Lower extremity focus helps cut risk of falls

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

Night splint treatment of plantar fasciitis pain

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

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

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

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

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

Methods

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

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

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

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

Results

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

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

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

Discussion

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

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

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

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

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

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

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

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

The epidemiology of plantar fasciitis

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

Compression stockings: One size definitely does not fit all

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.

Current Insights On Conservative Care For Heel Pain

Pertinent Tips For Performing Corticosteroid Injections
Corticosteroid injections can be helpful as part of the treatment plan you offer to the patient. I tell the patient the injection can help with the pain and inflammation. This can also be a good alternative for a patient who cannot take NSAIDs.
I inject at the medial aspect at the transition area of the dorsal to plantar skin. This approach can avoid the fat pad inferiorly and the calcaneus superiorly.
I always offer ethyl chloride to help minimize the pain. I penetrate the skin quickly and then slowly inject the heel. It is important to explain to patients that they will feel the cold spray, then a stick and a little burning or discomfort. I will usually inject dexamethasone phosphate or Kenalog (Bristol-Myers Squibb) with bupivacaine. I will do up to three injections depending on how the patient responds to the initial injection but usually one or two injections is sufficient to calm down the heel pain.

I stress that a corticosteroid injection is not a cure, just part of the treatment plan. If the patient does not respond to the injection series, I would consider an oral corticosteroid, such as a Medrol dosing pack. It is pointless to repeat steroid injections when there is little or no response in reducing symptoms. I typically do not offer cortisone injections in the acute phase. Also, I warn the patient of a possible steroid flare-up following the injection, which usually resolves in a short period of time. Be sure to caution the patient to reduce activity following a corticosteroid injection as it can mask the pain during activity and make the condition worse.

Can Physical Therapy Have An Impact?
Physical therapy can be beneficial in the treatment process and the earlier it begins, the better. There are many modalities that one can prescribe such as icing, massage, ultrasound, iontophoresis, stretching and strengthening exercises.
Remember that physical therapy is a prescription so you need to order the frequency and duration of therapy, and establish specific goals. Physical therapy needs to be at least two to three times per week to be effective. I will usually reassess the patient at three- to four-week intervals. If physical therapy is not helping patients after several weeks, reassess the plan. If patients are progressing well, I will often continue their therapy.
The major goals of physical therapy are to decrease pain and increase function. Patients need to understand treatment expectations. I also like to make sure patients receive home exercises to do so they take an active role in their treatment. It is important to work closely with a physical therapist and athletic trainer in the treatment of heel pain.

What You Should Know About Taping
Taping should be the key ingredient in treating heel pain that is mechanical in nature. As I said earlier, taping is becoming a lost art but it is therapeutic as well as diagnostic. When one properly applies a low Dye strapping, it can provide dramatic relief of symptoms. Physicians can apply this strapping with accommodative padding, such as a cobra pad or medial longitudinal arch pad. I will typically offer taping to all of my heel pain patients who have a biomechanical cause of the pain, which one typically sees with plantar fasciitis. I always check to make sure the patient has not had any trouble with taping in the past.

I use a pre-tape spray. Using 1-inch anchors and 2-inch strips, I apply the strips in an overlapping fashion from lateral to medial, causing an anti-pronation force. I will apply another anchor and then repeat another series of overlapping straps. Then I apply a retention strap on the dorsum of the foot to secure the tape job.
Ideally, the tape job can last several days. Sometimes I will do a criss-cross strapping under the arch if the patient has a cavus foot type and that will tend to provide better support. Although the tape will stretch some in a short time, the proprioceptive feedback benefit will last much longer.
I allow the patient to take a brief shower and then use a hair dryer to help dry out the tape job. Since I use porous cloth athletic tape, it holds up pretty well for several days to a week if needed. If you are taping the patient multiple times for several weeks, an under-wrap or pre-wrap will help protect the skin.
Taping restricts excessive motion but allows for functional movement. Taping is not a substitute for rehabilitation but rather an adjunct therapy. If patients respond well to taping, it is a good indication that functional orthotics will be a benefit for them. Usually, if the patient does not respond to a low Dye strapping, the problem is most likely not plantar fasciitis.

