May 22, 2019
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People who bought these Vibram FiveFinger shoes may be entitled to a refund

Back in the middle of the last decade, someone at the Vibram company had a brainstorm, the kind of once-in-a-career inspiration that undoubtedly is studied at business schools across the land. What if, this person must have mused, instead of marketing our FiveFingers shoe to the small community of boaters who use them to secure their footing on wet, slippery surfaces, we could convince tens of millions of people that they should run the streets in them? That running in flat, cushionless shoes with individual pockets for each toe is, in fact, better for your health than protecting your feet with all that soft, high-tech razzmatazz?

Vibram Komodo Sport (Vibram)

Even if you're not a runner, you probably know what happened next. The brilliant book "Born to Run," which celebrated a band of Mexican ultra-runners who lived in a hidden canyon and ran huge distances in sandals made from old tires, came out about the same time. A Harvard anthropologist, among others, launched a rigorous study of "barefoot running," concluding that the way people have been locomoting for hundreds of thousands of years is better for you than the raised sole of the modern running shoe.

The "barefoot" or "minimalist" boom was off and running, so to speak. Nike, Brooks and other major shoe companies jumped in with both feet, and soon you had an enormous choice of barefoot running shoes, with soles that ranged from totally flat to a few millimeters high at the all-important heel. Last time I checked, such footwear made up 10 percent of the $588 million U.S. running shoe market and had grown by 303 percent between November 2010 and November 2012, compared with 19 percent for running shoe sales overall.

We have since learned that Vibram has moved to settle a class-action lawsuit brought by a woman who claimed that the company deceived consumers when it claimed, without any scientific backup, that its shoes could decrease foot injuries and strengthen foot muscles. The company agreed to put aside $3.75 million to pay refunds of as much as $94 to anyone who had bought a pair since March 21, 2009, according to Runner's World.

Or as Deadspin put it in a snotty post Wednesday, Vibram acknowledged that the FiveFingers is nothing more than a "shoe foot-condom." (I'm sorry, that was unnecessary. "Deadspin" and "snotty" are redundant.)

Technically, Vibram has admitted nothing, "expressly" denying "any wrongdoing" or conceding "any actual or potential fault...or liability," according to court papers. This is like Rosie Ruiz refusing to admit that she took the subway to her victory at the 1980 Boston Marathon, but agreeing to let someone else be declared the winner so we can all move on.

It's not like this hasn't happened before. In 2012, Skechers agreed to pay a whopping $40 million in refunds to people who had spent $60 to $100 for a pair of their Shape-ups, swayed by the claim that they would promote weight loss and cardiovascular health better than other brands. Not long before that, Reebok agreed to pay $25 million to settle Federal Trade Commission charges that it misled people about the benefits of its toning shoes.

I tried the FiveFingers in 2009 and knew within a quarter mile that they were not for me. Yes, they forced me up onto the balls of my feet, where running coaches want you, because smacking your heels on asphalt roads without any padding to protect them will do that. That's the idea. It's self-preservation.

Does Vibram being caught flat-footed mean there's no merit to barefoot running? Absolutely not. There is conflicting research on the subject, but I've met dozens of people who gave up the sport because of leg injuries suffered in traditional running shoes, only to have their exercise regimens revived by the minimalist variety. In fact, I'm married to one. There's a niche for flatter-soled running gear, just as there's a market for people who prefer to drive Maseratis instead of Mazdas.

Any shoe that gets you moving is a good thing, even if it doesn't strengthen your feet, firm your butt or tone your legs. You can do that all on your own.

Coming soon.

Does The Evidence Support Traditional Concepts Of Achilles Tendon Rupture Etiology And Repair?

 

The approach to the evaluation and management of acute Achilles tendon rupture has experienced a constant evolution over the past five decades. Both surgical and non-surgical treatments have had extensive study, and a wealth of new evidence is available that has changed the most basic tenets of management of this common injury.

Despite the availability of very good studies that clarify and challenge our traditional thoughts, many traditions and misconceptions persist among foot and ankle surgeons. We will explore several aspects of acute Achilles tendon rupture including: whether repair is needed for good outcomes, current concepts of tendon hemodynamics and ischemia, and which steps in the repair algorithm are necessary.
To start the discussion, we will first explore the concept of tendon debridement during repair. This commonly recommended step highlights how historic evidence can create a bias in our approach to a common medical problem and how this bias can persist for decades despite the emergence of new evidence. The surgical repair of acute Achilles tendon ruptures commonly includes debridement of damaged tendon fibrils or “mop ends” at the rupture site.

