Even though the temperatures can often be stifling, someone has to get out and clean up your yard and garden this summer, so it might be that you find yourself spending this Saturday afternoon outside fulfilling those “yardly duties” of yours! One of the most commonly seen problems in patients who spend weekends tending their property is Contact Dermatitis. “Derma” meaning skin and “itis” meaning inflammation takes the guess work out of deciphering the meaning of Dermatitis. Thus, Contact Dermatitis is inflammation of the skin caused by the skin coming in contact with some object. Usually the skin reaction takes the form of a rash, sometimes in exactly the shape of the offending agent and other times spreading up the legs or arms leaving the patient questioning what it was that reacted with their skin. It can be itchy, painful or even burn and sometimes patients have symptoms of all three! It makes for a very uncomfortable few weeks as the rash clears, thus prevention in key.

Most people know what poison ivy is and that it causes a significant itchy rash in some patients when encountered. Other patients, not so much! Poison ivy is a form of Contact Dermatitis knows as “Allergic Contact Dermatitis.” When it comes in contact with the skin, in some patients it initiates a response by the body much the same as would occur in an allergic reaction to something that you’ve eaten. The only difference in this case, is that the trigger for the response was external (poison ivy plant) rather than internal (peanuts for example). The bodies immune system over-reacts to the poison ivy that has contacted the skin and cells are released that form the itchy rash we often associate with this plant. Other materials that commonly cause an Allergic Contact Dermatitis include nickel (found in jewelry), latex, hair dyes and shampoos or skin lotions containing fragrances.

In contrast to Allergic Contact Dermatitis, Irritant Contact Dermatitis does not initiate a response from the immune system. This reaction is simply a skin reaction that progresses the longer the skin is in contact with the offending agent. The most common cause includes household detergents and the reaction usually takes on the feeling of burning on the skin, rather than an itchy rash.

Deciphering between allergic and irritant forms of dermatitis can be difficult, but the good news is that both forms are usually treated in much the same way. Be sure that if you know you’ve come in contact with a material that reacts with your skin, you wash the areas immediately with cool water and soap, being careful not to increase the size of the area contacted. Cold compresses can help in situations where blistering has developed and the use of calamine lotion or over the counter anti-histamines (benadryl) can help relieve itching. Over the counter hydrocortisone creams can also help calm the skin reaction and alleviate symptoms quicker than without such creams, although the rash will resolve on its own over several weeks. If over the counter agents don’t seem to be doing the trick, seek out your physician, who can prescribe topicals that are slightly stronger, but accomplish the same tasks. Rashes on the legs and feet are well within the scope of your Podiatrist, so head to their office if symptoms persist!

Prevention is simple: don’t garden or tend to the yard! Although that might sound nice, unfortunately, avoiding the yard may not be an option, but there are some other steps you can take to protect yourself and your skin. Wearing pants, or long-sleeved shirts with gloves on your hands is the best option for protecting your extremities, in addition to wearing closed-toed sneakers or gardening shoes, however, all that clothing can be constricting and hot! Therefore, if you’re able to get up a little early this weekend, get out to the yard first thing before the temperatures have climbed up into the 90’s. You’ll be finished your work long before the temperatures rise, leaving the rest of the afternoon for lounging by the pool. In addition, if you’re one of the lucky ones and you know which plants or weeds in your yard induce a reaction in you avoid them and wait for another family member to come along and help you!

Some people sweat, and other’s sweat a lot! What makes the difference between these two patient populations is a condition known as hyperhidrosis. Hyperhidrosis literally means “a lot of water.” It is a condition that refers to an increased amount of perspiration (sweating) in a number of locations on a patient’s body including their face, hands, armpits and feet.

The greatest complaint for people with hyperhidrosis of the soles of their feet is the odor left behind. With sweating, moisture accumulates in socks and on shoes of such individuals and eventually odor-causing bacteria build-up resulting in an increase in odor, with subsequent embarrassment.

Although hyperhidrosis may be attributed to neurologic complications or sympathetic overactivity, a large percentage of patients with this condition have no contributing factors and suffer from this “just because.” In patients that have no predisposing conditions prevention is not the goal of treatment, but rather control of their excessive perspiration.

Hyperhidrosis can be very difficult to treat, and patience is a virtue while working with your Podiatrist to find a solution that works best for you! For starters, its best to keep feet clean and to change socks daily to prevent bacteria from colonizing on your feet, your socks or your shoes. Do not spray perfumes or body sprays on the feet in attempt to decrease odor as this can often increase the odor due to chemical reactions between sweat and perfume.