What About Functional Orthoses And Night Splints?
Functional orthotics can greatly benefit patients who have had heel pain and chronic plantar fasciitis. Typically, I will put them in a flexible orthotic with a deep heel cup, wide plate and rearfoot post. A medial heel skive of 2 to 4 mm is also helpful in patients with extreme pronation. A plantar fascial groove may be needed for patients who have a tight plantar fascia to prevent irritation of the medial arch. The easiest way to check is to maximally pronate the foot and dorsiflex the hallux as a tight medial band will be prominent. Sometimes one can use a cobra pad to help increase the medial arch height and decrease pronatory forces. A prefabricated sports orthotic can also be helpful in the interim but usually the patient will require a prescription custom orthotic because of the benefits of a heel cup and rearfoot posting providing more support. I typically do not use orthotics in acute or sub-acute cases, or with patients who have not postively responded to taping.
Try to avoid the trap of fitting the orthotic to the shoe. I will usually have patients wait to get any new footwear until they have their orthotics to help ensure a good fit. Then I will have patients bring in their new footwear and check for fit and control with the orthotic. I always advise the patient with heel pain to avoid flip-flops or sandals due to lack of support and cushioning. It is surprising how often a patient will be in flip-flops when he is she is being treated for a foot problem.

Night splints are also a good alternative for treatment to help retain the plantar fascia tension by providing constant force. However, patients may not tolerate the night splints for a prolonged period of time. One can set the night splints for positioning with dorsiflexion commonly from 5 to 15 degrees. This reduces the effect of post-static dyskinesia by reducing the effect of shortening of the plantar fascia and intrinsic muscles of the foot.

Emphasizing The Value Of Proper Footwear And Fit To Combat Heel Pain
Proper footwear is essential for the patient with heel pain. Often, part of the cause of heel pain is an improper shoe for that patient. Usually, the proper athletic shoe will be a great benefit. There are many brands and models of shoes out there so it is best to give your patients some qualitative guidelines. Most patients find they have gravitated to a particular brand that tends to fit their foot. However, it is often not the best model or size for them.
Depending upon the foot type and biomechanics, patients will typically need guidance toward one of the following shoes: motion control, stability or cushion shoes. I typically do a shoe exam that checks for heel counter rigidity, midfoot torsion stability and forefoot flexion of the shoe. Ideally, a removable sock liner or inner sole will allow for easy placement of an orthotic and allow the heel area of the orthotic to sit flat in the shoe.
Typically, a pes cavus foot type will do best in a cushion or neutral type of shoe. A pes planus/hyperpronated foot type will need a moderate to maximum motion control shoe. A normal foot type will usually do well with a stability or mild motion control shoe. One needs to address the shoes before even getting to the orthotic stage. At this point, there is no evidence that toning shoes or rocker bottom shoes provide any benefit for dealing with heel pain. The American Academy of Podiatric Sports Medicine has a helpful section on its website (www.aapsm.org) on athletic footwear recommendations, which can help the practitioner keep current on models and styles.
Have patients try on shoes in the afternoon or evening when their feet will be the largest. Measure patients with a Brannock device while they are standing. Use the measurements as a guide or reference only as different brands can run relatively different sizes. One can also use the shoe fit test to trace the foot and then the shoe, and compare for overlap. Patients should be wearing a similar style of sock. If they have an orthotic device, they should have it in the shoe. There should be a finger width between the end of their longest toe and the shoe. I always have them try on a half size bigger shoe to compare the fit.
I do not recommend breaking in shoes as this tends to break in the feet. Have patients wear the new shoes indoors for a day or two to make sure they feel comfortable. I will then repeat the three-point shoe exam with them to help make sure it is the proper shoe for them. Most patients do best in a running shoe as they offer the best support and cushioning (see “Keys To Ensuring A Good Fit With Athletic Shoes” above).

