in broader terms as potential explanations for the foot type causing pain. One study discusses pediatric obesity as a potential cause for flatfoot pain via Sever’s disease.14 The other study discusses an increase in symptoms in pediatric patients with rigid flat feet if the patients were in the 95th percentile or higher in weight for their age.15 Once again, there is no literature that offers evidence to suggest a youngster who is obese will eventually become an adult with painful flatfoot.

This is where the vacuum exists. This is our biggest hurdle to overcome to begin the process of justifying the treatment of the pediatric flatfoot. Whether the flatfoot is caused by obesity, connective tissue disorders, severe equinus, compensated metatarsus adductus or the myriad of other potential causes, our next hurdle is to show that left to its own devices, this foot type will cause lasting pain and potential disability if left untreated or supported.

The biggest problem we encounter is how to design a study protocol to test this theory. It is unreasonable to expect that a study protocol would suggest having a treatment group and a control group. In such a hypothetical study, one group would wear orthotics or undergo corrective surgery to reconstruct the foot into a more “neutral” and functional foot type. The other group would just have simple observation. This study would follow the “subjects” over the course of a generation and the results would be calculated regardless of the patient’s lifestyle or job choice. The “subjects” would be followed by a group of practitioners or via a multicenter study over the course of the doctors’ careers and would only be subject to statistical scrutiny as the pediatric patients mature into their adult lives, or beginning in their late teens.

Until a project such as the one described occurs, the evidence basis to justify treatment of flatfoot in obese pediatric patients remains elusive.

Almonds Can Improve Diabetes Control

2011-10-07T07:55:00.001-05:00

Two new studies into the potential health benefits of eating almonds have supported evidence that they can help people with type 2 diabetes to maintain their blood glucose and cholesterol levels....

One of the studies, published in the journal, Metabolism, showed that consuming an ounce of almonds straight before eating a high-starch meal brought a 30 per cent reduction in post-meal glucose levels for patients with type 2 diabetes, compared with a 7 per cent reduction for non-diabetics. In addition, after overnight fasting, patients with type 2 diabetes whose meal contained almonds had a lowering of blood sugar levels after their meal.

The effect of regular almond consumption on blood glucose levels for people with type 2 diabetes was also investigated, with the daily consumption of one ounce of almonds over a 12-week period being associated with a 4 per cent reduction in hemoglobin A1c (HbA1c) and the same reduction in body mass index (BMI).

The second study, which was published in Diabetes Care, revealed that nuts such as almonds could help to maintain healthy levels of blood glucose and cholesterol for both men and post-menopausal women who suffer from type 2 diabetes.

Karen Lapsley, chief science officer for the Almond Board of California, commented "Those with diabetes are faced with many challenges with their disease management, which is why we are always energized when new research is published that supports our understanding of almonds' role in helping alleviate some of the difficulties."

Diabetes UK, Diabetes Care, Oct. 2011

Reebok paying to settle charges over shoe claims

2011-09-28T13:32:00.004-05:00

WASHINGTON (Reuters) - Reebok International Ltd has agreed to pay $25 million to settle charges that it made unsupported claims that its "toning shoes" provide extra muscle strength, the U.S. Federal Trade Commission said on Wednesday.

The money will go toward consumer refunds.

Reebok advertisements said the shoes strengthened hamstrings and calves by up to 11 percent more than regular sneakers, and toned the buttocks by up to 28 percent more, the FTC said.

"To its credit, Reebok pulled these ads sometime in the middle of our investigation," David Vladeck, head of the FTC's Consumer Protection Bureau.

Toning shoes are designed to be slightly unstable. Makers of such shoes often say the instability requires the wearer to work harder, thus strengthening muscles.

"We did get consumer complaints. We watch TV. We read the newspapers," said Vladeck. "There is no such thing as a no-work, no-sweat way to a fit and healthy body."

Adidas, which owns Reebok, said in a statement that it disagreed with the FTC and stood behind the shoes.

"The (FTC) allegations suggested that the testing we conducted did not substantiate certain claims used in the advertising of our EasyTone line of products," Adidas said. "In order to avoid a protracted legal battle, Reebok has chosen to settle with the FTC. Settling does not mean we agreed with the FTC's allegations; we do not."

The company added, "We stand behind our EasyTone technology -- the first shoe in the toning category that was inspired by balance-ball training."

A variety of companies advertise toning shoes, including New Balance, Skechers, Ryka and Avia.

Skechers acknowledged in an August filing with the Securities and Exchange Commission that the FTC was looking at its advertisements for its Shape-ups and other toning shoes.

The FTC said Reebok began making the claims about its EasyTone and RunTone shoes in early 2009, and provided statistics about the purported benefits of the shoes.

The refunds to customers will be made available either directly from the FTC or through a court-approved class-action lawsuit, the agency said.

By Diane Bartz in Washington and Nivedita Bhattacharjee in Bangalore | Reuters

What Your Nails Say About You

2011-09-23T10:14:00.000-05:00

Toenail and fingernail disorders may signal problems that reach far beyond your fingers and toes. Nail abnormalities often indicate an underlying medical condition or a deficiency in certain vitamins and minerals. Warning signs to look out for include yellow nail discoloration, nail splitting, nail cracking, black fingernails, ridges on nails, and white spots on fingernails. So even if you skip regular manicures and pedicures pay close attention to your nails and discuss any toenail or fingernail changes or disorders with your doctor.

Nail Splitting and Nail Cracking: Split nails or cracked nails can be problematic all on their own, but they can also be fingernail disorders that signal another health problem. Nail splitting and nail cracking can be due to a thyroid condition (hyperthyroidism or hypothyroidism) or psoriasis. If you find that your nails are brittle or split or crack easily and often, talk to your doctor about health conditions that may be responsible.

Soft or Brittle Nails: Fingernails that are soft to the touch or flake apart easily are commonly caused by a lack of the protein keratin. Keratin deficiency often results from crash dieting or some other sudden dietary changes. A protein-rich diet can reverse the damage, as can taking a daily supplement of biotin, a B vitamin. Other causes of soft or brittle nails include chemicals in products used as part of a manicure or pedicure (such as acetone and methyl acrylate), and health conditions, including Crohn’s disease and anemia.

Ingrown Nails: When nails grow into the skin instead of straight, an ingrown nail occurs. This painful toenail and fingernail disorder is most often caused by an injury to the nail — someone steps on your foot or you stub your toe — or from wearing shoes that don't fit properly. But nail disorders such as a nail fungus can also trigger an ingrown nail. Ask your doctor if you can attempt to treat an ingrown nail yourself; a severely ingrown nail may require antibiotics to prevent an infection or minor surgery to remove some or the entire ingrown nail.

Nail Fungus and Yellow Nails: Nails that crumble and break, turn yellow, or begin to smell may signal a fungal infection, also known as onychomycosis, which can affect fingers or toes. You may have picked up the toenail fungus in a public pool or locker room — any place that's moist and warm. Have your nails inspected by a doctor who can confirm the diagnosis and recommend treatment, either with an anti-fungal cream or a course of oral antifungal medication. Frequent fungal infections may indicate a weakened immune system, a health problem like diabetes, or poor circulation. To prevent toenail fungus, keep your feet clean and dry, and wear shoes or sandals in public places.

Black Lines in Nails: A black line or streak that appears in a nail is often from some type of injury. But if you don't remember accidentally whacking your index finger or stubbing your toe on a table leg, start looking elsewhere for an explanation. These black lines could be warning signs of melanoma, an extremely dangerous type of skin cancer, so you should see a doctor to have them checked out.

Blood under Nails: You can accumulate blood under a nail when the nail has been injured — hit against something, crushed, pinched, or otherwise traumatized. The nail may look black due to the blood that pools beneath it, and the nail may eventually fall off. Sometimes, to alleviate pain and pressure, it’s necessary for a doctor to puncture a small hole in the nail to allow the blood to drain. Splinter-like streaks of red may be caused by an injury, but they could possibly indicate an infection of a heart valve, which showers the bloodstream with debris that causes the marks to appear. If you see streaks of red in your nails when you haven't injured them, ask your doctor about it.