Antiperspirants are the first line in treating hyperhidrosis, as many patients immediately notice a difference and thus, success is achieved! Antiperspirants for the feet come in the form of deodorant sticks that one would use for the underarm; in fact there are some over the counter antiperspirant sticks that are indicated for use on the soles of the feet. Look for products that contain aluminum chloride hexahydrate, as they are most effective in treatment. Your Podiatrist may write you a prescription for such antiperspirants containing as much as 30% hexahydrate for prevention of sweating. Through prevention of sweating, antiperspirants are often successful in decreasing bacterial build-up and eliminating odor of the feet. These products are best applied to the feet twice daily: once in the morning and once in the evening, and are applied to the soles of the feet just as deodorant would be applied to the underarms.

For patients who suffer from hyperhidrosis due to sympathetic overactivity or neurologic complications, prescription medications that act on the peripheral nervous system can be tried. However, it is uncommon that your Podiatrist will recommend or even prescribe such mediations due to the potential side effects these can induce on the body.

Iontophoresis is a completely non-invasive method for attempting to treat hyperhidrosis of the hands and feet that utilizes water to pass a mild electronic current through the patients skin. Although not completely understood, the belief behind this theory is based on a cooperative effect of the electrical current and the water to increase the thickness of the outside layer of the hands and feet. Thus, the ducts for which sweat is released from the body onto the palms and soles become essentially “blocked.” Several treatments, on consecutive days helps patients reach a significant decrease in their perspiration, with subsequent maintenance treatments as needed, usually once every 2-4 weeks.

Finally, a treatment method that has gained popularity over the last 5 years or so is Botox injections. Botulinum Toxin, or Botox (the same material used on the face for decreasing wrinkles) can be injected into the soles of the feet for relief of hyperhidrosis. The toxin works by blocking a hormone in the body that is normally responsible for turning sweat glands “on.” This toxin, by blocking that hormone, turns sweat glands “off” and leads to a reduction in sweating in the areas where it was injected. Your Podiatrist will determine how many injections you will need and based on your clinical presentation, how often follow-up injection should be given. These injections are certainly not a cure for hyperhidrosis, but they control symptoms for a significant length of time; in some patients up to 7 months.

Hyperhidrosis is a difficult condition to treat, but your Podiatrist can guide you through your treatment options and find a combination that works best for you. Having feet that smell like roses is just within your reach!

Following in the path of last’s weeks Blog, where we discussed foreign object injuries to the foot, this week I would like to talk about broken toes! As with stepping on a foreign object, broken toes are more often than not suffered when there is a lack of shoe involvement: meaning when patients are barefoot. Of course, a broken toe injury can come at anytime, even with shoes, but that doesn’t seem to be the common occurrence.

Depending on which toe, the severity of the break, and exactly where the toe has been broken, can alter the course of treatment, so its important that we first talk about which bones are where in the anatomy of your foot.

A normal foot has 4 toes (2, 3, 4 & 5) and 1 hallux (“big toe”). Toes 2-5 have 3 small bones and one larger, longer bone. The small bones are called “phalanges,” and are named according to their location: distal (furthest from the body), middle and proximal (closest to the body). The larger bone is called a metatarsal and is named by the number toe that it corresponds to. To simplify, the third toe of the foot consists of the distal, middle and proximal phalanges and the third metatarsal bone. The hallux, or “big toe” contains only 2 small bones: the proximal and distal phalanx; and a larger 1st metatarsal bone.

Each bone communicates with the next across a joint, which is surrounded by a capsule and allows for motion to occur between those two bones: bending and extending of the toes. The joint of most importance, when dealing with toes is what’s called the “metatarsal-phalangeal joint” (MPJ). This is the joint between the larger metatarsal bone and the proximal phalanx. As we will discuss in a minute, determination of conservative and surgical treatment for a broken toe depends partly on the joint involved.

The typical “toe fracture” occurs when the toe is “stubbed” or “jammed” into the floor or into an object such as a step, or when an object is dropped onto the toe. The patient usually admits that injury has taken place while they were wearing no shoes, or slippers, neither of which provides any protection to the toes! Whether the toe was stubbed or an object was dropped on to it, pain will be immediate and swelling of the toe or toes will follow suit! You may immediately, or shortly notice bruising of the toe and/or changes in the look of the nail, if it has been injured. Rarely, the bone that has been fractured will be sticking out through the skin; an open fracture. Certainly, if bone is sticking out of the skin, a trip to the Emergency Room is a necessity.

Following injury, it is important to keep a close watch on the area involved for new pains, increased pain, or a worsening in appearance. Loss of sensation, numbness, tingling or an unusually cold toe should all throw up red flags and encourage you to seek medical attention immediately. In the mean time rest, ice, elevation and over-the-counter anti-inflammatory medications can be used to decrease swelling and pain to the injured area.

Differentiating between a fractured toe and one that is badly bruised is often difficult, unless the toe appears grossly deformed. Being that this is the case, if medical treatment is sought, an x-ray of the involved foot is likely. The x-ray will provide the Podiatrist will a lot of information to help guide your treatment: location of the fracture (if there is one), if the bones are displaced or if they are in good alignment, if a joint is involved in the fracture, how many pieces the bone is in, and whether or not conservative or surgical treatment is necessary.