In Conclusion
A two-pronged approach is helpful in treating heel pain. Most heel pain will respond well to conservative care using this approach. Make sure to address biomechanical issues, footwear considerations and return to activity principles. I rely on taping and athletic footwear prescription as the gold standards of my approach to heel pain. Cross training and exercise prescription are also critical to successful rehabilitation. Stretching programs can be helpful, especially in children with calcaneal apophysitis or plantar fasciitis.
When the patient is not responding to conservative treatment measures, consider additional diagnostic tests to identify the cause and rule out some of the other differential diagnoses of heel pain. Extracorporeal shockwave treatments or surgical repair may be necessary. Consider post-treatment orthotics and proper footwear to prevent further problems.

Walk Your Way to Fitness

A regular walking workout can benefit your overall health. Find out why fitness walking is so important and how you can get started. If you’re like most people, you walk just under three miles every day in the course of your normal activities. Now it’s time to get a little more purposeful. The Centers for Disease Control and Prevention, the American College of Sports Medicine, and the Surgeon General all agree that at least 30 minutes of brisk physical exercise is good for your health, and walking is one of the easiest forms of exercise to get.

Some of the many benefits of a regular walking workout include:

Cardiovascular health. Fitness walking strengthens your heart, improves your circulation, and lowers your blood pressure. A study published in The New England Journal of Medicine evaluated 73,743 postmenopausal women enrolled in the Women's Health Initiative Observational Study and found that women who walked briskly 2.5 hours every week reduced their chance of heart disease by 30 percent.Bone health. As a weight-bearing exercise, walking can stop some of the bone loss of osteoporosis and may slow down arthritis.Weight loss. A regular walking workout burns calories. If you walk 4 miles four times a week, you can walk off about a half-pound of fat every month. Weight loss combined with a healthy diet can also decrease your risk of type 2 diabetes.Mental health. Studies show that fitness walking reduces stress and improves your overall sense of emotional well-being. A regular walking workout can help you enjoy deeper, more restful sleep, which may decrease your risk for anxiety and depression. How to Start Your Walking Workout

The speed and distance of your walking workout are not as important as the time you spend walking at a brisk pace. If you have any health issues talk to your doctor first and find out what is a safe pace for you. Start gradually and walk only as far and as long as is comfortable. Follow these fitness walking guidelines:

Work up to at least 30 minutes of brisk walking a day.
Warm up by walking at your normal pace for about 5 minutes and then pick up the pace for about 15 minutes.
While you walk, swing your arms and maintain good posture.
Take long strides, but don't strain yourself.
Slow down at the end of your walk and do some gentle stretching.
Every week you should try to add about 5 more minutes to the brisk part of your walking workout until you can get it to over 30 minutes.

By Chris Iliades, MD
Medically reviewed by Christine Wilmsen Craig, MD

Warding Off Muscle Cramps As We Age

If you're over 65, you probably know what a "charley horse" is. You may have gotten them during strenuous exercise as a younger person. But in older age, muscle cramps can be unlike any you've ever had before. That's because like so many other things in our bodies, our muscles and nerves wear out and function less effectively as we age.

"A cramp is a sudden painful contraction of a muscle that becomes rock hard," says Dr. Robert Miller, a neurologist who specializes in muscle cramps at the California Pacific Medical Center and teaches at University of California, San Francisco. "The muscle goes into a spasm and squeezes all the little nerve endings inside the muscle, and creates pain, and definitely ... gets your attention until you do something about it."

Uncontrollable Muscle Spasms

For Ken Holladay, 71, his muscle cramps started off mild and irregular. At first, he got them once every few weeks, but then they started to get more frequent. Eventually, they occurred every single night — often twice, between 2 a.m. and 6 a.m. It was a painful version of a charley horse, only it was in his feet and toes: "The big toe was at 90 degrees to the bottom of the foot; put your foot on the floor, and this big toe would be pointing straight up toward the ceiling; and I don't believe you can voluntarily pull a big toe that high."

Keeping Your Feet Happy
But as it turns out, your muscles can, all on their own. Holladay says that one time his toe actually curled down, "and I leapt out of bed to try and get rid of the pain and landed on that toe and broke the toe, broke the bone underneath that big toe, broke the toenail off." It was terrible, he says.