Ridges on Nails: Ridges on nails can be more than unsightly — they may indicate a nutritional deficiency. Ridges on nails can be a sign of malnourishment or a specific deficiency in iron, in which case you may also have depressed areas on the nail. Horizontal ridges on nails can also result from arsenic poisoning. See a doctor for evaluation if you notice ridges forming on your nails.
White Spots on Fingernails: White spots on fingernails are generally of no concern. They usually occur as a result of a minor injury to the nail that you may not even remember. Over time, they grow out and are clipped or filed off. But if you frequently see white spots on your fingernails and find that they don't go away, you may have an infection that requires medical attention.

Compression stockings: One size definitely does not fit all

2011-09-21T11:47:00.000-05:00

Proper selection and sizing of compression hosiery can be confusing, but both are essential for control of edema and management of more serious vascular conditions in patients with diabetes. And then there’s the even more challenging issue of patient compliance.

By Shalmali Pal

Fit shoes in the afternoon and compression stockings in the morning. That’s the simple but effective rule that works for Bill Meanwell, CPed, founder, CEO, and director of the International School of Pedorthics in Broken Arrow, OK.

Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner at Foot and Ankle Associates of North Texas in Grapevine, also follows a similarly streamlined model.

“For diabetics, usually we use 15 to 20 mmHg compression for those with edema and 10 to 15 mmHg for those without. Anything higher than 20 mmHg compression, patients should be custom measured by a physician, especially if they have peripheral arterial disease,” she said.

Indeed, the application of compression stockings would seem to be fairly cut and dry: Take leg measurements, use the manufacturer’s guidelines for determining the level of compression, choose a style, and hand over to the patient.

But not all diabetic patients are created equal, and neither are compression stockings. At one end of the spectrum are patients who may benefit from support pantyhose for light pressure to prevent or reduce mild swelling, a condition that is not only uncomfortable but can delay wound healing in diabetic patients. At the other end are those who suffer from significant edema or venous leg ulcers who are candidates for prescription-strength compression stockings. And then there are patients with peripheral arterial disease (PAD) and peripheral vascular disease (PVD). Issues that need to be addressed when prescribing compression hosiery include proper diagnosis, accurate measurements, and, of course, patient compliance.

Spotting vascular issues

While it may seem obvious, PAD and PVD require consideration beyond a visibly swollen leg, said David G. Armstrong, DPM, MD, PhD, professor of surgery at the University of Arizona College of Medicine and director of Southern Arizona Limb Salvage Alliance (SALSA), both in Tucson.

Some, but not all PAD and PVD sufferers, will show signs of intermittent claudication. But if the patient never walks far or long enough for leg pain or cramps to set in, then claudication may not manifest. Other symptoms to look for include:

Weak or tired legs
Difficulty with walking or balance
Cold and numb toes or feet
Slow-healing sores
Foot pain even while at rest
The prescription for compression hosiery in diabetic patients with PAD or PVD needs to come from a clinician. Armstrong offered a general guideline for when compression hosiery are appropriate.

“As long as the patient doesn’t have tremendously low outflow pressure into the extremity, I think it’s safe for them to wear compression hose,” he said. “If their outflow pressure is below the relatively mild amount of pressure applied by a compression stocking–for example, if the outflow pressure is below 30 or 40 mmHg–then that’s significant ischemia and the person has bigger problems that just swollen legs. They should be evaluated promptly by a vascular surgeon. The key is knowing this and measuring it. As we often say at SALSA, ‘You can’t manage what you can’t measure’.”

Measure for measure

Improper compression hosiery usage and incorrect sizing has been a recognized problem in the foot health community, but not necessarily well documented. Graduated compression stocks that are sized incorrectly may actually increase the incidence of vascular disease and may even lead to skin breakdown, neither of which are ideal in any patient, diabetic or otherwise. In a study published in the August 2002 issue of Medsurg Nursing, a group of nurses was interviewed about their fit technique for graduated compression stockings, and only two of 15 said that they measured the patient’s leg to determine the correct size.

In a 2008 study, researchers at Presbyterian Hospital in Dallas sought to determine if healthcare practitioners were correctly sizing compression stockings, how the patients rated the comfort level of the stockings, and whether they understood the purpose of the hosiery. The study population was made up of hospitalized, postoperative patients, and nurses dispensed the stockings, but the results can be applied to diabetic patients as well, according to lead author Elizabeth H. Winslow, PhD, RN, FAAN.

While it is important to note that there are differences between postop patients and diabetic patients in terms of their compression needs, a good fit is a universal must. Additionally, many of the issues that Winslow’s group saw in their study population may also crop up with diabetic patients.

“Any patient who has compression stockings prescribed needs to wear the appropriate size; know how to size, and use the stockings correctly,” Winslow said. “Patients, and their family members, also need to realize that the leg size may change. If swelling significantly increases or decreases, the patient will need to be re-measured to determine if another size is needed.”

The final study group consisted of 142 patients, the majority of whom (74%) were overweight. The most common type of surgery was gynecological (53%) followed by orthopedic surgery (41%). Seventy-four percent of all patients were prescribed knee-length stockings, and 26% wore thigh-length stockings.

Winslow and coauthor Debra Brosz, MSN, RN, ONC, NEA-BC, found that the compression stockings were used incorrectly in 29% of the patients, with the most common problems being that the stockings were rolled down or too loose. The authors did not ascertain if the stockings were deliberately rolled down by patients, Winslow said. But diabetic patients will be tempted to turn down the band at the top of the stockings, especially if the leg swells and the hosiery feels tighter.

Also, patients with a thigh circumference of greater than 25 inches were given thigh-high stockings when knee-length would have been more appropriate. However, a larger size than appropriate was prescribed in 26% of the patients wearing knee-length hosiery. In patients with a body mass index of 25 or more, the thigh-length stockings were more likely to be used improperly than the knee-length stockings. The findings were published in the September 2008 issue of the American Journal of Nursing.

The authors acknowledged that, in some cases, stockings were initially sized correctly, but subsequent swelling brought on changes to the patients’ needs (see Tables 1 and 2). Winslow also pointed out that patients with neuropathy “may have difficulty feeling any pressure areas or problems from the stockings until serious skin damage has occurred.” Again, stockings need to be measured and re-measured to meet the patient’s evolving needs.

Nancy Elftman, CO, CPed, stressed the importance of obtaining Ankle-Brachial Index (ABI) measurements.

“You have to know the ABI to put the stocking on,” said Elftman, founder of Hands on Foot in La Verne, CA. “If the ABI is less than 0.6, then it’s an arterial disease, not a venous disease, and you cannot put compression on it.”

Compression can actually worsen the already limited blood flow in patients with peripheral arterial disease and potentially induce ischemia.

“If (the ABI) between 0.6 and 0.8, then it’s a combination of venous and arterial and for that, you can only use a 20 mmHg stocking. If it’s a 0.8 to a 1.0 ABI, then that’s purely venous and you can use a 30-40 mmHg,” Elftman added. (see Table 3).

Knee vs thigh

In Winslow’s study, patients expressed a preference for knee-high stockings over thigh-high ones. They also found that more problems arose when patients were given thigh-high stockings. Their findings led to a policy change at their institution: Nurses are encouraged to work with physicians and nurse practitioners to make sure that knee-length stockings are prescribed. In addition, “we have removed the thigh-length stockings from all of our buildings.”

A patient survey done at California State University in Sacramento found that knee-length sequential compression devices for preventing deep venous thrombosis were more comfortable for patients, encouraged a higher level of compliance with treatment, and were less expensive. That study was published in the July/September 2007 issue of Critical Care Nursing Quarterly.

A systematic review of 14 randomized trials in hospitalized populations and passengers on long haul flights found that knee-length stockings did not appear to be worse than thigh length in hospitalized patients. That study, published in the December 2006 issue of the European Journal of Vascular and Endovascular surgery, found that knee-length stockings were actually better in passengers in flight for preventing DVT.

