Posts for: April, 2014

NEW YORK Wed Apr 16, 2014



(Reuters Health) - Diabetes is becoming increasingly common in the United States, but the risks of complications from the blood sugar disease have declined since 1990, according to a new study.

Better preventive care for adults with diabetes contributed to a 68 percent drop in their risk of heart attacks and a 64 percent drop in deaths from high blood sugar.

The risks of strokes and lower-limb amputations both fell by about one half, researchers found, and there was a 28 percent drop in cases of kidney disease so serious that dialysis or a transplant was required.

However, from 1990 to 2010, while the U.S. adult population rose by 27 percent, the number of adults diagnosed with diabetes tripled, from 6.5 million to 20.7 million, researchers reported in the New England Journal of Medicine.

"I tend to see this as more good news than bad news," lead author Dr. Edward Gregg told Reuters Health. "For the average person with diabetes, the complications are declining and, in some cases, more than expected."

But, "If we don't do something to reduce the incidence of diabetes, we're going to have a lot more diabetes complications down the road," said Gregg, a senior epidemiologist in the Division of Diabetes Translation at the Centers for Disease Control and Prevention in Atlanta.

Dr. Elizabeth Seaquist said she was surprised to see such a precipitous decline in the heart attack rate.

"That's bigger than I would have expected," she told Reuters Health.

Seaquist, president of medicine and science at the American Diabetes Association, was not involved in the new study.

The fact that individual patients are facing a lower risk of complications "is fabulous," she said. "But on a population basis, because of the epidemic, this is a problem that's not going away. We really need to address the whole problem of the epidemic of diabetes."

The researchers based their findings on three databases and the National Health Interview Survey, which poses health questions to about 57,000 U.S. adults each year.

The rates of heart attacks, strokes and lower-extremity amputations among non-diabetic people also declined, they found, but not nearly to the degree seen among those with diabetes.

The declines among people with diabetes were first seen in 1995 and continued in subsequent years.

"These findings probably reflect a combination of advances in acute clinical care, improvements in the performance of the health care system, and health promotion efforts directed at patients with diabetes," the researchers wrote.

"Hardly any of these declines just involve a single factor, and it probably varies by complication," said Gregg.

But the growing prevalence of diabetes meant that, from year to year, the number of cases of most complications increased overall despite improved care.

Compared to 1990, in 2010 there were 59,703 more cases of stroke, 22,703 more amputations and 32,434 more instances of advanced kidney disease among diabetes patients in the U.S.

In contrast, the total number of heart attacks among people with diabetes fell by 4,379 and the number of deaths from hyperglycemia dropped by 529.

The researchers note that the increasing prevalence of diabetes and the aging of the baby-boomer generation suggest the total number of diabetes-related complications "will probably continue to increase in the coming decades."

The study did not look at other complications of diabetes, such as blindness and dangerously-low blood sugar.

For young runners, shin splints all too common    


Vicki Huber Rudawsky | April 15, 2014. 

Every year, at the start of spring track, coaches and trainers brace themselves for the most common complaint from their young runners – shin splints.

It is sort of an “eye roll” injury, one that is basically expected to occur and many times not taken too seriously. But the pain from shin splints is serious.

Shin splints, clinically known as medial tibial stress syndrome, is very common in runners, as well as jumpers and dancers.

Shin splints can occur when an athlete has intensified his or her training routine, especially if done quickly. The muscles, tendons and the bone tissue of the lower leg become overworked with repetitive stress on the shinbone. This stress can cause a tenderness and soreness in the lower leg along the inner shin. There may even be some mild swelling.

Many times, shin splints seem to disappear while actually running or training, but flare up with a vengence once the workout is done. For a young athlete, this can be confusing because they may be able to get through a hard workout with no pain, but then can hardly walk afterward.

There are many factors that can contribute to shin splints, including running on hard surfaces with sudden stops and starts, uneven terrain, either flat feet or high archesor excessively tight calves. Over-pronation can also be a risk factor. Pronation is when the ankle rolls inward as the foot strikes the ground.

When running, this causes the muscle to fatigue quickly and renders it unable to absorb the shock from the foot hitting the ground.

The most effective treatment for shin splints is rest. An athlete can remain fit with non-impact cross training. Swimming, biking, elliptical, and aqua jogging are all great ways to stay in shape without further injuring the shins. Ice is also recommended. Over-the-counter pain relievers are helpful, but with young athletes, this is something for parents to decide for themselves. Loosening up the calves, especially via massage, can help tremendously.

The return to normal activity must be gradual.

Shin splints can vary in degree of pain depending on the athlete. I remember my shins hurting during track, but now I know that this was probably because we had to workout in the school parking lot until our dirt track dried out enough. While I had no problem running distance runs on the roads, the pounding of intense interval workouts would flare up my shins and ankles.

