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.

Plantar Fasciotomy is an Option in Only 5% of Plantar Fasciitis Patients

Over the last several weeks we have been discussing Plantar Fasciitis and treatment options for alleviating symptoms. The reason so much time has been spent discussing this topic is because plantar fasciitis is extremely common, seen in about 50% of new patients presenting to a Podiatrist’s office. The upside to the high prevalence of plantar fasciitis is that in 95% of patients who have “heel pain,” conservative treatment methods will result in success!

To recap, plantar fasciitis is an irritation of a band of tissue on the bottom of your foot extending from the heel into the toes. When this band of tissue is stretched in the wrong direction, or is too short to stretch correctly, it becomes irritated and inflamed causing heel pain. The most clinically indicative symptom of plantar fasciitis is pain in the morning, with the first step out of bed that lessens during the day with activity. The reason patients experience this “first step” pain is because as they were sleeping the plantar fascia started to repair itself, essentially shortening, and with that first step, it is stretched again and micro-tears in the tissue occur.

A few of the conservative options we touched on included: stretching exercises, supportive and constantly worn shoes, injection therapy to help break the chronic inflammatory cycle, and oral anti-inflammatory medications. Last week we discussed Acoustic Shock Wave Therapy for treatment of chronic plantar fasciitis after a 6-month period of failure with treatment using other conservative options. Shock Wave Therapy is a conservative method of treatment in that there are no surgical incisions, but it is slightly more aggressive than other conservative options and is thus reserved for specific patients.

With failure of all conservative options, including Shock Wave Therapy, in patients with long-standing plantar fasciitis/heel pain, it is likely that surgery will be discussed as an option. Keep in mind that the conversation of surgical intervention will only occur in 5% of patients with plantar fasciitis, so surgical intervention is rarely required! The goal of surgery is to relieve the plantar fascia of the tension that is residing within it, providing relief to the patient. There are surgical options that are in favor at this time, each achieving that goal in a slightly different way.

One option, called an Open Plantar Fasciotomy, is simply what it sounds like. Your Podiatric Surgeon will make a small incision along the heel, visualize the plantar fascia and release it near its origin in the heel bone. A calcaneal spur, should one be present, may also be removed during the procedure. The decision as to whether or not to remove a calcaneal spur (an area of extra bone growth along the heel bone from plantar fascial pull) will be made prior to surgery by your Podiatrist using x-ray evaluation. The procedure is done in an outpatient setting, meaning you will be able to go home and relax immediately following surgery. You will be restricted from placing pressure on the heel for at least a week and you should expect some normal pain and swelling in and around the heel. Ice and pain medication prescribed to you will help to alleviate some of these symptoms. As your body heels from surgery, the area where the plantar fascia was released will fill in with new tissue growth, essentially lengthening the plantar fascia and relieving tension in the tissue. With the added length, the fascia is no longer too short to accommodate for the stretch it was meant to achieve!

An Endoscopic Plantar Fasciotomy is a slightly less invasive procedure than the Open Plantar Fasciotomy, but it also aims to relieve tension on the plantar fascia and allow your body to fill in with new tissue, lengthening the fascia. This procedure utilizes a small camera for visualization of the plantar fascia, with two small incisions rather than one larger incision. The procedure is completed in an outpatient setting with the post-operative instructions being the same as with the “open” procedure, although slightly less recovery time is needed.

Finally, one less available and infrequently performed procedure utilizes “Autologous Platelet Concentration.” Essentially, what that concentration is made up of, is cells and healing factors from your own blood that have been spun down into a syringe. The concentration will be injected into the heel under ultrasound visualization of the plantar fascia, with the goal of the procedure to stimulate healing to decrease thickness of the plantar fascia tissue, essentially alleviating the symptoms of fasciitis. You will be casted for several days to eliminate any chance of pressure on the heel, and once those few days have elapsed you will be transitioned back into a sneaker.

Remember that no surgical procedure is without its risks; therefore both benefits and risks of the surgery should be discussed with your Podiatrist prior to consenting to a procedure. For these specific procedures you must understand that recurrence of pain to the plantar heel is possible as well as a very low possibility of infection, destabilization of the lateral foot, neve entrapment and heel bone fracture. In addition, you will still need to implement conservative and preventative treatment measures such as proper and supportive shoes and stretching of the musculature to maintain your surgical results!

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Enjoy Running? Stay tuned as next week we will tackle the topic!

Which is Better, Round or Square?

The answer is square. Always square…well, at least when we’re talking about how to trim your toenails! Improper trimming of the nail can commonly lead to an ingrown, the proper technique for trimming will be covered in a few minutes, but for now, let’s talk ingrown toenails.