An earlier study done at Semmelweis University in Budapest, noted knee stockings were less efficient at increasing venous outflow in postoperative patients, although they were deemed more comfortable and less likely to wrinkle. Those findings were reported in the February 2001 issue of Clinical Orthopaedics and Related Research.

But Elftman said that, in her experience, there are really only two circumstances where a thigh length stocking would be more appropriate in diabetic patients: If the patient has lymphedema, or if the patient prefers a longer stocking.

“Women, especially if they wear skirts, want [the stocking] to be up higher. Some patients have trouble with knee stockings rolling down so they’d rather have it go up higher. But as far as the physiological effects, the knee down is what you are working on,” she said.

Elftman pointed out that, according to noted vascular surgeon John Bergan, MD, founder of the Vein Institute of La Jolla in California, “it really doesn’t do any good in terms of compression to go to the thigh. There is so much volume in the thigh, it’s not really producing hydraulic compression. He says go to the knee unless they feel better having a higher stocking. It would be for patient preference, not for the compression.”

Armstrong said that at his institution, knee highs are preferred over thigh highs because many of the patients simply cannot manage longer stockings. The hemmed band can be difficult to negotiate over a thigh with a larger circumference, while the stockings that are attached with a bit may prove tricky to attach.

Compression and compliance

An October 2006 study published in the Journal of Vascular Surgery looked at the prevention of venous ulceration recurrence using class 2 and class 3 elastic compression. No surprise that the lowest recurrence rate was seen in patients who wore the highest degree of compression. The authors concluded that “patients should wear the highest level of compression that is comfortable.”

But the most effective level of compression and patient comfort don’t always jibe. One of the best ways to ensure compliance is to, once again, make sure that the stocking has been properly fitted. In Winslow’s study, one of the most common problems with the thigh-high stockings is that they were rolled down.

Another key is making sure that the patient understands what the intention is behind the compression stocking.

“As clinicians, you can’t assume that just because you said something, someone knows it and internalizes it. The key for clinicians treating people at high risk is to stay on-message. Every single person that sees a patient has to be talking to him with that same message. The more you drive home that message, the better adherence will be,” Armstrong said.

Elftman said she first does a trial run.

“We take the measurements together and then we put [the patient] in an Unna boot or an Ace wrap for a week,” she said. “They come back and we do the measurements again. Just during that week, they can see the difference, the decrease in the size of the leg. So by the time we measure for the stockings, [the patient has] seen the decrease and are much more compliant. You really have to build them up to it.”

Elftman also drives home that the stockings must be removed every night. Because the stockings can be difficult to put on, some patients prefer to leave them in place, but Elftman strongly discourages that, explaining to the patient that the small radius of compression in the heel could cause an ischemic ulcer.

Even if the patient comprehends the point of the stocking, clinicians also need to look beyond their vascular issues. Armstrong shared the case of a patient with mixed arteriovenous disease who needed to wear his compression hosiery. But Armstrong’s team had to overcome a major obstacle before they could get this patient into his stockings.

“(This patient) had some substance abuse problems,” Armstrong explained. “He was self-medicating when he initially came to see us and, in a fit of mania, he had ground a hole into his ankle and part of his foot with a PedEgg callus trimming device. He was committed to using that PedEgg on his calluses. We had to convince him that the hole in his skin was not a positive result of his PedEgg regimen. But when we tried to take the PedEgg away from him, he totally shut down. We were unable to communicate and he refused to even work with us. So instead of taking away the PedEgg, we focused on teaching him how to use it appropriately and safely—and checking in on him frequently.”

Once the wounds had healed, and Armstrong’s team were confident that the patient understood how to use his pedicure aid properly, the stockings were introduced.

“He is now very adherent, uses his hose diligently, and reports to us regularly and passionately about his stockings and his PedEgg use. He is now a partner rather than an opponent,” Armstrong said.

Compression stocking measurements: Dos and Don’ts

Do measure and fit the stockings according to the manufacturer’s recommendation.
Do document leg measurements and stocking size at baseline.
Do check the stockings to ensure correct usage and adequate perfusion.
Don’t assume that leg measurements are set in stone. Review measurements regularly to check for swelling and excessive pressure from the stockings.
Don’t let the patient go for more than one day without removing the stockings and performing a skin assessment.
Don’t monitor patients while they are lying down. Placing the patient in a seated position can help determine if the stockings are acting like a tourniquet.
Source: Adapted from Best Practice: Graduated compression stockings for the prevention of post-operative venous thromboembolism 12:4, 1-4, 2008, The Joanna Briggs Institute

Seven steps to obtaining the right measurements

1. Measure the circumference of the ankle around the narrowest part, above the ankle bone.

2. Measure the circumference of the widest part of the calf.

3. Measure the length of the calf from the back of the heel to the bend in the knee.

4. Measure the circumference of the widest part of the thigh just below the gluteal fold.

5. Measure the length of the thigh from the gluteal fold to the back of the heel.

6. Measure the circumference of the widest part of the hips.

7. Measure the circumference of the waist.

ABI measurements

Tools needed

Sphygmomanometer with appropriately sized cuff(s) for both arm and ankle
Hand-held Doppler ultrasound device with vascular probe
Conductivity gel compatible with Dipper ultrasound device
Calculating ABI

1. Measure brachial systolic pressure in both arms.

2. Measure posterial tibial and dorsalis pedis systolic pressures in both legs.

3. Divide each ankle systolic pressure by the brachial systolic pressure.

ABI key

Normal: 1.0-1.1
Borderline: 0.91-0.99
Abnormal: <0.9 or >1.3
Source: Adapted from Ankle-Brachial Index: A Diagnostic Tool for Peripheral Arterial Disease, American Academy of Nurse Practitioners

Compression cross-checked: Flight-related data and diabetes

The subject of vascular problems and long-haul flights has taken off in recent years. Multiple studies have shown that being airborne for more than 10 hours increases the risk of deep venous thrombosis (DVT) or edema. However, the risk of both conditions can be reduced with compression hosiery.

The question for lower extremity practitioners is: Is the research on “travel stockings” relevant for diabetic patients? Yes, according to Armstrong.

“I think these (results) apply equally to people with and without diabetes,” he said. “The key for the people with diabetes is that they are under the care of a diabetologist, a vascular specialist, and a foot specialist. You have to make sure that they’ve been properly assessed by one or all of those specialists in terms of their risk for DVT.”

Results from the LONFLIT4-Concorde study are the most relevant to diabetic patients. Conducted by the A San Valentino Vascular Screening Project in Chieti, Italy, the study evaluated edema during seven to eight hours flights and whether it could be controlled with compression stockings (20 to 30 mmHg). There were 144 subjects (74 in the stocking group and 76 in the control group), all of whom had edema-associated microangiopathy from diabetes, venous hypertension, or anti-hypertensive treatment.

The level of edema was comparable in the two groups at baseline. Post-flight, the stocking group’s average edema score was three times lower than in the control group (P < 0.05). Also, there were no cases of DVT in the stocking group, compared to a 3% incidence in the control group. The level of compression was well tolerated in both groups. The results were published in the March-April 2003 issue of Angiology.

The shoe review: From high heels to low flats, local podiatrists analyze footwear

2011-09-20T09:04:00.000-05:00

Tuesday, March 15, 2011

By Robyn Gautschy ~ Flourish

Women have been told that sometimes they have to suffer for fashion. That is certainly true when it comes to shoes.

Whether it's sky-high stilettos or the latest sandal trend, women's shoes are not often designed for function over fashion.

Local podiatrists give us the low-down on how our feet are affected by various styles of shoes.

Furry boots

How they affect your feet: "They're very comfortable and warm, but there's not much support in them," says Dr. Hugh Protzel, podiatrist at Foot and Ankle Centers of Southeast Missouri. Wearing these popular boots may lead to heel pain, foot aches and arch pain, especially if you have flat feet. "I wouldn't go for a long walk in them," says Protzel.

