As the technology of three-dimensional printing becomes more ubiquitous, these authors note that 3D printing could be a viable adjunct for surgical planning and orthotic fabrication, and suggest that increased access to this technology may have broader implications on healthcare delivery in the future.

Three-dimensional printing has become an awe-inspiring, household term for the creation (and recreation) of amazing items, and we suspect it will play a major role in the forthcoming third Industrial Revolution. As we will have the ability to rapidly create and iterate physical objects much in the way that we have been able to create and modify computer files, the only thing that remains clear about the future of this disruptive technology is that it will drive change.

In practical terms, 3D printing is nothing more than a newer means of manufacturing. Original patents for 3D printing date back to the late 1970s and early 1980s as it was originally referred to as “rapid prototyping” or stereolithography. As with desktop paper printers of that era, 3D printing was crude and low resolution in comparison to today’s standards. However, 3D printing (or additive manufacturing as it is more properly known) largely went unnoticed until this current decade. Why is that? Supply and demand.

Rapid prototyping machines originally required a bit of technical expertise to operate and were prohibitively expensive. Prices of these machines ranged from three to ten times more expensive than the cost of a reasonable desktop paper printer. It was not until these original technology patents expired in the late 2000s that tinkerers and hardware hackers began developing inexpensive desktop-sized 3D printers. Although the reliability and overall quality of these printers were fairly poor, the use of these printers was a truly captivating experience for many technology enthusiasts of their time, and the open-sourced designs became a foundation for much of what the mainstream media has popularized.

Today, some of the more common demonstrations of 3D printing in education, art and commercial business are part of an overnight explosion that is a quarter of a century in the making. In what direction does this lead the next five to ten years of everyday manufactured goods and services?

To understand additive manufacturing, it is important to understand manufacturing in general. As you read this article, the large majority of everything surrounding you was likely manufactured by one of several processes. Casting, molding, forming and machining are the most common categorical descriptions. Everyday examples include a craft doorknob poured from a cast, injection-molded protective smartphone cases, vacuum-formed plastic bottles and machine-carved (a.k.a. subtractive manufacturing) wooden table legs. Additive manufacturing is essentially just one more member of this family.

Additive manufacturing is a process that starts with nothing and creates the final product one layer at time. Three-dimensional printing is showing great promise with exceedingly intricate manufacturing capabilities as well as custom applications. Whereas most of the previously mentioned processes have inherent limitations to complexity with corresponding cost increases, 3D printed products often do not increase in price or time when one adds more details to the printed result.

Can 3D Printing Reinvent Surgical Planning For Complex Deformities?
Three-dimensional printing has become a poster boy for Silicon Valley technological innovation and status quo disruption. As empowering as this may seem, 3D printing still has a longer and gradual transition, and has yet to achieve widespread, everyday use. However, this movement is already inspiring healthcare modalities, generating new opportunities for personalized patient care and pre-surgical education via the utilization of computer drafting and additive manufacturing (3D printing).

Complex, challenging surgical procedures have the potential to create stress on care providers and patients alike.1 Research has shown that these stressors have the potential to adversely affect intraoperative performance and human interactions, ultimately reducing the quality of patient outcomes.2 Multiple researchers have investigated methods of reducing stress and improving operating circumstances in a variety of theaters.3-5

The reconstruction of complex deformities secondary to Charcot neuroarthropathy continues to pose challenges for diabetic limb preservation efforts. Failure to properly address this problem has the potential to reduce mobility and increase mortality.6 The senior authors have previously described the use of simulated perioperative surgical planning by means of computer-aided design (CAD) software as well as computer-aided manufacturing (CAM) methods via additive manufacturing.6 In this article, the senior authors described a novel, inexpensive 3D template printing technique that uses a normal printer to produce multiple “copies” of the foot that is slated for surgical repair. We believe one could use this technology to plan surgical repair or revision of other complex foot deformities.

Surgeons have likewise replicated this technique in orthopedic and other surgical specialties. Zein and colleagues described the use of 3D printing to simulate liver transplantation.7 These advantages of simulated surgical planning are further elucidated in the field of neurosurgery, where researchers have observed complex challenges and considerations.8 Modeling advantages to additive manufacturing and computer-assisted design are also happening in pediatric plastic surgery.9

While simulated perioperative surgical planning functions well as a surgical training tool and a tangible adjunct for patient education, it is likely still too costly and cumbersome for high volume workflow.

Much of these accomplishments are admittedly minuscule in comparison to the glaring potential benefits that additive manufacturing could bring to individualized regenerative medicine. Atala and his tremendous work with bioprinting of tissues and organs demonstrate some of these advantages.10,11 While stem cells alone have limitations with growth patterns and morphogenetic tendencies, additive manufacturing may overcome many challenges to organ replacement and other pathologies such as tissue degeneration in people with arthritis.