If the fracture is located in one of the phalanges, is in good alignment and does not involve a joint, conservative treatment with the use of “buddy taping” and a surgical shoe to protect the toe while it heals will be initiated. If the bone appears as though it is displaced, involves the joint and is in several pieces, surgical treatment becomes a greater possibility. Surgery attempts to realign the pieces of the bone and hold them in position while they heal themselves.

As was mentioned before, involvement of the MPJ presents a bit more serious of a problem than if one of the smaller joints in the toe was disrupted. The MPJ plays a significant role in walking and provides a lot of structural support to the foot. Therefore, involvement of the MPJ will require surgery with “pin” fixation and non-weight bearing post-operatively to allow for appropriate healing to take place.

The moral of the story this week, as it was last week, is: don’t walk around without shoes on! Leaving the foot unprotected, whether it is the toes or the sole of the foot, greatly increases your risk of injury. Next time you get up off the beach blanket and head back to your summer beach house for lunch, make sure to put your shoes on and protect your feet.

The top four reasons not to walk around without shoes are as follows: sewing needles, glass, wood (toothpicks) and metal.

Year after year, once the Memorial Holiday has been celebrated, shoes are often left behind in the house, around the pool, or on the beach blanket! During the summer months, patients complain that shoes can be “constricting,” “hot,” and “uncomfortable,” but I can assure you that nothing will be more uncomfortable than a foreign object that’s found its way into the sole of your foot.

If you step on an object, the initial response is to immediately extract it from your foot, but this may not always be the best course of action. Unlike splinters on the hand, when you step on an object the potential for it to penetrate far into the sole of the foot is great, for the simple fact that you’ve stepped on it! Refrain from extracting the object yourself, especially if there is immediate and profound bleeding or if you have an immediate loss of sensation to the foot/toes or burning and tingling sensations. These may be signs that important structures within the foot have been penetrated and without visualization of those structures, more damage can be induced upon retrieval of the object! Getting yourself to the Emergency Room is your best course of action with this type of injury.

In such a situation it is important that you know a few things about your health to help guide appropriate treatment once you’ve reached the hospital. It is important to know if you have been immunized against Tetanus bacteria and how current your immunization is. If your immunization or “booster” shot was within the last 5 years, it is unlikely that you will need to receive a “booster” in the emergency department, however, if your last “booster” shot was greater than five years ago, you will need to a “booster” shot to ensure coverage against Tetanus bacterium. If you have never been immunized, you will be given a series of two injections: one for immediate immunization against tetanus bacteria and a subsequent injection for long-term immunization.

Knowing which medications you are allergic to and what your body’s response to taking those medications is will help the ER Physician in prescribing an antibiotic. Whether the foreign object stays lodged in the sole of the foot or not, it carries the potential to generate infection and initiate an immune response by the body. The reason it carries this potential is because most objects encountered while walking barefoot are not sterile and thus bacteria is inherent to them. Once the skin barrier is broken and the object enters the sole of the foot, infection becomes a possibility and the body identifies that object as foreign and works to “fight against” it.

After initial treatment has been started, the Podiatric Physician “On-Call” will come and evaluate your injuries in the emergency department. Depending on the type of object that is lodged in the foot and whether there is immediate danger to your foot or not, will determine the Podiatrist’s next course of action. They may first ask for x-rays, an MRI, CT scan or Ultrasound of the foot in order to locate the object, determine what, if any structures the object is penetrating and to better determine the next course of action in treating your injury. If there is imminent danger to your foot, meaning there are concerns about viability of the tissue, nerve penetration and compromised blood supply, the Podiatrist may want to take you to the operating room immediately to extract the object, clean out the tissues, and repair any damage.

No matter what the immediate course of action, once the object has been removed you will be given a 10-day course of antibiotics for prevention of infection. You will also need to follow up with the Podiatric Physician who treated you in the hospital, for evaluation of the site of penetration and to monitor healing.

The next time you think about walking around the house or the backyard without shoes, think again! Going barefoot is certainly not worth the risk of stepping on an object, lodging it into your foot and increasing your chance of infection with a subsequent recovery period during the beautiful summer vacation months!

For the diabetic population, especially those patients with neuropathy, walking without shoes is never a good idea. You are less likely to feel an object penetrate your foot, thus you are less likely to seek treatment and more likely to contract infection with poor healing outcomes due to the nature of diabetes.

Shin-splints, especially to a high school track athlete, can be very debilitating and recovery periods can exclude competitive participation for several weeks as the healing process takes place. The definition of a shin-splint is variable, depending on who you ask, so it is first important to begin by differentiating between what the average citizen calls a shin-splint and what a “true” shin-splint really is.