Although we have historically seen debridement as necessary in the repair algorithm, we question whether it is necessary or prudent to resect any portion of the ruptured tendon. Removal of even a small segment of the midportion of the Achilles tendon results in shortening of the muscle-tendon unit and subsequent iatrogenic equinus.

In order to critically assess the common practice of tendon debridement in Achilles tendon ruptures, we must first answer the following questions:

1. What evidence supports the surgical resection of any portion of the damaged tendon?
2. How do we determine which portion of the tendon is beyond the capability for natural biologic repair?  
3. Is ischemia the proximate cause of Achilles tendon rupture?
4. Has this notion of midsubstance ischemia of the Achilles led to the recommendation of debridement because we think this section of tendon is necrotic?   

Addressing Ischemia And Vascularity In Achilles Tendon Ruptures

Although the notion of ischemia as the main etiology of Achilles rupture is ubiquitous in the discussion of the condition, there is little to no experimental evidence to support this conclusion.

The original study by Lagergren and Lindholm in 1959 used a cadaver model and mapped the blood supply with standard anatomic latex injection technique.1 The authors ascribed the term “watershed” to the vascular anatomy of the tendon because there were vascular components that came from both proximal and distal portions of the tendon, similar to the geographic term of a river watershed. They concluded that this anatomic distribution and orientation of blood supply leads to ischemia in the midsubstance of the tendon. Carr and Norris duplicated this experiment with the same conclusion in 1989.2

It is interesting that this notion of avascularity has persisted for many decades based on mapping of the static arterial anatomy in cadavers alone and not hemodynamic flow studies in live patients. Recent literature questions the concept of avascularity as a significant or sole factor for Achilles tendon tears.3 With the use of quantitative laser Doppler flowmetry, Astrom in 2000 and Astrom and Westlin in 1994 found that the midsection and origin are the areas of the Achilles tendon that are the most vascularized uniformly along the tendon, and that only the distal insertion has noticeably lower blood flow.4,5

Using a sodium washout, Hastad and colleagues showed there is a decrease in blood flow in all zones as we age, but the blood flow is consistent along the longitudinal course of the tendon.6 Astrom confirmed the uniformity of blood flow.4 Further evidence highlights a uniform increase in tendon blood flow to the Achilles tendon throughout its length.7–10

We wonder if this notion of ischemia, which began with non-hemodynamic cadaver studies, coupled with the visual cues we see during exposure for acute repair, including hematoma and tendon fragmentation, has led us down the path of resection of a portion of the tendon without scientific cause. Let’s face it. The tendon at the rupture site looks bad when we directly visualize it. If we are biased by what we learned about “watershed ischemia,” debridement seems reasonable.

What The Literature Says About Non-Operative Achilles Care

A somewhat less direct approach to answer the question of whether the tendon is ischemic is to examine the results of non-surgical care for Achilles tendon ruptures. A growing number of recent studies indicate that the functional outcomes and re-rupture rates for non-surgical management using early functional rehabilitation are equivalent to surgical repair.

A 2017 Canadian study by Sheth and colleagues detailed that, although there has been a rise in acute Achilles tendon ruptures in recent years, there has been a significant decrease in the incidence of surgical repairs since 2009.11 The authors found that the rate of surgical repairs in Ontario, Canada dropped from 20.1 percent in 2003 to 9.2 percent in 2013.

This drop in surgical repairs in Canada could have contributed to recent literature that supports non-operative treatment. In a 2017 systematic review and meta-analysis, Deng and coworkers found no statistically significant difference in the incidence of deep vein thrombosis (DVT), functional scores or ankle range of motion (ROM) between the surgical and non-surgical groups.12 The authors also showed that the re-rupture rate for surgical patients of 3.7 percent was statistically lower than that of the non-surgical group (9.8 percent).