An ingrown toenail is caused by a sharp edge of the nail that digs into the surrounding skin creating pressure and pain. Improper trimming of the nail is the most common cause of an ingrown as a sharp edge or corner may remain, or too much nail has been removed allowing the nail to pinch the surrounding skin as it grows. Trauma to the nail, especially in adolescents who are actively involved in athletics, can also create an ingrown. Repetitive kicking, of a soccer ball for example, can cause the skin to pinch inwards towards the nail. Tight fitting shoes can cause the same sort of reaction, resulting in an ingrown nail. A hereditary component may exist, so if you have ingrown toenails, it is likely that your son or daughter will suffer from the same. It is not the toenail, per say, that is hereditary, but the structure of the bones within the toe that predisposes development.

The first sign of an ingrown will be pain. If the pain is ignored too long or if you attempt to relieve the pain on your own by cutting back the nail via “bathroom surgery,” infection is likely to occur. You will know infection is present when the area where the skin and nail come together begins to become red, hot, and swollen and when it begins to drain fluid. If you haven’t seen your Podiatrist, which if you’ve reached this point its likely that you haven’t, its time to give him or her a call and get an appointment as soon as possible. If you are experiencing chills, fevers, or night sweats, take yourself to the emergency room, as these are signs of systemic infection.

Treatment for an ingrown nail is very straightforward and most Podiatrists will follow a variation of the same protocol. A portion, or the entire nail needs to be removed to alleviate pressure and eliminate the source of the ingrown. Your Podiatrist will start by numbing the toe and cleaning the area around the nail to eliminate any bacteria living on the skin. Next he or she will free the underside of the nail from the toe, cut back the portion of the nail that is digging into the skin and remove it. Once it has been removed, they may or may not use a chemical called phenol to help prevent the nail from growing back. Your toe will be bandaged and you will be given instructions on how to care for the area at home. Depending on the severity of infection, you may or may not be given a prescription for antibiotics. You will need to follow-up with your Podiatrist within a week to ensure everything is improving. It is important that you do not try to remove the nail yourself, as the bone in your toe is situated directly under the bed of the nail and using unsterile techniques can lead to infection of the bone or abscess (basically a sac filled with infection).

Now, back to how to properly trim your toenails: A very common misconception the average person makes, in relation to trimming their toenails, is belief that the nails should be rounded off on the sides, keeping the edges smooth. The edges should be smooth, but rounding off the sides increases the risk of creating an ingrown toenail. As I said above, square is always better. You want to ensure that when trimming your nails, or your child’s nails, you trim straight across leaving the edges of the nail square. DO NOT try to round the edges down towards the skin and DO NOT trim the nail too low causing irritation at the end of the toe. If you’re not used to trimming your nails this way, it will take some getting used to, but I can assure you, you will thank yourself later when you’re not suffering from the discomfort associated with an ingrown toenail! The reason ingrown toenails are more predominant in those ages 8-12, is because it is around this age that children become responsible for trimming their own nails. If you, as their parent, haven’t taught them the proper technique, your Podiatrist will be seeing you soon!

Did a Frog Kiss My Childs Feet?

If you’ve noticed new, small areas of growth on the sole of your child’s foot recently, there’s no need to panic! They may have been kissed by a frog, but more than likely your child has been exposed to Human Papilloma Virus (HPV); a virus that can infect the skin leading to the development of plantar warts. Plantar warts are the most common infection of the skin caused by a virus and are typically seen in patients ranging in age from 12-16.

HPV is a virus that can infect several areas of the body, including the soles of the feet, and is spread via direct contact to the skin. Most often it comes in contact with the skin when patients go barefoot in public showers where the virus has been left behind by another individuals feet. It is important to keep in mind that the strain of HPV causing plantar warts cannot be spread to other areas of the body, such as the mouth or genitals.

The incubation period for HPV on the sole of the foot ranges anywhere from 1 to 20 months, thus it can be difficult to determine when and where the virus was picked-up by the patient. Once it does present itself it may go undetected, as many patients do not experience symptoms such as pain or do not notice a change in the skin on the sole of the foot. Infection is often disregarded as a callus in the early stages, due to increased thickness of the skin, overlying the area where the virus lives. One defining feature of plantar warts is the presence of small, black circular dots just visible underneath the skin. These “dots” are areas of blood, contained in capillaries that in a healthy foot are not seen, as capillaries typically do not extended into visible areas of the skin on the foot. However, as the HPV grows and comes up towards the surface of the foot, it stimulates blood supply to come with it, helping the virus thrive.

Warts can resolve on their own, as the body’s immune system attacks the virus and rids it from the body, but not all warts will resolve without treatment. Over the counter methods that can be tried include Salicylic Acid preparations (pads, liquid, gel, or ointment) and Vitamin A, in addition to keeping feet clean and dry to eliminate moisture and decrease the viruses chance to thrive. All of the above mentioned options are likely to work on new infections, but for warts that are long-standing, professional treatment from your Podiatrist is recommended.