And since the cramps typically occurred twice every night, it was impossible to get a good night's sleep or feel well-rested during the day. But that's not what drove Holladay to seek treatment. What really scared him, he says, was the possibility that, as he got older, he might become bedridden due to disease or injury. If that happened, Holladay says, he wouldn't be able to get out of bed and walk, stretch and flex his muscles. He would just have to lie there, in terrible pain.

It was too scary a thought.

Searching For Treatment
So, Holladay went searching for help and treatment. First his doctor had to determine whether the spasms were an indicator of any other muscle or nerve degenerative disease, like ALS. With that established, Holladay tried a number of potential treatments: acupuncture, and then prescription quinine, which has since been taken off the market as a treatment for muscle cramps due to concerns about side effects. Neither one worked.

Finally he drove over an hour to see Dr. Yuen So, director of the neurology clinic at Stanford University. As it turned out, So and colleagues had just finished an evidence-based review of treatments for muscle cramps. Unfortunately, they turned up little. There were hundreds of studies but no conclusive or compelling evidence that any particular treatment would work for all or even most patients.

Dr. Hans Katzberg headed the review. Katzberg says some treatments held promise, including a certain type of calcium channel blocker used to treat blood pressure, as well as Vitamin B complex. Even with them, however, results were not convincing. "We were surprised to find out how little is documented in the treatment of cramps," says So. "A lot we do in medicine is based on anecdotal experience, and in this case, a lot of the treatments we use fall into the unproven category."

For Holladay, So ended up prescribing an anti-seizure medication. The meds worked.

"After a week or two, no cramps. After a month or two, no cramps," Holladay says. It was miraculous, he says, and he can't speak highly enough of the neurology department at Stanford or of Dr. So.

Keeping Spasms At Bay
Even though things eventually worked out for Holladay, that's not the case for many patients who suffer severe nighttime muscle cramps. According to UCSF neurologist Miller, older people are at greater risk for cramps simply because of their age. Nerves control muscles, and nerves just wear out.

"As we age, there are changes in both nerves and muscles. Muscles get more weak and small. And nerves undergo some decay, with the tissue becoming thin. And when that happens, the connections that the nerves make to the muscle become less secure."

And cramps occur at the place where nerves meet muscle, says Miller. When the brain sends the signal for the muscle to move, "the signal does have to cross through tiny nerve twigs, or nerve terminals." Excessive signaling, excessive irritability — which may result from thinning and weakened nerves — seems to be the generator for cramping.

At 68, Miller is a candidate for cramps himself. But he keeps them at bay, he says, by eating a banana a day and drinking lots of water. The banana provides electrolytes with its magnesium, potassium and calcium. The water provides fluid. Fluid and electrolytes, says Miller, while not proved to decrease muscle cramps, do seem to help by keeping nerve pathways healthy.

And Miller also benefits from stretching, doing weekly yoga and daily bike riding. Every day, he traverses San Francisco's hills for a total of two hours back and forth to work, "stretching my calf muscles and hamstring muscles by standing up on the pedals and stretching first one and then the other." Stretching is a tried-and-true cure for muscle cramps by pretty much any sufferer's description, says Miller, despite the lack of scientific evidence.

How Can I Protect My Child From Gym-Class Injuries?

Q: I just read about a new study showing that injuries in kids' physical education classes have increased by 150 percent since 1997. Now I'm worried. What are the most common types of gym-class injuries, and what can be done to help kids avoid them? How can I work with my child at home to help him prevent injuries or strain in gym class? What types of PE activities pose the greatest risk of injury to my child, and how do I, as a parent, find out about the qualifications of my child's gym teacher?

A: The study you're referring to, which was recently published in Pediatrics, a journal of The American Academy of Pediatrics, highlights that strains, sprains, and contact injuries are indeed happening in physical education classes and on school sports teams in increasing numbers each year. A variety of factors contributes to this kids' health risk, many of which can be prevented.

To start, it's important to be aware of the types of activities your child is participating in; a lot of kids get overuse injuries from engaging in physical activities that work the same groups of muscles and joints each day. Just like adults, kids need variety in the types of exercises they do. Children should not be doing the same activity every single day — they need at least one day off per week. On their day off they could do a “cross-training” activity that works different joints or muscles. This helps them develop balanced muscle strength to help prevent injuries, which is particularly true for activities like throwing a baseball.