Most people diagnose themselves with shin-splints when they have pain anywhere in the front of their leg. However, true shin-splints delineate pain within the bone in the front, or anterior portion of the leg (tibia), as inflammation of the periosteum of the bone itself is what induces shin-splint pain. Every bone in the body is covered by periosteum, which is the outer covering of bone providing the bone with its blood supply and allowing it to thrive. When the periosteum is disrupted as is the case in shin-splints, the periosteum reacts generating inflammation, pain and swelling. In shin-splints, he periosteum becomes disrupted when the muscles attaching to it, and to the bone that it surrounds, apply “pull” on the bone, creating a periosteal reaction. The resultant symptoms include pain that is increased with activity, especially early in a workout session, as well as pain with pointing the toes downward (plantar flexion) of the foot.

The question becomes: why are muscles in the leg applying extra pull to the periosteum and bone, so much so that they generate a periosteal reaction? The answer: it can be a number of things!

Running on uneven surfaces is a huge contributor to the development of shin-splints. This often occurs during pre-season training sessions and in cross-country runners, who are constantly running from pavement to grass, and gravel to synthetic track surfaces. The extra stress and strain on the muscles of the leg as they adjust from one surface to the next creates disruption of the periosteum and eventually, symptomatic shin-splints. In addition to uneven surfaces, improper training techniques can also be an inducer of leg pain and increased pull of the muscles on the tibial bone, leading to shin-splints. As a young athlete it is important to have a regimented training routine that has been reviewed by a coach or trainer who can advise you on what workouts are best for your specialty, but also best for your body and your health!

There are also outside factors, unrelated to athletic activity, that can contribute to the development of shin-splints, which include flat feet (pes plano valgus) and calf tightness. We’ve touched on calf tightness before and its contribution to heel pain syndrome (plantar fasciitis), and unfortunately, the same etiology applies here! When the calf muscles are tight, they don’t allow the ankle joint to work maximally, flexing the foot upwards and downwards as intended. Therefore, in order to get the motion at the ankle joint that is needed for daily activity, the body looks elsewhere and tends to apply stress on the muscles of the anterior and posterior leg. Prevention and treatment of shin-splints in patients who have calf tightness as the sole etiology of their problem can be quickly rectified with some simple stretching exercises!

Take a look back at our blog entitled “Plantar Fasciitis,” posted on May 5, 2010 (http://advancedfootcarecenters.com/blog/?p=143). The following stretches mentioned in that blog can also apply here and should be used daily whether you suffer from symptoms of shin splints or not, as they can be great preventative exercises:
A. Wall Gastrocnemius Stretch
B. Stair Gasctrocnemius Stretch
C. Soleus Stretch

Shin-splints can be extremely painful and can result in a withdrawl from activity for several weeks as the body heals itself and the periosteal reaction subsides. Rest is certainly the best thing, but application of ice is also helpful to decrease inflammation. Anti-inflammatory medications can also be beneficial in decreasing symptomatic pain in addition to helping control inflammation of the periosteum, leading to a faster recovery! In prevention, stretching as mentioned above is extremely important in addition to wearing appropriate shoes and running on even and shock absorbing surfaces such as synthetic tracks, as opposed to sidewalks and grass. Shin-splints can be very debilitating to the competitive athlete, thus it is important to treat them at their onset, otherwise your recovery period increases as the pain and inflammation takes longer to leave the bone.

The root of all evils when it comes to blister formation is moisture. As the humidity rises, moisture content in the air also rises, leading to increased perspiration and friction between feet, socks and shoes! Blister formation occurs when friction and moisture combine separating the top layer of skin (epidermis) from the layer below (dermis) allowing the area to fill with fluid. Often times, the fluid is clear, but can be bloody or infection filled. For simplicity, we will address the most common form of blistering on the feet; those filled with clear fluid.

No one is immune to blistering and time again, athletes pull over at the medical tent during their marathon or charity-walking event, for blister care. In the summer month, sandals tend to induce blisters between toes, or on the sole of the feet, as motion of the foot isn’t well controlled in a sandal and that extra motion combined with moisture, creates friction and blister formation. Depending on the location of the blister, some are much more painful than others and can inhibit daily activities. The following “Blister Tips” address some of the myths in treating blisters and will guide you towards appropriate treatment.