As for the furry lining, doctors don't see any relationship between the material and foot fungus.

"If someone already has a problem with excessive foot sweating, they could have a problem with foot fungus. But for the average person, there shouldn't be any kind of issue," says Dr. Robert Daugherty of Advance Foot & Ankle Center.

How to find a good pair: You may want to get a prescription insert for added support, says Protzel.

Flip flops

How they affect your feet: Flip flops are a good way to protect your feet when you're hanging out at the pool, says Protzel, but if you plan on going for any length of walk, they offer no support. "They don't allow for the proper gait cycle your foot should go thorough with each step," he adds. Protzel's flip flop-wearing patients have problems with heel pain and tendinitis.

How to find a good pair: Look for sturdier sandals. Protzel says Birkenstocks offer very good support.

Stilettos

How they affect your feet: "The visual, aesthetic things going on are nice, but functionally, they are potentially deforming," says Dr. Zenon Duda, podiatrist at Cape Foot Clinic. Stilettos alter the way the head and shoulders sit, increase the arch in the back, relax the calf muscles and cause the chest to protrude. As a result, you place excessive pressure on the balls of the feet, take unnaturally short steps, and struggle to maintain stability. With long-term wear, you're likely to see hammertoes, bunions, corns and red spots. Pointy-toed heels will eventually mold your feet into a triangular shape.

How to find a good pair: If you must wear stilettos, look for a pair made of soft leather and with not many stitches -- these will be more flexible and protective than heels made of man-made materials. Duda suggests wearing them in short bursts, with time in between for the feet to breathe and stretch.

Flats

How they affect your feet: "Most don't have any cushion or support, but then again, they don't cause any problems because they're nice and wide and are often made of soft leather," says Dr. James Main, podiatrist in Cape Girardeau. "Other than if you have a problem where you need cushion or additional support, these are probably not too bad. They're better than heels or pointy shoes." Daugherty thinks most women without foot problems can get by wearing flats, but he worries about the long-term effects. "If you wear them excessively over time, you might wind up with some problems. They have no support, especially for the arches, and people that stand a lot with their jobs will probably have some pain," he says.

How to find a good pair: Look for flats with enough room for an insert -- that way, you at least have some type of arch support, said Daugherty.

Wedges

How they affect your feet: "They're a good way to hurt your ankles," said Dr. James Main, podiatrist in Cape Girardeau. "Anytime you wear a heel, you shift your body weight forward to the front of the foot, and you're inherently unstable." Like heels, wedges place more weight on the front part of the foot, which can cause knee and lower back problems, says Main. Wedges usually have no support on the sides, making it easier to lose balance and topple over. "On a wedge, the weight is at least spread out over the heel," he concedes.

How to find a good pair: "A woman should go with the very lowest heel height that she can go with. The lower the better," says Main. Many wedges have a rubberized or corklike bottom, which Main believes may add more support than a hard material.

Platform heels

How they affect your feet: Platforms are better than stilettos, but still, "Any kind of shoe that puts abnormal stresses on the balls of foot can cause problems," said Daugherty. "Occasional wear is not a big deal, but this is definitely a shoe that I don't recommend."

How to find a good pair: A stable bottom should be the No. 1 concern, says Daugherty. Wood bottoms are probably more stable and will last longer.

Bunion research focuses on patient quality of life

2011-09-19T08:11:00.000-05:00

Lower extremity practitioners know the effect of hallux valgus on a patient’s quality of life starts with a frustrating inability to find fashionable shoes that fit—but evidence suggests it doesn’t end there. Pain, function, and self-image all play significant roles.

By Larry Hand

Recent studies have concluded that increasing severity of hallux valgus (HV) leads to a series of conditions or behaviors—increasing pain, decreasing functional ability, withdrawal from normal daily activities—that contribute directly to a progressive decline in health-related quality of life.

The chain reaction applies to men and women, but studies have shown that women are much more likely than men to develop HV and more likely to experience a drop in quality of life. And practitioners interviewed for this article said more and more younger people are being seen with juvenile-onset HV, a disorder that is most often inherited.

It’s logical to think that eliminating the deformity would necessarily reverse any downward quality of life trends. And recently published research does conclude that some surgical procedures are effective for correcting HV. What happens after surgery, however, can vary greatly, depending on the procedure done, the patient’s own tendency to stiffen after surgery, whether patients get physical therapy, and whether they comply with surgeons’ recovery instructions.

“The most common quality of life issue is they just can’t put on the kind of shoes they want to wear,” said Lowell Weil, Jr., DPM, of the Weil Foot and Ankle Institute in Des Plaines, IL. “A typical patient is a woman in her mid- to late-40s who has seen her bunion progressively get worse and she’s tried wider shoes, deeper shoes, and less-high-heeled shoes. While that works for a time, the shoes are becoming less and less comfortable because of the progressive pain. She could probably find an ugly orthopedic shoe that she could get into, but that just doesn’t work for her professionally or socially.”

As the bunion progresses, Weil continued, women start to become embarrassed by their feet.

“They don’t want to go barefooted. They don’t want to wear sandals or flip flops. It’s an ugly deformity to them, and some people even have concerns that the opposite sex find it unappealing,” he added.

Mounting evidence

In a study e-published ahead of print in November by Arthritis Care & Research, researchers at the Musculoskeletal Research Centre at LaTrobe University in Australia and Keele University in the U.K. concluded that a progressive reduction in both general and foot-specific health-related quality of life occurred in people with increasing severity of hallux valgus deformity, or greater HV angle. They analyzed the records of people aged 56 and older in a six-year follow-up of the North Staffordshire Osteoarthritis Project in the United Kingdom.

More than 36% of the study’s participants were affected by HV, which was more prevalent in females and older patients. However, after adjusting for age, sex, education, and body mass index, Medical Outcomes Study Short Form 36 (SF-36) quality of life scores decreased as HV severity increased. After the same adjustments, increasing HV severity also was linked to greater impairment on the pain and function subscales of the Manchester Foot Pain and Disability Index (MFPDI). The same type of association existed for bodily pain, general health, social function, reduced physical function, and mental health subscale scores after adjusting for pain in the back, hip, knee, and foot.

The researchers used survey questionnaires to obtain their self-reported data, and they used five validated line drawings that showed various degrees of HV, with angles ranging from 0° to 60°. They started with a population of more than 11,300 people registered with three general practices from the North Staffordshire Primary Care Research Consortium. The researchers reasoned that, since more than 95% of people are registered with a general practice in the UK, the registers provided a valid sampling population.

Almost 3600 people completed the first of two surveys three years after recruitment into the trial, and the second survey three years later returned about 2800 responses, for an adjusted 83.9% response rate. Those reporting HV were most likely to be female and older than others, and they generally had a lower body mass index and shorter stature. Just over 40% had unilateral HV and just under 60% had bilateral HV. Of the 2681 respondents who could be considered for foot deformity severity, just over 33% characterized their worst foot severity as a 30° angle or higher, while most (almost 45%) characterized their foot angle as at least 15°. Only 57 people said their angle was more than 60°.

An earlier study, published earlier in 2010 in Osteoarthritis & Cartilage, was the first study to assess quality of life’s association with HV and big toe pain in a general community population. (An association had previously been reported in small hospital-based studies.) Researchers at the University of Nottingham in the UK analyzed results of almost 3100 responses received from more than 13,600 questionnaires mailed to individuals registered with two general practices in Nottingham. They used the short version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF).

They concluded that concurrent HV and big toe pain—but not HV alone—is associated with overall dissatisfaction with health and low scores on the WHOQOL-BREF physical, psychological, and social domains. They also compared the significance of the association to that of patients with severe knee and hip osteoarthritis who are in line to have joint replacement surgery.

Research involving such large numbers of people relates well to individual patients being seen by practitioners in the United States.

“Much of it has to do with the types of shoes people have to wear and their activity levels,” said Vincent Marino, DPM, a podiatrist who practices in San Francisco, Novato, and Sacramento, CA. “Many of our professional women [patients] who have to wear fashionable shoe types during the day usually suffer more and at an earlier stage than someone who can wear more comfortable shoes. It becomes frustrating because they are in pain a great deal and it becomes an issue with work requirements.”