Does 3D Printing Facilitate Increased Access, Collaboration And Innovation?
Recently, popular crowdfunding opportunities have laid the foundation for progressive market developments, increasing widespread “homebrew” endorsement for personal additive manufacturing platforms. In tandem, works to make products more available and low-cost by the “open source movement” have pioneered renovations in recently expired software, successfully “remixing” purchaser-only applications into industry-leading “free to use” programs.

Previously, the exploration and advancement of technology was the sole work of industry professionals or highly skilled enthusiasts. A relatively new phenomenon termed “hackerspaces” or “makerspaces” has brought about nationwide venues for hobbyist, educational and collaborative work, facilitating a dynamic change in the availability of resources.12  These movements strive to lower the barriers to education and training, revolutionizing the means by which we obtain individual skills. Direct examples of this include Makerspaces in Tucson and Atlanta. In addition, the triad of increasing machine capabilities, decreased material and technological costs as well as patent expiration in tandem with the aforementioned educational centers have led many theorists to predict an upcoming third Industrial Revolution.13,14

The resonating effects of these penetrating sociological ideals and educational opportunities are quite intriguing. It is likely that many of these principles will produce unexpected results, circumventing the accepted limitations of education and defying established socioeconomic rules and traditional business models.15 Disruptive changes as a result of technological advancements are a common thread throughout human history.

Just as the widespread adoption of viable free software and rapid Internet connectivity disrupted the previously accepted form factor of purchasing compact discs, it is our belief that the current healthcare practices will be revolutionized by the concepts currently developing by the means of homebrew, think tank and startup technology operations. While the safety and legality of these practices have yet to resolve, the end result is no less inspirational. Never before has a consumer been so connected with a digital engineer, an evolving relationship already influencing widespread commercial segments. The advances in all 3D technologies, from 3D design, scanning and capturing, “augmented reality” and additive manufacturing, can theoretically help “open source” the world itself. In the coming decades, digital sharing and replication of everyday commodities may be as accessible as current consumer technology.

Additive manufacturing will likely not replace everyday items until the material properties of these goods can improve. Currently, additive manufactured materials do not hold up well against repetitive loading and high impact forces like many traditionally manufactured goods do. Also, there is a significant limitation on material choices. Improvements to resolution, printing methods and chemical mediums will likely overcome much of this in the next 20 to 30 years.

Will 3D Printing Redefine The Roles Of Healthcare Providers?
Orthoses and prostheses, perhaps like no other technologies in podiatric medicine and surgery, may conceptually benefit from the democratization of 3D printing. Already, many “legacy” orthotic companies advertise the use of variants of additive manufacturing in this area. The fact is, however, that this technology has been around in one form or another for a long while. Whether the near term shows benefits from 3D printed insoles over other insoles remains to be seen. The particular excitement in the area involves “homebrewed” technologies that may result in a greater number of individual clinicians (and perhaps individual patients at some point) making their own orthoses.

While this sounds heretical, we believe that it is ultimately inevitable. Whether this fundamentally changes the roles of podiatric and orthopedic surgeons, physical medicine and rehabilitation specialists or prosthetists from “prescriber” to “adviser” remains to be seen. Additionally, issues surrounding intellectual property for these technologies are no less complex than when the Napster file sharing service upended the music industry in the 1990s.

Where Do We Go From Here?
The social implications of 3D printing’s advancement will likely be very profound and yet unexpected. Although bootlegging and digital piracy are major concerns for product designers and patent holders, premium services will still likely rise to prominence among the noise. One meaningful comparison is with streaming media, whereby “free-to-play” models exist with support from advertising revenue.16,17 Donations and the recently described “thank you economy” are showing increased gains.18 Naming one’s price and patron support of content providers are becoming prominent business models.

YouTube may be the best example of this from the authors’ perspective. From a variety of hardware machines running several different operating systems and web browsers, users are able to experience a variety of different content. Users can upload artist- and user-generated content, and advertising revenue supports the means of hosting. Users can upload, download, share, promote, comment and vote on content based on merits or relevance. This fundamental platform has been one of the centerpiece platforms of social media, next to Facebook and Twitter.

Whereas the Internet provides the digital backbone of this tight social integration, digital 3D models and blueprints will also be shared and created by collaborative social efforts. This future is both promising and somewhat startling based on recent news. Less than three months apart, popular news outlets promoted coverage of both a 3D printed handgun, “The Liberator” and a 3D printed prosthetic hand replacement for children, the “Robohand.”15,19-20 Additive manufacturing is yet another empowering technology for the masses.