1. Don’t pop blisters at home! It can be rather tempting to pop a fresh blister and relieve the pressure by expressing the fluid, but that’s not recommended. Blisters, by nature, contain sterile fluid, meaning that there is no bacterium inside and infection is a remote possibility. If you decide to pop a blister with a needle that you might have “sterilized” in your bathroom, you run the risk of inducing infection. Not only from the needle, but also because now you’ve exposed this sterile environment to the outside environment. Resist the urge to pop your blister and allow your body to resorb blister fluid on its own.
2. If I shouldn’t pop blisters at home, why does the medical staff pop them during a race? In an acute setting, such as during a marathon, blisters are typically popped by the medical staff. The reason: immediate relief of the excess pressure allows runners to continue through the remainder of the competition. The medical staff cleans the skin surrounding the blister with alcohol, uses a sterile needle to puncture the skin, and drains fluid out at it’s lowest point of gravity. Although the method isn’t perfect, and not recommended at home, the medical staff does their best to prevent infection while providing immediately relief for the athlete.
3. What to do if your blister pops on its own: As mentioned above, once your blister is exposed to the outside environment, infection becomes a possibility as there is now an entry point for bacterium. When this occurs, you need to do your best to keep the blistered area extremely clean. Using warm water and soap is sufficient, making sure to dry the area thoroughly and protect it using a band-aid that covers the entire blister. Avoid using hydrogen peroxide to cleanse the area. If dead skin remains, leave the skin in place, as it is still capable of providing a barrier for infection while providing a good environment for new skin to grow underneath.
4. Get your feet measured for shoe-size accuracy. As we’ve mentioned, blisters are mainly caused by friction combined with moisture. Shoes that are tight in the wrong places can cause recurrent irritation and frequent blistering. Getting your feet measured for an accurate shoe size can make a difference if you’ve been wearing the wrong size! Adjusting your running shoes to fit your feet may also increase your distance and comfort level while engaging in activity.
5. Blisters can occur separate from friction and moisture. Blisters that are small in size and seem to continually appear for unexplained reasons may indicate a problem separate from friction and moisture. Check the other areas of your feet looking for scaly skin on the soles and heels. If you find areas of scaly skin, it is likely that you have a fungal infection and the blister formation is a result of that. Contact your Podiatrist for an appointment, as they can treat your fungal infection quickly with topical medications!
6. Prevention is your best option! The goal in prevention is to decrease friction and eliminate moisture, as those are the most common predisposing factors. As discussed wearing shoes that fit your foot size is important in decreasing areas of pressure where friction is imminent. In addition, keeping your feet dry and wearing socks that allow the feet to breath, versus cotton socks that hold in moisture, is very important. Finally, treating any underlying conditions such as fungus that may be causing blister formation will help tremendously in prevention.

When a Podiatrist diagnosis a patient with a stress fracture, patients only hear the “fracture” part of the diagnosis. However, the “stress” part of that statement is extremely important and delineates a stress fracture from other types of fracture in its mechanism of injury and prognosis for recovery.

Stress fractures differ from other fractures in that they are not caused by acute trauma, but rather repetitive trauma and stress to the bone. Therefore, patients suffering from a stress fracture can relay no history of injury to the area. They are more commonly seen in athletes and especially runners who are constantly demanding their bodies to perform. Typically, stress fractures start as a small break in the outer (cortex) portion of the bone leading to inflammation within the bone and pain for the patient. If a stress fracture is not detected in its early stages and the patient continues on with normal activity, the size of the break can increase resulting in fracture completely across the bone. Although the most likely location for stress fractures in the foot are the 2nd and 3rd metatarsals (long bones), they can be found in the leg as well, just less frequently.

Signs to look for when you are suspect for a stress fracture include pain that is increased with activity and that may or may not be accompanied by swelling. The pain will be progressive, meaning that with each day it seems to increase, and it will become painful to the point where you will begin to cut back on your athletic and normal daily activity. As mentioned before, you may not remember injuring yourself, as stress fractures don’t present themselves in association with acute trauma, thus symptoms, rather than physical presentation becomes important. If a stress fracture becomes a possibility in the back of your mind, it’s best to withdrawal from activity and seek out your local Podiatrist.

After ruling out other possibilities for the cause of your recent pain, your Podiatrist will take x-rays to evaluate the bones of the foot. This is where the diagnosis for a stress fracture becomes tricky: a stress fractures’ break in the cortex of the bone may not appear on x-ray until 10 to 14 days after the initial break. In the early stages there is not enough bone resorption (washing away of bone in the area of the fracture) to be picked up by plain x-ray. Therefore, despite what the x-ray may or may not show, the Podiatrists index of suspicion for a stress fracture, combined with your clinical symptoms and history, will likely be the basis of your diagnosis. In some cases you may be given a prescription for an MRI or CT scan which can look closer at the bone and be able to pick up a stress fracture from day one, however, this is not always necessary.

The treatment of choice in patients with stress fractures is rest and immobilization, meaning you will likely need to wear a CAM (controlled ankle motion) walker in addition to discontinuing athletic activity. A CAM is a removable boot that should be worn as much as possible, but can be removed at bedtime for comfort. It is used initially because it decreases motion and stress on the foot while allowing patients to walk while wearing it, without the use of crutches. When patients are compliant and wear the CAM as instructed, it is usually sufficient enough to allow healing of the bone. More aggressive forms of immobilization such as casting can be utilized, but are reserved for patients who don’t comply with the initial treatment attempts using a CAM. Keep in mind, the longer you continue normal activity on the stress fracture the higher your risk of breaking the bone completely, which inevitably leads to a longer recovery time. Therefore, it is in your best interest to limit activity and immobilize the foot!