A good warm up is essential to warding off shin splints,. Supportive shoes help out. Avoid running in shoes that may be too old and worn out. Arch supports can also help.

If the problem persists, a physical therapist can provide a routine of stretches and strengthening exercises.

Sometimes, it is hard to determine if the shin splint may have grown into a stress reaction or a stress fracture. A stress fracture is an incomplete crack in the bone, and females are about three times more likely to progress from a shin splint to a stress fracture. Many who have experienced stress fractures describe the feeling as “deep” or even a “nauseating” pain.

The most accurate diagnostic tool is a bone scan.

While shin splints may be common and annoying, they are to be taken seriously. A healing time of three to six months is not unusual, so for an athlete, this can be more than an entire season.




Minor foot wounds a major threat for diabetics

NEW YORK Mon Apr 14, 2014


(Reuters Health) - For people with diabetes, one foot ulcer is very likely to lead to another, according to a new study that finds even minor lesions create a major risk of more severe foot wounds.

The best defense, Dutch researchers say, is to treat even minor sores carefully and to protect feet from pressure and injury with specialized footwear.

"I hope medical specialists, and other health care practitioners will use this knowledge and implement it in clinical practice," said senior author Sicco Bus, staff scientist with the Academic Medical Center at the University of Amsterdam.

People with diabetes often lose feeling in their feet as a result of nerve damage, known as neuropathy. The lack of sensation makes diabetics prone to injure their feet without realizing it, and allows small wounds to grow into serious ulcers that can eventually lead to infection or gangrene.

In the U.S., 26 million Americans have diabetes. Every year, 65,700 of these patients have lower-limb amputations.

Past research has shown that having had a foot ulcer is a significant risk factor for having more of them.

"Ulcer recurrence is a debilitating condition for the patient, risking further complications such as infection and amputation, and influencing loss of patient mobility and quality of life," Bus told Reuters Health.

To find out what factors most strongly predict who will develop foot ulcers, Bus and his colleagues analyzed data from a large trial of specialized footwear for diabetes patients with nerve damage in their feet (see Reuters Health article of January 24, 2013

For the new analysis, the researchers focused on 171 participants, all of whom reported having a foot ulcer at least 18 months before the study began. For a period of 18 months, each person was checked for new ulcers every three months, and interviewed about their daily habits.

The pressure on their feet while walking barefoot and in the special footwear was also measured. During one week, sensors in the shoes reported how often the participants wore their shoes and how many steps they took.

During the study period, 71 people developed ulcers on the soles of their feet, 41 of them as a result of unrecognized "trauma," Bus and his colleagues report in the journal Diabetes Care.

Among those 41, the people who had minor lesions when the study began were nine times more likely than those who didn't to develop an ulcer. Often the wounds were in the same place as a previous ulcer, suggesting there was ongoing pressure or injury happening at that spot, according to the researchers.

Patients who wore shoes customized to the pressure points of their feet, however, had a 57 percent lower risk of developing a new ulcer compared to those who didn't.

Currently, to prevent ulcers, doctors and nurses have to check the feet of diabetic patients every day for wounds or use specialized tools for determining pressure points that might be prone to blisters.

"Some diabetics wear wounds on their feet kind of in the same way that a person might wear a hole in their sock, but for a diabetic, this hole gets infected and often leads to an amputated foot," Dr. David Armstrong, a professor of surgery at the University of Arizona, told Reuters Health.

"(Neuropathy) is a massive problem, it's silent, and it doesn't hurt, even in instances of gangrene. It's no one's fault, but no one pays attention to it. This study opens up avenues for prevention," said Armstrong, who was not involved in the research.

The protective effect of customized footwear seen in the study highlights the benefits of personalized healthcare in high-risk patients, noted Dr. Lawrence Lavery, a professor of surgery at the Texas A&M Health Science Center College of Medicine and the Scott and White Memorial Hospital in Temple, Texas.

Private insurers will have to step up to pay the expense, Lavery said. "This is something that is well worth investing in."

Point-Counterpoint: Stretching: Is It Beneficial For Plantar Fasciitis?

April 2014 | Lisa M. Schoene, DPM, ATC, FACFAS, and Stephen Pribut, DPM, FACFAS

Offering pertinent biomechanical insights, this author examines the positive effects of stretching for plantar heel pain and the potential consequences of equinus.

By Lisa M. Schoene, DPM, ATC, FACFAS

Plantar fasciitis is probably the most common condition that the podiatric physician treats. We all have a myriad of treatment regimens and protocols that ultimately get our patients back on their feet.

   Usually, we suggest stretching of the gastrocnemius and soleus muscles very matter of factly. We know that these two muscles distally form the Achilles tendon and that tendon expands around the posterior aspect of the calcaneus to join into the plantar fascia. The plantar fascia or plantar aponeurosis is a thick, fibrous band made of collagen tissues that have a tensile strength of 7,000 pounds per square inch within the central portion.