Twaddle and Poon previously explained the prevention of this increased rate of re-rupture in non-surgical patients in 2007.13 The authors observed surgical and non-operative patients who both partook in early range of motion, and found no significant difference in complications, re-rupture rates, dorsiflexion, plantarflexion, calf size or the Musculoskeletal Function Assessment index between the two groups. Lim and Gwynne-Jones also found no significant difference in Achilles tendon total rupture scores between operative and non-operative treatment groups that followed the same functional bracing protocol.14 Thus, Twaddle, Lim and and their respective colleagues concluded, as did Barfod and colleagues in 2014, that early active rehabilitation is more important for tendon healing than surgery.13–15

Comparing Achilles tendon repair patients in early weightbearing and six-week delayed weightbearing groups, Suchak and colleagues found the early weightbearing group had better RAND-36 and ROM outcomes at six weeks.16 At six months, there was no longer this difference between the two groups and patients had the same complication rate. Young and coworkers achieved this early active rehabilitation by allowing non-operative patients to use weightbearing casts, and these patients had outcomes equivalent to non-operative patients who were non-weightbearing.17

Hutchison and colleagues noted low re-rupture rates (1.1 percent) and satisfactory Achilles Tendon Total Rupture Score, Achilles Tendon Repair Score and functional outcomes when using the Swansea Morriston Achilles Rupture Treatment program (SMART), which includes early weightbearing.18 A Level I study by Willits and coworkers “supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures” due to the patients having similar clinical outcomes as operative patients while avoiding the complications associated with surgery.19 Bergkvist and colleagues agreed that non-operative treatment is the preferred protocol in most patients with acute Achilles tendon rupture due to a low re-rupture rate (6.6 percent) in non-surgical patients and the nonexistent chance of infection.20   

It would stand to reason that if the tendon can heal without surgery, it must not be significantly ischemic and is certainly not dead. In fact, the Achilles is just injured and experiences the normal physiologic reparative process as with any similar tissue failure. Additionally, limited exposure or percutaneous techniques for repair are now available and provide encouraging results.21–23 These techniques do not include any form of tendon debridement, further supporting the concept that the damaged, but not necessarily ischemic, tendon can heal through normal physiologic processes.

Final Words

While open surgical debridement may have been the standard treatment of acute Achilles tendon ruptures in the past, that does not mean that it is the gold standard of patient care now. Numerous studies have shown there is sufficient blood flow along the length of the tendon. Therefore, there is no ischemia and no need to debride the tendon. This point is further supported by the knowledge that Achilles ruptures may heal non-operatively with excellent functional results and low complications. As the research shows, the new standard in care is setting down the blade, taking a break from the OR and having your patients with Achilles tendon ruptures start early weightbearing and ROM.

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Pages: 18 - 21
 
Author(s): 
Paul Dayton, DPM, MS, FACFAS, Sean Harper, DPM, Rachel Egdorf, BS, and Andrea Cifaldi, BS

Dr. Dayton is affiliated with UnityPoint Clinic Foot and Ankle in Fort Dodge, Iowa. He is an Assistant Professor in the College of Podiatric Medicine and Surgery at Des Moines University. Dr. Dayton is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Harper is affiliated with UnityPoint Clinic Foot and Ankle in Fort Dodge, Iowa.

Ms. Egdorf is a third-year podiatric medical student with the College of Podiatric Medicine and Surgery at Des Moines University.

Ms. Cifaldi is a third-year podiatric medical student with the College of Podiatric Medicine and Surgery at Des Moines University.