Your clinical symptoms will indicate to your Podiatrist when appropriate healing has taken place and transition back to a sneaker with a slow increase in your activity is safe. However, you should plan on about 4-6 weeks of immobilization, as that is how long it will take for your pain to decrease and for the defect in the bone to fill in with new bone and fibrous tissue. Certainly you can take ibuprofen for pain as needed, as well as apply ice to the area in attempt to keep the swelling down, but rest and immobilization are key!

Unfortunately, there isn’t much you can to do to prevent a stress fracture, but there are things you can do to cut down your risk. If you already have a workout routine and you plan to increase your level of activity or distance running, do so slowly. Changes and increases in activity often bring on a stress fracture, as your body is not adequately prepared. If you don’t have a consistent routine, but want to get moving, start slowly and with short distances, building up to your ultimate goal. In both situations your bones need a chance to adjust to the increased stresses and if given adequate time to do so, you decrease your risk of injury.

To Run With or Without Shoes…That is The Question!
In recent years, much discussion has surrounded the topic of Barefoot Running. The benefits versus the risks of running barefoot have the medical community divided on which is “best” and for which running populations. International athletes suck as Abebe Bikila of Ethiopia have successfully competed in long-distance running events without the aid of shoes; if he can run without shoes, why can’t the rest of us?

It is not so much that you can’t become a “barefoot runner,” but the more important question becomes, is it safe? What are the risks and benefits of running without shoes?

Running barefoot has come into favor in recent years because runners and sports science researcher alike believe that running barefoot allows a runner to expend less energy in addition to decreasing their risk of acute injury, such as ankle sprains. Proponents believe that the risk of injury increases with shoe-wear due to slowed proprioceptive feedback from the foot to the brain. Proprioceptive feedback is a message sent from the foot up to the brain that tells your foot that it is on the ground and in which position. Without shoes, there is no interference from the material of the shoe and the feedback from the foot to the brain is faster and more efficient, thus your body can adjust to uneven surfaces quicker, preventing injury.

The theory behind a decrease in energy expenditure in the athletes running barefoot has no substantial research behind it, but theorist believe it may have something to do with proprioceptive feedback in addition to the simultaneous use of foot and leg muscles. It is believed that when running barefoot an athlete must use all the muscles in their foot and leg to run, thus no one muscle must work harder than it was intended, as they believe is the case in those running with shoes. They say that shoes and “high-tech” athletic sneakers prohibit certain muscles in the legs from working at their maximum capacity, forcing other muscles to work harder, which could lead to the increase in energy expenditure.

Proponents of running with shoes believe that without the use of supportive shoes and/or orthotic devices during running, the musculature of the foot and leg is incorrectly aligned or stretched. Muscles function at their maximum capacity, with the least energy expenditure while in their correct anatomical alignment, so unless a person has a “perfect” foot, chances are their muscles are not functioning at the top of their game! Orthotics and shoes to some extent, place the foot and leg in their “neutral position,” aligning the muscles, tendons and ligaments correctly so as to allow them to exert their maximum benefit.

In terms of injury, it remains to be seen whether more acute injuries are suffered with or without shoes because there simply isn’t enough research to support one side or the other. However, it has been proven that the skin on the soles of the feet is 20 times thicker than any other skin on the body. This may make the sole of the foot more resistant to injury over other areas of the body, but it certainly doesn’t make it immune to injury! Those against barefoot running can show clear evidence to support an increase in puncture wounds to the soles of the feet in athletes running without shoes. Objects that could be encountered while running without shoes, such as rocks, glass and nails still have the potential to cause serious injury and debilitation to the soles.

Certainly if you suffer from peripheral neuropathy, as a complication of diabetes, alcoholism or other inducing factors, shoes should be worn at all times. In patients with neuropathy, infarct on the plantar aspects of the foot may go undetected due to lack of sensation, and further complications such as infection and non-healing wounds are imminent!

Adjusting to barefoot running, should you bravely attempt it, may take up to 4 weeks, at which time the skin on the plantar surfaces of your feet with become thicker and more adept to handling new terrain. You should begin by walking barefoot as much as possible, and slowly work your way into jogging, and eventually running when you feel comfortable.

No matter which thought process you follow, exhibit safety. Carefully weigh the options, know which is best for you, and get running!

In recent years, much discussion has surrounded the topic of Barefoot Running. The benefits versus the risks of running barefoot have the medical community divided on which is “best” and for which running populations. International athletes suck as Abebe Bikila of Ethiopia have successfully competed in long-distance running events without the aid of shoes; if he can run without shoes, why can’t the rest of us?

It is not so much that you can’t become a “barefoot runner,” but the more important question becomes, is it safe? What are the risks and benefits of running without shoes?