   The fascia splits into three bands: the medial, central and lateral. The medial portion is thinner, originates from the flexor retinaculum and the medial calcaneal tubercle, and blends together with the central portion. The central portion, which is the thickest portion, is triangular in shape as it fans outward and into its distal deep and superficial layers. The deep layer attaches into the flexor tendons of each toe and helps to maintain the fat pads and plantar plates. The superficial layer merges with the transverse metatarsal ligaments. The lateral band originates from the smaller lateral tubercle, covering the abductor digiti minimi muscle and then inserting into the proximal and plantar surface of the fifth metatarsal. Under ultrasound inspection, the medial and central bands normally measure on average 2.5 to 2.7 mm thick from dorsal to plantar, and the lateral band should measure about 1.7 to 1.9 mm thick.

   Due to the proximal attachments into the Achilles tendon, it would make sense that calf stretching both with the knee straight and with the knee bent would be an important part of the treatment protocol. Stretching will lessen the strain or pull into slips of the plantar fascia band from proximal to distal.

Understanding The Potential Impact Of Equinus

Looking at the anatomy, we know that a tight gastrocnemius and/or soleus muscle will result in a loss of dorsiflexion range of motion at the ankle joint. Tightness that predominates with the knee straight would suggest the gastrocnemius is tight whereas tightness with the knee bent would indicate that the soleus is the culprit. Either way, we typically define this as equinus.

   There are many etiologies of equinus. These include spastic equinus, like one would see with cerebral palsy or high muscle tone issues, congenitally short musculature, prolonged casting, limb length discrepancies, a plantarflexed forefoot deformity, excessive use of high heels, lack of stretching, and/or general muscle weakness. Ultimately, partial or fully compensated equinus will produce some untoward effects within the foot and/or up the kinetic chain. When compensation occurs, it has to affect another area of the body.


   The definition of “compensation” is a good thing to review since we treat many of the maladies it causes. The definition of compensation is an abnormal change of structure, position or function of one body part or joint in the attempt to neutralize the effects of improper deviations, positions, functions of another body part or joint. Given the profound nature of compensation, the true work of the thoughtful podiatrist can therefore change everything from head to toe. What happens “to,” “from” or “within” the foot will ultimately affect something else in the body. What will happen? Will that compensation go distally or proximally?


Is Your Pain Caused by a Heel Spur?

Jamie Yakel | March 31, 2014. 

If you have played sports for very long, you've likely experienced heel pain. At times, the pain can be quite debilitating, even causing you to miss practice or training time.

Heel pain has multiple causes, but people tend to assume the cause is a heel spur, which is not always the case. Many athletes with heel pain don't have heel spurs, yet they experience the same symptoms.

What exactly is a heel spur?

Heel spurs are new bone that forms in response to stress to the heel. They serve to protect the bone against the development of microfractures. Spurs start out as cartilage and progress to solid bone. They are present in about 50 percent of the population, yet not everyone has heel pain— that's the first clue that heel spurs don't always cause heel pain.

Other causes of heel pain

Micro tears in a ligament called the plantar fascia (a condition known as plantar fasciitis) often lead to heel pain. When you stand, your foot flattens, leading to elongation of the foot and stretching of the plantar fascia. Running, jumping and other similar activities lengthen the ligament even further. The plantar fascia is not made to stretch, so it can tear due to overuse, sudden stretching or rapid increases in activity. When this occurs, rest and inactivity will allow those micro tears to begin to heal. However, when you resume activity that stretches this band of tissue again, the pain cycle can start all over again.

Most likely, the pain won't go away on its own, but occasionally it does. People try ice, over-the-counter arch supports, anti-inflammatories, stretching, night splints and changing shoes. While these can work, often they're not enough to resolve the symptoms. You may need professional treatment to resolve the pain and to resume training. Medical professionals can provide treatments that include steroid injection and platelet-rich plasma (PRP)—and a newer alternative, an injection of stem cells. Often a cortisone injection will help, but it's short-term, and the pain can come back, requiring multiple injections.

PRP is used in other parts of the body. Blood is drawn and spun to separate. Platelets that contain growth factors are injected back into the injured area to increase the healing potential. Most insurance companies do not cover this type of treatment, however.

The best long-term treatment option is orthotics, custom-made from a mold of your foot. Liken them to prescription eyeglasses. They stabilize the foot and relieve the tension on the plantar fascia. Stretching the calf muscle is also an option, although it takes several weeks or even months of stretching to achieve the desired result.

Preventative measures include replacing shoes on a regular basis, stretching and seeking treatment early in the process, not after six to 12 months of pain and self-treatment. Long, sustained calf stretches of 30-60 seconds are ideal, but don't bounce when stretching. Heel pain can be the result of a nagging injury that won't go away. Professional treatment is available when self-treatment fails.


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