References

  1. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand. 1959;116(5-6):491-495.
  2. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71(1):100-101.
  3. Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury. 2005;36(11):1267-1272.
  4. Aström M. Laser Doppler flowmetry in the assessment of tendon blood flow. Scand J Med Sci Sports. 2000;10(6):365-367.
  5. Aström M, Westlin N. Blood flow in chronic Achilles tendinopathy. Clin Orthop Relat Res. 1994(308):166-172.
  6. Hastad K, Larsson LG, Lindholm A. Clearance of radiosodium after local deposit in the Achilles tendon. Acta Chir Scand. 1959;116(3):251-255.
  7. Langberg H, Olesen J, Skovgaard D, Kjaer M. Age related blood flow around the Achilles tendon during exercise in humans. Eur J Appl Physiol. 2001;84(3):246-248.
  8. Langberg H, Bülow J, Kjaer M. Blood flow in the peritendinous space of the human Achilles tendon during exercise. Acta Physiol Scand. 1998;163(2):149-153.
  9. Boushel R, Langberg H, Green S, Skovgaard D, Bulow J, Kjaer M. Blood flow and oxygenation in peritendinous tissue and calf muscle during dynamic exercise in humans. J Physiol (Lond). 2000;524 Pt 1:305-313.
  10. Kubo K, Ikebukuro T, Tsunoda N, Kanehisa H. Changes in oxygen consumption of human muscle and tendon following repeat muscle contractions. Eur J Appl Physiol. 2008;104(5):859-866.
  11. Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27,607 patients. Bone Joint J. 2017;99-B(1):78-86.
  12. Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2017;56(6):1236-1243.
  13. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35(12):2033-2038.
  14. Lim CS, Lees D, Gwynne-Jones DP. Functional outcome of acute Achilles tendon rupture with and without operative treatment using identical functional bracing protocol. Foot Ankle Int. 2017;38(12):1331-1336.
  15. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014;96(18):1497-1503.
  16. Suchak AA, Bostick GP, Beaupre LA, Durand DC, Jomha NM. The influence of early weightbearing compared with non-weightbearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am. 2008; 90(9):1876–83.
  17. Young SW, Patel A, Zhu M, et al. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(13):1073-1079. Accessed Feb 11, 2018.
  18. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Joint J. 2015;97-B(4):510-515.
  19. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775.
  20. Bergkvist D, Astrom I, Josefsson PO, Dahlberg LE. Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am. 2012; 94(13):1229–33.  
  21. Chiu C, Yeh W, Tsai M, Chang S, Hsu K, Chan Y. Endoscopy-assisted percutaneous repair of acute Achilles tendon tears. Foot Ankle Int. 2013;34(8):1168-1176.
  22. Karabinas PK, Benetos IS, Lampropoulou-Adamidou K, Romoudis P, Mavrogenis AF, Vlamis J. Percutaneous versus open repair of acute Achilles tendon ruptures. Eur J Orthop Surg Traumatol. 2014;24(4):607-613.
  23. Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB. Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015;36(11):1279-1286.

The good news is that with a little preparation, leg cramps can be prevented.

1.  STAY HYDRATED
Dehydration causes concentration of the blood and increased lactic acid levels in the muscles. Adequate hydration dilutes the blood and lowers the lactic acid levels in the muscles. While sports drinks are currently in vogue for sports training, regular water is both affordable and appropriate for preventing dehydration problems. The average adult should drink eight to ten 8-ounce glasses of water a day. Drink more if you exercise, or if it's hot or humid. And remember, you don't have to be thirsty to get dehydrated. We exhale up to a pint of water in the form of water vapor each day and our water loss can be very subtle over time so it’s nearly unnoticeable.

2. EAT A BANANA
Bananas are a great source of potassium, which helps to prevent muscle cramps. Eating a banana on race day can help to prevent post-race cramping. But be careful not to eat too many. Too many bananas can cause stomach aches and diarrhea. Too many bananas can also cause irregular heartbeats due to potassium overload.

3. STRETCH
Stretching improves circulation in the muscles and helps to break up adhesions within the muscle fibers. Toe touches and wall push-offs are a great way to stretch those tight calves and hamstrings and break up the muscle adhesions. I recommend three sets of 10 twice daily, but more often if you have the time or inclination. If you have a night splint lying around from your last bout of plantar fasciitis, dust it off and start wearing it again to prevent cramping. If you practice yoga, ask your instructor to help tailor your classes to emphasize the stretching of your feet, leg, and back muscles.

4. DRINK TONIC WATER
Tonic water has quinine, which is also good for preventing cramps. Drink a small bottle (4 ounces) after your run to prevent cramping. Like the caution with bananas, be careful about ingesting too much tonic water because it can cause stomach aches and diarrhea. Quinine in high doses can cause seizures and irregular heartbeats.

5. WEAR GOOD SHOES
If your shoes are worn out, they can transmit the stress of footstrike into your body in abnormal ways and force your muscles to work harder to compensate for the increased stresses. Wearing high-quality, motion-control running shoes that are in good repair (for example, no mid-sole tilting, no holes in the out-soles, etc.) can reduce impact stress and muscle fatigue/overuse injuries.