Often, the pain causes a person to forego activities that, under normal circumstances, they would be doing on a daily basis.

“A lot of times patients will say they’re not able to do the things they normally do, or they have to curtail it; if they usually go out for an hour or two, now it’s just a half hour,” said Althea Powell, CPed, LPed, OST, who operates Powell Shoes in Vero Beach, FL. “We’ve had patients who said they were just unable to exercise. They can’t go for a walk even though the doctor says they need to walk for exercise.”

And the effects go well beyond middle-aged and older women. In an article published last year in the Journal of Foot and Ankle Research, researchers from the University of Queensland reported HV prevalence of 36% in elderly women and 16% in elderly men, 26.3% in adult women and 8.5% in adult men, and 15% in juvenile (under age 18) girls and 5.7% in juvenile boys.

“The unsightliness of the deformity has an effect on many teenage girls and young women. They’re hesitant to wear open-toed shoes because they perceive their foot as being ugly,” Marino said. “They come in because they want to wear some open-toed sandals without having people stare, and it has an effect on their psyche. It also affects the ability of men and women to exercise. They lose the ability to run comfortably and do some of the activities that they put in their everyday lifestyle to help control their stress levels. They stop running. They stop using the elliptical. They stop doing aerobic activities. Every time they put a shoe on, they’re in pain.”

Just getting into a properly sized shoe makes a big difference for even minor bunions, said Chad Brown, CPed, of Brown’s Enterprises, a specialty shoe retailer in St. Louis.

“But in more severe cases, hallux valgus deformity can be just as debilitating as someone who suffers from migraines,” he said. “You’re going through excruciating pain, and it affects everything from going to the grocery store to taking vacations with your family.”

Even professional basketball players are susceptible.

“One player who was a patient of mine probably wore a size 20 or 21 shoe and he had two different-sized feet,” said Dennis Janisse, CPed, president and CEO of National Pedorthic Services and a clinical assistant professor of physical medicine and rehabilitation at the Medical College of Wisconsin in Milwaukee. “I actually had to cast his feet for a high-end dress shoe company so that they could make a shoe over the cast. Because he had such a big-sized shoe, it was so hard for him to get footwear anyway. He was cramming that bigger foot into a smaller shoe, and he ended up with a significant deformity on the one foot and the other foot was fine.”

Wide range of treatments

Treatment for HV, most often a hereditary disorder, ranges from just trying to control the symptoms with proper shoes and orthotics to surgery, often considered a last resort.

“Unfortunately there’s not a lot that really works,” Weil said. “For somebody who is developing a bunion, there’s nothing you can do to arrest the progression. No mechanical device or change of shoe gear is going to prevent the progression of the problem. Basically you treat it with finding wider and deeper shoes that are more amenable to the deformity. You change activities to make it more comfortable. Shoes and orthotics may make it less painful—until it gets bad enough to have surgery.”

More than 130 procedures have been described for HV as far back as the early 1900s, but in the last 20 years, techniques have improved and have been refined based on technological advances in surgery in general, Weil said.

In 2000, a Cochrane Database Systematic Reviews article cited a consistently high (25% to 33%) rate of dissatisfaction among osteotomy patients postoperatively. However, recent publications have pointed to different, highly positive results. A June 2007 paper published in Quality of Life Research concluded that surgery improves the quality of life for HV patients in terms of bodily pain, vitality, and mental health. A study to be published in the March 2011 issue of Clinical Orthopaedics & Related Research cites improvements in AOFAS pain and function scores from 61.5 to 90.3 in patients who underwent a unilateral scarf osteotomy combined with distal soft tissue alignment at the Hospital for Special Surgery in New York City.

Still, opinions vary as to the effectiveness of surgical procedures, depending on who you ask. Some pedorthists and physical therapists still see patients postoperatively who may be predisposed to stiffness in joints or otherwise have not fared well after surgery for various reasons, including not complying with surgeons’ instructions. Marino, however, said noncompliance is not a significant problem in his San Francisco practice.

“I personally drill into their heads that I won’t operate unless they know what they have to do afterward. I tell them, ‘If you don’t listen, then we’ll just end up doing this again,’ ” he said.

Some results depend on the reason for the surgery in the beginning, and the expectations of the patients, particularly with regard to wearing stylish shoes.

“In our neighborhood, people have surgery based on what they can’t wear and the amount of deformity, which is a lousy reason to do it, quite frankly,” said Stephen Paulseth, PT, DPT, SCS, ATC, in private practice in Los Angeles, near Beverly Hills.

He recommends the use of orthotics before and after surgery, as needed.

“We always try to get the patient in before they consider surgery, to see if we can get them a little bit more mobility, get them in some calf/soleus exercises and calf stretching, and to use their flexor hallucis during push-off. They tend to allow their foot to deviate at push-off, which drives their first-toe into abduction,” he said.

Most of the patients seen by RobRoy Martin, PT, PhD, assistant professor of physical therapy at Duquesne University in Pittsburgh, PA, are postoperative patients.

“A lot of them have inappropriate preoperative expectations, thinking they can go back to the shoes they wore before they had surgery,” he said. “The really fashionable shoes are just so bad. I’ll trace their foot and then put the shoe on top of the trace and ask the patients, ‘how can you possibly jam your foot back into that?’ ”

Other people, he added, are simply prone to stiffness after surgery. He tries to counter that with aggressive joint stretching and mobilization exercises, and he recommends a good cross-training shoe that is sturdier and stiffer than a running shoe to maintain forefoot stability.

If a person’s job requires a higher fashion, therein lies the rub. Although most shoes that are wide enough and deep enough to accommodate HV are functional, Powell said, “They’re not pretty. It does not matter the age group, whether someone is in their 30s or 80s, they are looking for function as well as aesthetic.”

That said, the footwear options available for patients with HV today are much better than in the past, Janisse said.

“You’re not going to find a three-inch spike heel or anything like that that’s going to accommodate something like a significant deformity. But a lot of the footwear out there today is much more accommodating and is acceptable, unlike it was years ago,” he said.

Still, shoe manufacturers “definitely need to keep their efforts strong in making shoes that are more fashionable, even though they have made a lot of progress in the past 10 years,” said Brown in St. Louis.

And the shoes need to accommodate all ages, he added.

“The younger people don’t want to look like they’re wearing the same pair of shoes their mom or grandmother wore,” Brown said.

Nicotine Raises Blood Sugar Levels in Lab

2011-09-17T10:57:00.003-05:00

SUNDAY, March 27 (HealthDay News) -- Smoking is damaging to everyone's health, but the nicotine in cigarettes may be even more deadly for people who have diabetes.

In lab experiments, researchers discovered that nicotine raised blood sugar levels, and the more nicotine that was present, the higher the blood sugar levels were. Higher blood sugar levels are linked to an increased risk of complications from diabetes, such as eye and kidney disease.

"Smoking is really harmful for diabetics. It's even more harmful to them than to a non-diabetic," said study author Xiao-Chuan Liu, an associate professor in the department of chemistry at California State Polytechnic University in Pomona. "This study should encourage diabetics to quit smoking completely, and to realize that it's the nicotine that's raising [blood sugar levels]."

For that reason, it's also important to limit the use of nicotine replacement products, such as nicotine patches, Liu said.

"If you're using them for a short period of time to quit smoking, that's OK. But, if you still have this addiction to nicotine and are using this product long-term, it will do harm. Don't use electronic cigarettes or nicotine gum for a long time. You need to stop nicotine intake," he advised.

Liu is scheduled to present his findings Sunday at an American Chemical Society meeting in Anaheim, Calif.

It was already well-established that smoking increased the risk of problems in people with diabetes, Liu said. What hasn't been clear, he said, is if there is a specfic component of cigarettes that increases the risk.