To avoid exacerbating strained muscles and putting stress on bones, tendons, and ligaments, listen to your child if he or she complains of muscle or joint soreness or pain. Rest is a good place to start with most exercise-related injuries, especially in a growing body. As noted above, different types of activities can help avoid repetitive injury to the same joints, bones, and muscles. You can also work with your child at home on strength-training and endurance exercises, and make sure they're eating a healthy diet to support their growing bones and joints.

Some children, especially girls, may have “loose ligaments." These children are often described as very flexible and can hyperextend their arms and legs. Loose joints are at increased risk for strains and sprains. Strengthening muscle groups around the joint can act like a brace for the joint and help prevent injury. If your child has ever had a sprain, he or she is at risk for recurrence. You should talk with your pediatrician about specific exercises that your child can do to help strengthen the joint. Sometimes bracing of an ankle or knee can help give stability to avoid future injury. Appropriate and properly fitting shoes can also help decrease injuries such as shin splints and plantar fasciitis.

Exercise is especially important for children who are overweight, but be aware that being overweight puts increased stress on a child's joints, so you'll need to make sure they don't overstress their joints. In general staying slim can help decrease pressure on knees, hips, and back.

It is incredibly important that children engaging in contact sports or sports that require helmets like biking have properly fitted equipment. Another important aspect of injury prevention is to make sure your child isn't being pushed too hard in gym class or on a sports team. Today, some kids are participating in an unbelievable amount of physical activity. Sports are only getting more competitive. And some activities can create a lot of psychological issues. In wrestling and gymnastics, for instance, restrictive weight requirements can put a lot of pressure on kids. So check in with your child regularly to make sure he's not being pushed past his limits.

As for the qualifications of your child's coach or gym teacher, you're certain to run into some inconsistencies here. As schools try to initiate more physical education programs — without additional funding — it's not uncommon to find that a math or science teacher is leading a sports team, rather than a well-trained physical education instructor. For gym class, this may be less of a risk when it comes to injury, but for any intense sport that your child will be participating in regularly, you'll want to make sure the instructor has been trained specifically in that activity.

Seniors' Walking Speed May Predict Life Expectancy

Gait speed correlated with expected years of life remaining to people aged 65 years and older, with increased walking speed predicting longer life expectancy....

Dr. Stephanie Studenski of the division of geriatric medicine at the University of Pittsburgh, and her associates, stated that, for both sexes and at any age older than 65 years, a gait speed of 0.8 meters per second correlated with the median life expectancy for a person's age and sex. Faster walking speeds consistently correlated with extended survival, they said.

They assessed the relationship between gait speed and survival in a pooled analysis using data from nine cohort studies of community-dwelling adults. Each study included at least 400 people, gait speed data at baseline, and follow-up for at least 5 years. All of the studies measured gait speed by having subjects walk at their usual pace from a standing start for 6-8 feet indoors.

There were 34,485 study subjects, including "substantial" numbers of African American and Hispanic patients, as well as 1,765 who were older than 85 years. Follow-up ranged from 6 to 21 years, with a median of 14 years. Gait speed ranged widely, from less than 0.4 meters per second (in 1,247 people) to more than 1.4 meters per second (in 1,491 people). There were 17,528 deaths during follow-up.

Predicted years of life remaining correlated with gait speed for patients of both sexes and all ages.

A walking speed of approximately 0.8 meters per second was associated with the predicted median life expectancy for a subject's age and sex. Gait speeds faster than that rate predicted longer-than-average life expectancy, while slower gait speeds predicted shorter-than-average life expectancy. Gait speeds of 1.2 meters per second and faster predicted "exceptional" life expectancy, the investigators said

Gait speed "was especially informative after age 75 years" in patients who had no, or only minor, functional limitations. It may be less helpful in predicting life expectancy for patients who already report functional impairments and dependency on others for performing the activities of daily living, the investigators noted.

The data allowed Dr. Studenski and her colleagues to calculate survival estimates for a broad range of gait speeds, and to calculate absolute rates and median years of survival. "Compared with prior studies that were too small to assess potential effect modification by age, sex, race/ethnicity, and other subgroups, we were able to assess multiple subgroup effects with substantial power," the researchers said.