Running barefoot has come into favor in recent years because runners and sports science researcher alike believe that running barefoot allows a runner to expend less energy in addition to decreasing their risk of acute injury, such as ankle sprains. Proponents believe that the risk of injury increases with shoe-wear due to slowed proprioceptive feedback from the foot to the brain. Proprioceptive feedback is a message sent from the foot up to the brain that tells your foot that it is on the ground and in which position. Without shoes, there is no interference from the material of the shoe and the feedback from the foot to the brain is faster and more efficient, thus your body can adjust to uneven surfaces quicker, preventing injury.

The theory behind a decrease in energy expenditure in the athletes running barefoot has no substantial research behind it, but theorist believe it may have something to do with proprioceptive feedback in addition to the simultaneous use of foot and leg muscles. It is believed that when running barefoot an athlete must use all the muscles in their foot and leg to run, thus no one muscle must work harder than it was intended, as they believe is the case in those running with shoes. They say that shoes and “high-tech” athletic sneakers prohibit certain muscles in the legs from working at their maximum capacity, forcing other muscles to work harder, which could lead to the increase in energy expenditure.

Proponents of running with shoes believe that without the use of supportive shoes and/or orthotic devices during running, the musculature of the foot and leg is incorrectly aligned or stretched. Muscles function at their maximum capacity, with the least energy expenditure while in their correct anatomical alignment, so unless a person has a “perfect” foot, chances are their muscles are not functioning at the top of their game! Orthotics and shoes to some extent, place the foot and leg in their “neutral position,” aligning the muscles, tendons and ligaments correctly so as to allow them to exert their maximum benefit.

In terms of injury, it remains to be seen whether more acute injuries are suffered with or without shoes because there simply isn’t enough research to support one side or the other. However, it has been proven that the skin on the soles of the feet is 20 times thicker than any other skin on the body. This may make the sole of the foot more resistant to injury over other areas of the body, but it certainly doesn’t make it immune to injury! Those against barefoot running can show clear evidence to support an increase in puncture wounds to the soles of the feet in athletes running without shoes. Objects that could be encountered while running without shoes, such as rocks, glass and nails still have the potential to cause serious injury and debilitation to the soles.

Certainly if you suffer from peripheral neuropathy, as a complication of diabetes, alcoholism or other inducing factors, shoes should be worn at all times. In patients with neuropathy, infarct on the plantar aspects of the foot may go undetected due to lack of sensation, and further complications such as infection and non-healing wounds are imminent!

Adjusting to barefoot running, should you bravely attempt it, may take up to 4 weeks, at which time the skin on the plantar surfaces of your feet with become thicker and more adept to handling new terrain. You should begin by walking barefoot as much as possible, and slowly work your way into jogging, and eventually running when you feel comfortable.

No matter which thought process you follow, exhibit safety. Carefully weigh the options, know which is best for you, and get running!

Plantar fasciitis is probably the most common cause of heel pain in adults. The plantar fascia is a thick band of fibrous connective tissue that attaches to the heel bone, runs across the bottom of the foot and then fans out to connect at the base of each toe (Figure 1). It provides support for the arch of the foot, helps to lift the arch during normal walking, and also acts as a shock absorber during walking and running.

Overuse of the plantar fascia, most commonly during weight-bearing athletics such as running or even extended periods of standing, can cause small, repetitive tears in the fibers that make up the fascia.

The resultant inflammation and swelling produces the pain of plantar fasciitis. Damage is most common in areas where the stress on the connective tissue is greatest and where the fascia is thinnest, as it curves around the back of the heel. Plantar fasciitis is particularly common in older people because the heel fat pad that normally protects the plantar fascia in this region thins with age. Patients with plantar fasciitis typically feel a sharp pain in the heel, particularly on rising in the morning and at the beginning of a walk or run, that may fade as they warm up. The pain may also occur with prolonged standing and is sometimes accompanied by stiffness.

Treatments for plantar fasciitis include:

• Icing

• Exercises

• Rest

• Steroid Injections

• Orthotics

• Splints

• Use of non-steroidal anti-inflammatory drugs (NSAIDs) to treat pain and inflammation

Exercises are not only effective for the relief of active plantar fasciitis, but also help to minimize recurrence of this painful condition. This brochure will provide practical instruction in the use of some of these simple exercises.

EXERCISES

Exercises for recovery from or prevention of plantar fasciitis are generally divided into two types:

1) Stretching Exercises, 2) Strengthening Exercises.

STRETCHING EXERCISES

Stretching exercises are used to increase the flexibility of the muscles of the thigh and calf and of the plantar fascia itself. Tightness in the muscles of the leg can result in disproportionate stress being applied to the plantar fascia during walking and running, increasing the risk of injury. Stretching exercises for the plantar fascia itself can increase the flexibility of the fascia and thus reduce the potential for damage. Five examples of stretching exercises with illustrations follow:

A. WALL GASTROCNEMIUS STRETCH

The gastrocnemius is one of major muscle groups in the calf. To stretch this muscle, place your hands against the wall and stand with both feet flat on the floor, one foot forward of the other (Figure 2). Keep the rearmost leg straight and the foot pointed straight ahead. Lean forward without arching the back, placing your weight on the forward leg while bending it at the knee. You should feel stretching in the mid-calf of the straight leg. Hold the stretch for 10-15 seconds, release, and then repeat 6-8 times. Reverse the position of the legs and then stretch the other leg.