To test whether or not nicotine, an addictive substance found in cigarette smoke, contributed to higher blood sugar levels, Liu and his colleagues added equal amounts of glucose (sugar) to samples of human red blood cells. They also added varying levels of nicotine to each sample of red blood cells for either one day or two days.

They then tested the hemoglobin A1C (HbA1C) levels of the samples. HbA1C is a measure of what percentage of red blood cells have glucose molecules attached to them. In diabetes management, the HbA1C -- sometimes referred to just as A1C -- test gives doctors an idea of average blood sugar levels for the past three months or so. Most people with diabetes strive for a level of 7 percent or less, based on American Diabetes Association guidelines.

The researchers found that nicotine raised HbA1C. The smallest dose increased HbA1C levels by 8.8 percent. The highest dose -- after two days of nicotine treatment -- increased blood sugar levels by 34.5 percent.

"Nicotine is a toxic substance, and our results show that nicotine caused an increase in HbA1C," said Liu. "This is important for the public to know, and for smokers to know. It's not just the cigarette smoke. If you think you can just use a nicotine replacement product indefinitely, there's still a risk, and your chances of getting complications will be a lot higher," he cautioned.

Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, said that the researchers showed that nicotine can significantly raise A1C levels in the lab, but it's important to also know if it does so in the body.

But whether or not nicotine is the specific reason that blood sugar levels are higher in smokers, he said, "Everybody -- whether they have diabetes or not -- should stop smoking. Patients with diabetes already have a much higher risk of cardiovascular disease, and smoking adds to that."

He said that using nicotine replacement products for a month or two is fine. "If nicotine replacement is used for a short period of time with smoking cessation as the goal, there's no risk. But it's not OK if someone plans to replace smoking with nicotine replacement products indefinitely," said Zonszein.

Star QB has to have part of leg amputated following freak injury

2011-09-16T15:04:00.000-05:00

One of the top quarterback prospects in Virginia is facing a difficult and uncertain future that will almost certainly not include college football after he was forced to amputate part of one of his legs at a hospital in suburban Washington, D.C.
As first reported by the Charlottesville Daily Progress, Woodberry Forest (Va.) School quarterback Jacob Rainey had part of one of his legs amputated on Saturday, just more than a week after he suffered a freak injury in a final preseason football scrimmage against Flint Hill (Va.) High.

According to the Daily Progress, Rainey suffered a broken knee cap when he was cleanly tackled from behind by a Flint Hill player. After he arrived at the nearest hospital, doctors discovered that he had suffered other complications from the injury, most drastically a ruptured blood vessel.

In a statement released by Woodberry Forest officials it was revealed that Rainey was moved to Fairfax Inova hospital when his condition failed to improve. There, Inova doctors determined that he had severed the main artery in one of his legs and that he had to immediately undergo vascular surgery to avoid further serious health issues. The only solution was to amputate part of one of his legs, a procedure which was carried out on Saturday, just a day after Woodberry Forest opened the season with a 16-13 victory at Richmond (Va.) Benedictine High without its expected starting quarterback.

Woodberry coach Clinton Alexander was given the unenviable task of telling the rest of the team that Rainey would have to lose part of his leg, a job which immediately transformed the program's buoyant mood following its season-opening victory to a somber discussion of how the team could keep Rainey -- one of the top junior quarterback prospects in the state who was being recruited by a number of ACC programs -- involved in their season.

Alexander said that his team was still dealing with the shock of learning that one of their closest friends had suffered such a dramatic injury on the field, though he said that the close ties that made them particularly sensitive to his injury also will help the team move on from it.

"I have had situations in my career were we have had a player's parent pass away during the season and have had two players on two different teams die in a car accident, but nothing like this," Alexander told Prep Rally in an email.
"Our players love Jacob very much and were very upset when it happened and were very worried about him after he was taken to the hospital. Our team is very close, one of the benefits of a boarding school football program. They get so much time together on dorm that the depth of the relationships they form is quite amazing. This has certainly helped our players understand how important it is to care about each other and attempt to overcome adversity together."

One of the ways Woodberry Forest plans to memorialize their missing leader is by passing around his jersey number each week. In the team's first game at Benedictine, Rainey's closest friend, Nate Ripper, wore his number 9 jersey. In each subsequent week for the remainder of the season, a different player will don it to honor Rainey's place with the program.

Fittingly, Rainey will even be part of the group that decides which player wears his own jersey each week.

"One of our parents gave us the idea to allow a different player each week to wear Jacob's number 9 jersey in each game so he will be with us," Alexander told Prep Rally. "Our leadership committee which Jacob is part of makes the decision."
Sadly, Rainey isn't the first prep football victim to have to undergo such a drastic surgery in the past calendar year. In October 2010, McLouth (Kan.) High's star running back Trevor Roberts had to have the lower segment of his left leg removed after it became infected following a compound break in a game.

Amazingly, the Daily Progress reported that Rainey remained in high spirits despite the tragic circumstances that have befallen him. It seems unlikely that he will continue to garner the kind of recruiting interest he had attracted to this point, but he can at least rest easy knowing that one of the programs which had forged a bond with him was thinking about him just after his operation.

"A young man playing at Woodberry Forest suffered a tragic thing where he lost his leg," Virginia coach Mike London said in his weekly press conference Monday. "Our thoughts and prayers go out to the whole Woodberry Forest football family and to this young man's family in particular. Wins and losses are important, but sometimes the realities of what's really important are the young men and the family members and the sons that we are responsible for."

Thu Sep 15
By Cameron Smith

How Repetitive Foods Can Mean Weight Loss

2011-09-14T09:48:00.000-05:00

Monotony at mealtime can reduce calorie consumption....

Want to lose weight? How about trying to bore yourself thin? According to a new study, monotony at mealtime might be a clever -- if unexciting -- way to reduce calorie consumption.

Human beings come pre-loaded with a sort of habituation threshold and it shows itself in a lot of ways. Hear the same pop song too often and you eventually want to fling the CD out the window. See the same sitcom re-run enough times and the jokes just aren't funny anymore. The same holds true for food -- even your favorites get boring if you eat the same thing over and over without shaking up the menu a little. It's not even necessary that the repetitive food be boring: you'll habituate to pizza almost as easily as you do to boiled chicken.

Straightforward as that simple idea seems, there's been surprisingly little hard research to measure it in any kind of empirical way. In the new study, University of Buffalo nutritionist Leonard Epstein and his colleagues recruited 32 women -- half of them obese, half nonobese -- and divided them into two groups, also with equal numbers of overweight and normal weight subjects. The women were instructed to perform an assigned task for 28 minutes, after which they were given 125-cal. portions of macaroni and cheese and allowed as many additional helpings as they wanted.

All of the women went through five such 28-min. sessions -- the only difference was, half of them did so on five consecutive days and half came back once a week for five weeks. By the end of all of the sessions, the once-a-day group had decreased its calorie intake of macaroni by about 30 cal. per session, while the once-a-weekers had increased theirs by 100 cal. The conclusion: the first group had simply gotten sick of the stuff.

Epstein writes that, "The study suggests a starting point for further research." "Repeated presentations once a day compared with once a week provide a reference point for the interval between food presentations that could lead to long-term habituation." In other words, adjust the sliding scale of lag time between repetitive meals until you find the point at which the food is not so over familar that you go running to some high-calorie alternative, but not so novel that you gorge on it when you see it.

Further research, the investigators believe, could also shed light on the link between overeating and addiction. Some nutritionists theorize that the obese may suffer from a too-high habituation threshold, taking much longer to get tired of a food than other people.

The American Journal of Clinical Nutrition, Aug 2011

HEALTH LINE: Wearing Heels Could Lead to Arthritis Later in Life

2011-09-13T10:41:00.004-05:00

CINCINNATI—Beauty is pain: We’ve heard women say that—joking or not—for decades.

This mantra helps you get through those agonizing last few miles on the treadmill or jazzes you up when going to the salon for an eyebrow wax or tweeze.

But some of the pain associated with society’s image of beauty could truly be harmful for health, says one UC Health primary care physician, and it doesn’t have to be as extreme—or as expensive—as surgery or injections.