6. BUY A PAIR OF "GOOD" INSOLES
When an old house settles on its foundation, window frames warp and cracks develop in the walls. Our bodies are like houses and our feet are our "foundations." Our feet are designed to collapse (or "pronate") to absorb the shock of standing, walking, and running. If our feet are excessively pronated, we can be predisposed to developing foot and leg pains because our feet and leg muscles have to work harder to hold us upright and allow us to move forward.

The use of a high-quality insole from a running store may provide enough arch support/motion-control to prevent excessive muscle strains and the resultant cramping. If your symptoms improve but are still present despite the use of athletic insoles, consider seeing a chiropodist for evaluation for custom-molded foot orthotics (molded appliances which provide even more support than athletic insoles).

7. GO ON A RECOVERY RUN/WALK
Going on a light (20-30 minutes) recovery run/walk the afternoon of (or the day after) your long run encourages the movement of blood in the worn-out muscles to help flush out the excess lactic acid. Yoga, lower-extremity aerobic weightlifting (i.e., multiple, rapid repetitions performed with light weights), spinning, or swimming are other activities which could be used as alternative recovery activities after long runs.

Ontario Improving Wound Care for Patients with Diabetes

Province Funding Casts to Treat Diabetic Foot Ulcers

Ministry of Health and Long-Term Care

Ontario is covering the cost of specialized casts to provide more support for patients with diabetic foot ulcers.  

Wound care devices, which include removable, non-removable and total contact foot casts, can significantly improve patients' quality of life by relieving pressure around the heel, ankle and toes so the foot can properly heal. These casts will be made available free of charge at eligible locations such as foot and wound care clinics, specialized programs for diabetes and community health, complex continuing care and rehabilitation centres.

The province is also supporting wound care training and education for health care workers, which will include specialized skills development in diabetic foot ulcer management.

Ontario's plan to create fairness and opportunity during this period of rapid economic change includes a higher minimum wage and better working conditions, free tuition for hundreds of thousands of students, easier access to affordable child care, and free prescription drugs for everyone under 25 through the biggest expansion of medicare in a generation.
 

Quick Facts

  • Ontario is providing more than $8 million over three years to provide three types of foot casts, also referred to as offloading devices, to treat diabetic foot ulcers. These devices include removable, non-removable and total contact foot casts which can cost between $150 and $620.
  • This funding followed Ontario’s acceptance of the Ontario Health Technology Advisory Committee’s recommendations to fund three types of offloading devices.
  • The province is also investing more than $50,000 this year to support 14 health care specialists across the province to attend the Wounds Canada Conference for hands-on training and education. This funding is part of the larger wound care strategy.
  • Offloading devices can be an effective treatment tool for diabetic foot ulcers and can significantly improve patient outcomes and reduce the risk of amputation.

Additional Resources

Quotes

“Making it easier for patients to access the services they need is a key priority for our government. Diabetic foot ulcers can be extremely debilitating, and if not properly treated, can negatively impact a person’s health and quality of life. We are making these wound care devices available free of charge to patients who need them in order to improve their healing and subsequently, their overall health.”

Dr. Eric Hoskins

Minister of Health and Long-Term Care

“The government's announcement today is excellent news for persons with diabetes who suffer from diabetic foot ulcers. The funding of offloading devices (pressure relieving), will prevent amputations and the devastating suffering and cost that result from them. We are proud that Ontario is the first province to provide universal funding for offloading devices for the treatment of foot ulcers and we encourage all other provincial governments across Canada to implement this evidence based cost saving therapy. The announcement is the culmination of a meaningful partnership between organizations representing nurses, physicians, other health professions and the public.”

Doris Grinspun, CEO, Registered Nurses' Association of Ontario (RNAO), and Mariam Botros, CEO, Wounds Canada

“Amputations are one of the most feared consequences of diabetes. Diabetes Canada recognizes the Government of Ontario’s leadership in providing public funding for offloading devices, which treat diabetic foot ulcers and prevent amputations. Diabetes Canada encourages the Government of Ontario to continue working on this issue, and encourages other provinces to follow Ontario’s leadership in helping Canadians living with diabetes with their foot care.”

Amanda Thambirajah

Director of Government Relations, Ontario, Diabetes Canada





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