Depending on the severity and length of infection time, there are many treatment options that can be utilized by your Podiatrist. Selection of a method will both be based on your Podiatrists opinion and evaluation of your child’s infection as well as discussion with you, the parent, to help determine which treatment methods can be tolerated by your child. Acids and ointments, similar to those available over the counter include Canthrone, Efudex and Salicylic Acids. If such treatments fail, cryotherapy (freezing of the wart with sodium nitrate) can be utilized causing the wart to turn black, and eventually fall off. This treatment is slightly more painful than some other options and often requires several applications for success. Debridement, or trimming and cutting out of the wart can be successful, but to ensure that enough of the wart is removed to prevent recurrence local anesthetic, injected with a needle, must be used. Laser treatment is a relatively new method of treating warts and is generally clean, accurate and effective in riding your child of the infection. There is minimal to no pain associated with treatment, making it a good choice! Marigold therapy (the flower), even newer than laser treatment, has shown incredible success in treating HPV infections on the plantar surface of the foot, and is great for children as it is non-invasive and induces no pain. The only downfall with Marigold therapy is its limited availability in offices across the country.

This month we will be focusing on your child and their feet! Check back next week for information on another common Podopediatric problem: ingrown toenails. You’ll learn the best way to trim your child’s nails, and other tricks for preventing an ingrown.

How to Tell if Your Child Will Suffer from
Foot Abnormalities in the Future!

Commonly, parents will present to the Podiatrists office with their 16 or 17 year old son or daughter who has been complaining of recent pains or aches in their legs and/or feet. When they find out that their child’s current foot problem was one that could have been diagnosed and corrected much earlier in life, parents become upset and wonder why their Pediatrician never said anything! It is becoming less often the case, but Pediatricians have long believed that children will “out grow” their foot problems and that it is nothing to worry about. We now know that this is not the case, and dismissing earlier indicators can lead to severe problems in a child’s early adult life and on occasion surgical interventions are required.

It is often difficult to tell before your child begins to walk if they are experiencing trouble, pains or aches, because without bearing weight on their feet it is impossible to know how those feet will feel. However, you can help catch abnormalities early on, just by using your eyes! Look at your infant’s feet: does something look abnormal? If there is something that sticks out to you, contact your Podiatrist. Many Podiatrists specialize in Pediatrics, and if they don’t they know someone who does! It never hurts to have a professional assess your child’s foot and leg position early on. If there is no abnormality present, all the better, but if there is one present, it has now been detected early on and can be monitored or corrected from the start.

Once your child does begin to walk there are a few important indicators that may signal a foot problem, and that you as parents can easily identify.

Toe Walking: Infants will commonly walk on their toes, which can be normal, but what isn’t normal is persistent toe walking. If you find that your child continually walks on their toes, it might be wise to have your child evaluated.

Pain: Children should never complain of muscle or joint pain. If your little one starts to complain of foot, knee or hip pain, it is worth have a professional investigate its source.

Family History: If you as parents have suffered from a foot problem, it is possible that you have passed on that same wonderful foot-type to your child, and they are likely to follow suite with presentation of foot problems.

In-Toeing: In-toeing is never normal in a child and can signify a rotation in your child’s foot, leg, thigh or hip! Do not let anyone tell you that your child will outgrown this problem. In-toeing can be indicative of a common but more serious abnormality in your child’s feet and with early intervention, casting and bracing can correct this deformity. If left untreated it can cause complications down the road for your child, and often they will require surgery for correction. A sign of in-toeing, to the untrained eye comes with activity by your child. Your child’s schoolteacher may inform you of frequent falling or tripping and withdrawal of your child from activities at school and these are all comments you should take seriously. Bring your child in to see a Podiatrist for evaluation.

If your child has an identified abnormality that a Podiatrist would like to initiate treatment for, first get a second opinion. It is always important to investigate all options, and hear several opinions before making a decision. Secondly, it is important that you, as the parent, take an active role in your child’s treatment plan. So many times casting and bracing regimens fail because parents do not want their child to wear a brace or leave the casting on for the specified time period. As Podiatrists, we understand that it is not an easy thing to see your child confined by their treatment modalities, but I assure you, early intervention is the key to successful treatment. Being lackadaisical with treatment leads to recurrence of their initial abnormality and again, leads to complications later in life that may require surgery.

As mentioned, if you do notice any of the signs and symptoms mentioned above, it is important that you see a Podiatrist for evaluation of your child’s feet. However, do not hesitate to contact your local Podiatrist if none of those signs or symptoms are present. It may help give you peace-of-mind to have your child evaluated for safe measures. It can assure you that everything looks as it should, and it will help you build a relationship with a Podiatrist who knows your child and can monitor them on a yearly basis to ensure their feet continue to look health and structurally normal.