"There are all sorts of products on the market that are truly unnecessary, but we are told we need these things to fit into society,” says Shyamala Jagtap, MD, who sees patients in the UC Health Physicians Office in West Chester, citing teeth whitener as an example and a new deodorant that is supposed to stop underarm hair growth in women. "These are not harmful, but they are not vital to our health. In some cases, what makes us fit in could not only mean pain now, but also health problems down the road.”

Specifically, Jagtap relates this to a fashion staple in most women’s closets: High heels.

A recent poll by the Society of Chiropodists and Podiatrists found that 25 percent of women who wear high heels are more likely to get arthritis.

"When you stand, the forces of gravity supporting your body go along your spine, then split into two along your pelvic bones to your hipbones, downward into your thigh bones, then down your leg bones to your heel, and then along the outer margin of your feet. The forces then spread throughout the rest of the foot, to your toes and finally to your big toe,” Jagtap explains. "If you change that alignment, causing weight to be borne on your toes instead of your heels, throwing your whole weight bearing system off and changing the line of gravity, it can affect your joints negatively, eventually leading to arthritis in your knees, ankles and back.”

She adds that more immediate problems could arise before the aches and pains of arthritis begin.

"Feet, like one’s ears and nose, keep growing throughout a lifetime,” Jagtap says. "In most women’s shoes, high heels in particular, the front of the shoe comes to a point at the center, causing the bigger toe—our longest toe—to get pushed towards the middle of the shoe, causing bunions.”

Jagtap adds that cramming your feet into the small and narrow shoe box of high heels can lead to hammer toe, in which the end of the toe is bent downward. High heels can also lead to Achilles’ tendonitis and additional back problems.

In addition to purchasing shoes with a large enough shoe box to allow toes to align side-by-side, Jagtap suggests:

Buy shoes at the end of the day. Feet swell throughout the day, and to avoid shoes that pinch, its best to buy when your feet are at their largest.
Measure the right and left feet separately and buy shoes to fit the larger one, providing padding for the smaller one.

Leave a little room in the shoe box, enough to slip an extra finger.
Buyshoes with good arch and heel support.

If you do buy heels, make sure they are no higher than an inch to an inch and a half.
Walk around in new shoes to make sure they fit correctly; shoes should have a slight give when you lift the foot, and the back of the foot should not feel tight.
"If you really want to wear the most fashion-forward stilettos, you can carry something more comfortable and foot-friendly to change into,” says Jagtap. "The older you get, the more you should think about comfort shoes, and you should always think about getting shoes that fit well. It’s OK to be fashionable, but we must keep our health in mind and try to decide which is more important or determine a way to be both trendy and healthful.”

08/09/2011

More Muscle Mass Knocks Out Insulin Resistance and Prediabetes

2011-09-09T13:44:00.000-05:00

Having more muscle mass can protect against insulin resistance and prediabetes, no matter overall body size, researchers said....

In a cross-sectional study, every 10% increase in the ratio of skeletal muscle mass to total body weight was associated with an 11% reduction in risk of insulin resistance and a 12% drop in risk of transitional, prediabetes, or overt diabetes. The findings point to the importance of gauging muscle mass, in addition to other established risk factors such as body mass index (BMI) and waist circumference, when assessing a patient's metabolic health, the researchers said.

The results may also have implications for the role of muscle-building exercises in preventing metabolic dysfunction.

It's known that very low muscle mass (sarcopenia) is a risk factor for insulin resistance, but it's unclear whether increasing muscle mass outside of the sarcopenic range can boost insulin sensitivity or protect against diabetes.

So to determine whether increases in muscle mass are associated with improved glucose regulation, the researchers looked at data on 13,644 patients from the National Health and Nutrition Examination Survey (NHANES) III, conducted from 1988 to 1994.

Patients had data on homeostasis model assessment of insulin resistance (HOMA-IR); glycated hemoglobin (HbA1c); prevalence of transitional, prediabetes, or overt diabetes (PMD); and prevalence of overt diabetes mellitus. These four factors served as the study outcomes.

Muscle mass was assessed via bioelectrical impedance, which measures opposition to the flow of an electric current through body tissues, determining total body water to estimate body composition.

The researchers found that all four of the outcomes declined across quartiles from lowest to highest skeletal muscle index, or the ratio of skeletal muscle to body weight. The smallest effect size was seen for HbA1c, with a 5.8% relative mean reduction between the highest and lowest quartiles.

On the other hand, the most striking effect was in diabetes prevalence, with a relative reduction of 63%. Prevalence was 14.5% in the lowest quartile compared with only 5.3% in the highest, the researchers reported.

After adjusting for confounders including age, ethnicity, sex, and obesity, the relationships persisted for insulin resistance and prevalence of transitional, prediabetes, and overt diabetes.

Specifically, each 10% increase in skeletal muscle index was associated with 11% relative reduction in HOMA-IR and a 12% relative reduction in the combined diabetes endpoint.

After excluding patients with diabetes, these relationships were strengthened. For every 10% increase in muscle mass ratio, there was a 14% reduction in HOMA-IR and a 23% reduction in combined diabetes prevalence.

They explained that the weaker associations when diabetic patients were included were likely due to the effects of diabetes on muscle mass and on pancreatic beta-cell mass.

The researchers concluded that the relationship between muscle mass and insulin resistance was not limited to sarcopenia, as "increases in muscle mass above even average levels were associated with additional protection against insulin resistance and prediabetes."

The study was limited by its cross-sectional nature, and by its use of bioelectrical impedance alone to estimate muscle mass. Also, there was no differentiation between type 1 and type 2 diabetes in the original survey, they said.

As well, patients with high muscle mass tend to have low fat mass, so any of the associations may be due to adipose tissue, they cautioned, although they attempted to control for this.

Despite these findings, prior prospective studies of short-term strength training programs in overweight and obese patients have been unclear in terms of their effects on metabolic abnormalities, they said.

They called for more work to determine the proper duration of exercise interventions needed in order to improve insulin sensitivity and glucose metabolism, and ultimately to have an effect on diabetes incidence.

Study Cites Eleven Risk Factors That Could Predict Amputation

2011-09-08T14:47:00.000-05:00

Given that lower extremity amputation is a devastating consequence of diabetic foot infection, physicians must be vigilant for the signs that could presage amputation. In a new study in Diabetes Care, authors have developed a risk score of 11 factors that could predict amputation.

Researchers identified 3,018 patients who were hospitalized for culture-documented diabetic foot infection at 97 hospitals in the U.S. between 2003 and 2007. Among those patients, 21.4 percent underwent a lower extremity amputation.

The 11 risk factors for amputation, in ascending order of point value, are: chronic renal disease or creatinine >3 mg/dL; male sex; temperature <96°F or >100.5°F; age 50 or older; ulcer with cellulitis; history of amputation; albumin <2.8 g/dL; history of peripheral vascular disease; white blood cell count >11,000 per mm3); surgical site infection; and transfer from another acute care facility.

Authors note that treatment of a patient with a low score may require fewer medical resources than a patient with a high risk score. The study also says in an attempt to avoid amputation, healthcare providers should concentrate efforts on a patient with a risk score of more than 21 as they have a 50 percent chance of amputation.

Lead study author Benjamin A. Lipsky, MD, notes researchers developed the risk score specifically to use information that is present at (or soon after) the time of hospitalization. As he notes, this info includes findings from the history, physical examination or simple laboratory tests. He foresees “relatively minimal” organizational challenges for healthcare facilities implementing this scoring system. Dr. Lipsky says facilities would just need to educate providers about the score and perhaps provide a score sheet with explanations on how to use it.

Although the study used a database of patients who were hospitalized for their diabetic foot infection, this risk score would likely apply to the majority of patients who do not require hospitalization, according to Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the VA Puget Sound Health Care System. He and his co-authors would like to see the score validated in such a population.

David G. Armstrong, DPM, MD, PhD, cites the importance of the risk score system, saying it will be helpful to have a predictable system as another tool to predict outcomes. He compares this to a wound classification system, which is “highly predictive of good and bad outcomes” when a patient presents with a wound.