B. STAIR GASTROCNEMIUS STRETCH

The gastrocnemius can also be stretched using a simple exercise that can be performed while standing on a stair (Figure 3). Stand with the ball of the foot on the edge of a stair and heels off the step. While holding the banister for balance, rise as high as possible on the toes and then lower yourself slowly as far as you can without rolling the foot inward or outward for 1-2 seconds and then repeat 10-20 times.

C. SOLEUS STRETCH

The soleus is the other major muscle in the calf. To stretch this muscle, assume a position similar to that for the Wall Gastrocnemius Stretch but with both of the legs bent and the buttocks dropped (Figure 4). Make sure your feet are facing straight ahead and not turned out. Gently lean into the wall and keep your heels on the floor while bending both knees, putting a little more weight on the back leg. Continue until you feel stretching in your lower calf. Hold the stretch for 30 seconds and repeat 2-3 times on each side.

D. HAMSTRING STRETCH

The hamstring is a major muscle of the thigh that runs from just below the knee to the buttocks and lifts the lower leg and bends the knee. If the hamstring istoo tight, the bend in the knee during walking and running is exaggerated, which, in turn, results in increased pull on the heel bone and too much tension in the plantar fascia.

To stretch the hamstring, lie with your back flat to the floor with your eyes focused upward. Grasp the back of the thigh with both hands and, with the leg bent, pull the thigh until it is perpendicular to the floor and then slowly straighten the knee (Figure 5). Repeat the exercise with the other leg.

E. SEATED PLANTAR FASCIA STRETCH

During normal walking, the plantar fascia lengthens and then shortens as the foot lands. If the plantar fascia is insufficiently elastic, repetitive lengthening and shortening can result in damage to the fibers of the fascia with subsequent inflammation. Exercises that stretch the plantar fascia can improve its flexibility and help it withstand the stresses that are placed on it without damage.

The plantar fascia can be easily stretched while sitting. Sit on a chair or on the edge of a bed with one leg crossed over the other (Figure 6). Place the fingers of the hand of the same side as the crossed leg across the base of the toes and pull the toes back toward the shin while keeping the leg steady until stretch is felt in the bottom of the foot. Repeat the exercise five times for each foot. This exercise is particularly effective when done before taking the first steps of the day and after prolonged sitting or inactivity.

F. ROLLING STRETCH

The rolling stretch (Figure 7) is another simple way to stretch the plantar fascia. To perform this exercise, sit on the edge of a bed and place your foot on a hard cylindrical object such as a plastic water bottle or a ball. Roll the foot over the object while maintaining pressure against it. Continue rolling for 30-60 seconds, stop, and then repeat for a total of five times. This stretch should be performed three times per day. For pain relief while performing the exercise, use a water bottle filled with cold water or chill the ball in the refrigerator prior to performing the exercise.

STRENGTHENING EXERCISES

These exercises are designed to strengthen the muscles in the foot and ankle that support the arch of the foot. Strengthening these muscles will take stress off the plantar fascia. All of these exercises are best done barefoot. Three examples with illustrations follow:

A. TOWEL CURLS

Lay a hand towel on an uncarpeted floor and place the bare foot on the towel (Figure 8). Keeping the heel on the floor, curl the toes, pulling the towel toward you. Continue pulling the towel with the toes until it is bunched under the arch of the foot. Repeat this procedure 10 times with each foot. As your feet get stronger, resistance can be increased by placing a soup can or other weighted object on the end of the towel.

B. TOE WALKING

With your body erect and your hands behind your back, walk on your toes with the toes pointed straight ahead (Figure 9). As the foot is placed down, allow the heel to come as close as possible to the floor without touching. Then rise on the toes as high as possible before pushing off the ground. Taking very short steps, walk across the room. Repeat the exercise with the toes pointed outward 30° and then with the toes pointed inward 30°.

C. HEEL WALKING

With your body erect and your hands behind your back, lift your toes as high as you can and walk across the room on your heels with the toes pointed straight ahead (Figure 10). Take very short steps and do not allow the toes to touch the ground. Repeat the exercise with the toes pointed outward 30° and then with the toes pointed inward 30°.

SUMMARY

Inflammation of the plantar fascia, most commonly as a result of overuse, is a painful and potentially debilitating condition. Icing, rest, and use of nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve the pain but do little to treat the underlying causes of plantar fasciitis. Regular performance of a series of leg and foot exercises is not only an effective treatment for the pain of plantar fasciitis but also an effective deterrent for recurrence of this painful condition.

Please check with your doctor or podiatrist before starting any exercise routine.