"Because gait speed can be assessed by nonprofessional staff using a 4-meter walkway and a stopwatch, it is relatively simple to measure compared with many medical assessments," they added.

In practice, gait speed can be used to identify elderly patients with a high probability of living 5-10 more years, who can then be targeted for preventive interventions that require a long time before benefits are realized. It can also identify patients at increased risk for early mortality, who can then be targeted for interventions to maximize health and survival, the researchers explained.

If gait speed is tracked over time, it can serve as an indicator that new health problems have arisen. It can also be helpful in stratifying risks from surgery or chemotherapy, the investigators said.

Wearing High Heels Can Lead to Osteoarthritis of the Foot

If you wear low heels or sturdy one- to two-inch heels or limit your wearing of high heels to evenings or special occasions, you're probably okay. However, if you wear very high heels day in and day out, you may increase your risk for developing osteoarthritis of the foot. “It’s harder to stand straight when wearing high heels, and this causes a lot of stress on the balls of your feet and your toes” says Dr. Weaver. Feet are one of the chief areas to be hit by osteoarthritis. In addition, high heels that are tight across the toes can aggravate bunions, or arthritis of the toes. You're better off wearing low heels and leaving the stilettos to the models

Medical Attention Or Been Hospitalized Because Of Wearing Trendy Shoes

LONDON, 2010 -- One in 10 women in Britain admit they've received medical attention or been hospitalized because of wearing trendy shoes, a survey indicates.

The survey of 3,000 women in Britain who wear high heels was conducted by Hotter Shoes, a British shoe manufacturer.

Nearly half of women say they have twisted their ankle because of their footwear and two-thirds admit wearing shoes that have caused them injury. The most frequently reported injuries caused by shoes were broken ankles, twisted knees, infected blisters, bunions and torn tendons.

"As a comfort shoe maker we were amazed to discover the pain and discomfort that women were prepared to endure for a pair of killer heels or an ill-fitting impulse sale bargain," Lisa McCarten of Hotter Comfort Concept Shoes says in a statement. "Nothing can ruin a day more than sore and tired feet, every person in our design and technical team works hard to ensure that our shoes are stylish and comfortable."

Why Does My Achilles Tendon Hurt?

You don’t have to be an accomplished athlete to suffer Achilles tendon injuries. They can occur from performing minor household tasks, such as climbing a ladder. Achilles tendon weakness is common in adults and prompt treatment when symptoms occur can prevent more serious injury.

The Achilles tendon is the longest and strongest tendon in the body, but is subjected to considerable wear and tear. When the tendon becomes inflamed from overuse or too much sudden stress, tendonitis can weaken it over time and cause microscopic tears. Going without treatment only increases risk for further deterioration and possible rupture.

Pain, stiffness and tenderness in the area are the main symptoms of Achilles tendonitis. Pain occurs in the morning, improves with motion, but gets worse with increasing stress and activity.

In addition to athletes, Achilles tendonitis is common for anyone whose work routine puts constant stress on the feet and ankles. Achilles tendon injuries happen most often to less conditioned, “weekend warrior” athletes who overdo it.
When pain and other symptoms indicate possible Achilles tendonitis, a thorough diagnosis is necessary to determine the extent of the trauma and evaluate the flexibility and range of motion in the tendon. Treatment options depend on the extent of the injury.

They include:
• Casting to immobilize the Achilles tendon and promote healing
• Ice to reduce swelling
• Non-steroidal anti-inflammatory medication to reduce pain and inflammation
• Physical therapy to strengthen the tendon
• Surgery, if other approaches fail to restore the tendon to its normal condition

Recreational activities involving jumping and running are the major cause of Achilles tendon injuries. In sports like basketball and tennis, muscles and tendons in the back of the leg are prone to injury from an imbalance that occurs from a lot of forward motion. As a result, the frontal imbalance can weaken the tendon unless stretching exercises are performed regularly.

The best way to prevent Achilles tendon injuries is to warm up gradually by walking and stretching. Further, it’s best to avoid strenuous sprinting or hill running if you are not in shape for it.