Dr. Armstrong has found the most critical predictors of amputation to be infection, ischemia and renal disease. He expresses surprise that renal disease was not more of a factor in the study.

“We believe that people on dialysis, people with end-stage renal disease and people with kidney disease are going to become increasingly important targets for aggressive intervention or hospice,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).

Dr. Lipsky would like to see if the score can be further simplified and refined so clinicians can remember it more easily. He would also like to see the risk score applied to patients in other countries and healthcare systems.

By Brian McCurdy, Senior Editor

Diabetics are more prone to bone-related conditions

2011-09-07T13:01:00.001-05:00

DUBAI - Diabetic patients suffer disproportionately from common musculoskeletal conditions in terms of increased prevalence, severity, and morbidity, according to a doctor.

“The high glucose, high insulin milieu of diabetic tissues affects many of the key cells,” said Dr Saleh Mohammed Kagzi, Orthopaedics Surgeon, Zulekha Hospital, Dubai.

Osteoarthritis is the most common form of arthritis in adults and as such would frequently co-occur with diabetes by chance alone, he said. “Peripheral neuropathy, a common complication of diabetes, may also adversely affect joints and increase the risk of advanced, aggressive forms of osteoarthritis.”

“Diabetes may also affect the outcomes of therapy in osteoarthritis. It was noted in a study that there is a propensity for diabetic patients to have more severe pain and radiographic changes both preoperatively and postoperatively, an increased risk of deep tissue infection as well as an increased revision rate compared with non-diabetic,” he added.

Although diabetes is not recognised as an independent risk factor for the development of rheumatoid arthritis (RA), many patients suffer from both conditions. “Carpal Tunnel Syndrome (CTS) is a common compression neuropathy of the median nerve associated with many conditions including diabetes.”

Diabetes may induce structural alterations of tendon, increase obesity, and produce metabolic abnormalities that result in proliferation or fibrosis of the connective tissues surrounding the nerve.

Metabolic conditions including diabetes are thought to impair bone homeostasis. Type 1 diabetes has been associated with abnormal bone formation or bone turnover, or both possibly leading to decreased bone mineral density (BMD) and increased marrow adiposity.

“Gout is an acute and chronic arthritis caused by monosodium urate (MSU) crystals. Hyperuricemia is a necessary condition for gout and is part of the constellation of lipid and non-lipid cardiovascular risk factors typically defined as the metabolic syndrome,” explained Dr Kagzi.

“Type II diabetes is also a part of this syndrome and as such, an association of gout and type II diabetes would be expected. Renal insufficiency, a common complication of diabetes, also predisposes to gout.”

In contrast, several of the musculoskeletal syndromes associated with the hydroxyapatite-like basic calcium phosphate (BCP) crystals such as calcific tendinitis are clearly associated with diabetes. Charcot arthropathy, which is also called neuropathic arthritis, is a serious complication of diabetes, he said.

“It is characterised by fracture, dislocation, and subluxation of the affected joint in the presence of a significant sensory deficit. Charcot arthropathy typically affects the foot in diabetic patients with peripheral neuropathy. Late stages are often complicated by refractory skin ulcers and may culminate in amputation.”

Tendinopathies occur frequently in patients with diabetes. Painful tendinopathies, including shoulder tendinitis, limited hand mobility (cheiropathy), tendon ruptures, and adhesive capsulitis affect 30-60 per cent of diabetic patients, and cause considerable disability among affected patients.

Flexor tenosynovitis in the hand is also quite common in diabetic patients with a prevalence estimated at 10-20 per cent of diabetic patients. Interestingly, diabetes and its control may also affect therapy, he said. Although inter-sheath injections are typically very successful for flexor tenosynovitis in the hand, high hemoglobin A1C levels, reflecting poor diabetic control, adversely affect results from this intervention. Tendon rupture may also be associated with diabetes.—news@khaleejtimes.com

Real life: 'They think it's witchcraft'

2011-09-03T11:15:00.000-05:00

The issue of diabetes in Haiti -- where one is 16 suffers from the illness -- has a unique set of problems

Monday August 01 2011

If Jean Bernadette (56) hadn't discovered she was diabetic, she would probably be dead by now. In Haiti, where the health focus remains fixated on infectious diseases like HIV, Non-Communicable Diseases (NCDs) like diabetes are often detected late, when patients need extensive and expensive hospital care.

Yet, cardiovascular diseases and diabetes rank first and fourth in Haiti respectively, while HIV-AIDS now sits well below them in 10th position.

Jean Bernadette got diabetes 15 years ago. However, like many Haitians, she hasn't had access to the right medication or treatment.

Pointing to a gap in her right foot she tells me: "Six months ago I had to go to hospital to have a surgeon cut it off."

A study released by the General Hospital in Port-au-Prince in 2009 shows that more than 50pc of patients in the capital have diabetic foot, with ulcers and infections in the feet standing out as the major source of death in these patients.

According to 2006 figures supplied by the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), a private organisation affiliated to the International Diabetes Federation (IDF), one in every 16 Haitians is diabetic.

To add to the problem, FHADIMAC's Vice-President Dr Philippe Larco explains, "the concept of a chronic disease is not understood in Haiti.

"People think that it is supernatural, some kind of witchcraft, and there is nothing you can do against it. This is a big challenge for our healthcare teams in terms of the compliance of the patient with the treatment."

In addition to such challenges lie a lack of proper funding, data collection, surveillance, available medication and treatment.

These vital pieces in the Haitian health puzzle are all scarce commodities for diabetics, as the country's health development continues to be tied almost exclusively to more visible and campaign-ready infectious diseases like HIV, malaria and tuberculosis.

Dr Larco explains that the "cost of medication is too high and patients simply cannot afford it".

"With more than 60pc of the population living on less than €1.50 a day, it is very difficult for a family to buy insulin on a regular basis and many of them let a parent die because the economic burden is too great."

Both of Jean Bernadette's parents were diabetics and died from cardiovascular-related complications. Her father developed chronic kidney disease and her mother died from a heart attack that she believes stemmed from years of high blood pressure.

She shows me a diabetic glucose monitor that FHADIMAC gave her last year when they began screening for diabetic patients in the post-earthquake camps.

Unfortunately she doesn't have any test strips to use with the monitor. "I can't check my sugars without strips but I can't afford them either," she explains.

Vicious circle

Dr Larco says that a vicious circle exists where the international community doesn't fund these silent, invisible diseases and thus "NCDs don't end up on the list of priorities for the Haitian Ministry of Health which in turn blocks funding activities related to NCDs," he says.

According to the charity UNAIDS, in 2010 up to $145m (€100m) was used to target HIV prevention, medication and management in Haiti.

As for diabetes, less than $15m (€10.5m) was used. The country has one of the lowest expenditure rates on diabetes in the Americas with only $48 spent per person.

Ironically, the earthquake at the start of last year did spark some positive change for diabetics in Haiti, with more funding becoming available for the cause.

In April this year, FHADIMAC began work on a two-year project in conjunction with the World Diabetes Foundation to open up 12 new diabetic clinics. Mobile clinics will also be set up for patients in remote rural areas. They will all carry out basic glucose testing along with eye and feet exams.

Following the earthquake, international organisations such as Medecins Sans Frontieres (MSF) have had a strong presence in the country. Dr Andre Munger, the medical chief at one of MSF's trauma hospitals in the outskirts of Port-au-Prince, says they "are now starting to take action because of the health catastrophe posed by non-communicable diseases like diabetes".

Later this year, MSF aim to carry out a new survey on the number of people suffering from diabetic and cardiovascular complications in Haiti. "Without proper data and statistics we'll never be able to address these issues properly," Dr Munger explains.

In order to bring this work on to the international stage and begin to tap into possible new sources of funding, FHADIMAC will present its plan at a UN summit in New York in September.

For many diabetics and other NCD patients like Jean Bernadette, such efforts could be the difference between life and death.