Could medical care providers and patients soon be witnessing a rapidly evolving change of interaction and delivery of service? Scientific literature as well as popular news sources have already demonstrated significant enhancements to medical treatments as a direct result of novel collaborative efforts and technology. Many of these stories emphasize the partnership between physicians, surgeons and scientists as being critical to positive outcomes. For instance, our team has worked with teams of surgeons at UCSD to rapidly prototype a human ear to surgical repair a congenital defect (microtia) by simply scanning the healthy ear and “flipping” it 180 degrees much as we would do in Photoshop before sending the template to a 3D printer.6

Additionally, the continued collaboration between patients and physicians further demonstrates an independence from commercial reliance. As the influence of consumer-driven technology subverts the industry-dominated creation and delivery of media, so too will the influence of patient-centered technology supersede the industry-dominated formulas for healthcare diagnostics and treatment. The ability to self-generate will continue to emphasize inexpensive personalized care, pushing traditional industry further from the frame of influence in the healthcare setting. Healthcare stands to benefit greatly from these technologies, both from large industrial and academic developments in machine design and sophistication, as well as from the consumer and hobbyist level.

 
Author(s): 
Nicholas A. Giovinco, DPM, John D. Miller, BS, and David G. Armstrong, DPM, MD, PhD
 

Mr. Miller is a third-year podiatry student at Des Moines University and a former research intern with the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Giovinco is an Assistant Professor in the Department of Surgery at the University of Arizona. He is the Director of Education with SALSA.
Dr. Armstrong is a Professor of Surgery at the University of Arizona College of Medicine. He is the Director of SALSA.

References

  1.     Mongin C, Dufour F, Lattanzio F, Champault G. Evaluation of stress in surgical trainees: prospective study of heart rate during laparoscopic cholecystectomy. J Chir. 2008;145(2):138–42.
  2.     Ahmed N, Conn LG, Chiu M, et al. Career satisfaction among general surgeons in Canada: a qualitative study of enablers and barriers to improve recruitment and retention in general surgery. Acad Med. 2012;87(11):1616–21.
  3.     Parvaneh S, Grewal G, Grewal E, et al. Stressing the dressing: Assessing stress during wound care in real-time using wearable sensors. Wound Medicine. 2014; 4(1):21–26.
  4.     Schwenk M, Mohler J, Wendel C, et al. Wearable sensor-based in-home assessment of gait, balance, and physical activity for discrimination of frailty status: baseline results of the Arizona Frailty Cohort Study. Gerontology. 2014; 61(3):258-67.
  5.     Rankin TM, Mailey B, Cucher D, et al. Use of 3D printing for auricular template molds in first stage microtia. Plast Reconstr Surg. 2014; 134(1):16–17.
  6.     Giovinco NA, Dunn SP, Dowling L, et al. A novel combination of printed 3-dimensional anatomic templates and computer-assisted surgical simulation for virtual preoperative planning in Charcot foot reconstruction. J Foot Ankle Surg. 2012;51(3):387–93.
  7.     Zein NN, Hanouneh IA, Bishop PD, et al. Three-dimensional print of a liver for preoperative planning in living donor liver transplantation. Liver Transpl. 2013;19(12):1304–10.
  8.     Klein GT, Lu Y, Wang MY. 3D printing and neurosurgery—ready for prime time? World Neurosurg. 2013;80(3-4):233–5.
  9.     Rankin TM, Giovinco NA, Cucher DJ, Watts G, Hurwitz B, Armstrong DG. Three-dimensional printing surgical instruments: are we there yet? J Surg Res. 2014; 189(2):193-7.
  10.     Skardal A, Atala A. Biomaterials for integration with 3-D bioprinting. Ann Biomed Eng. 2015;43(3):730–46.
  11.     Merceron TK, Burt M, Seol YJ, et al. A 3D bioprinted complex structure for engineering the muscle-tendon unit. Biofabrication. 2015;7(3):035003.
  12.     Adam AE. Hacking into hacking: gender and the hacker phenomenon. SIGCAS Comput Soc. 2003;33:3.
  13.     Gershenfeld N. Fab: The Coming Revolution On Your Desktop--From Personal Computers To Personal Fabrication. Basic Books, New York, 2008.
  14.     Anderson C. Makers: The New Industrial Revolution. Crown Publishing Group, New York, 2012.
  15.     Turner F. From Counterculture to Cyberculture: Stewart Brand, the Whole Earth Network, and the Rise of Digital Utopianism. University Of Chicago Press, Chicago, 2010.
  16.     Wilson F. The freemium business model. AVC Blog. Available at http://avc.com/2006/03/my_favorite_bus/ . Published March 2006.
  17.     Pujol N. Freemium: attributes of an emerging business model. Social Science Research Model. Available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1718663 . Published Dec. 1, 2010.
  18.     Kay G. The Thank You Economy: Gary Vaynerchuck. Int J Adv. 2011;30:721.  
  19.     Frauenfelder M. Make: Ultimate Guide to 3D Printing 2014. Maker Media, Inc., Sebastopol, CA., 2013.
  20.     Vincent CJ, Niezen G, O’Kane AA, Stawarz K. Can standards and regulations keep up with health technology? JMIR Mhealth Uhealth. 2015;3(2):e64.
  21.     Blackman J. The 1st Amendment, 2nd Amendment, and 3D Printed Guns 2014. Available at http://joshblackman.com/blog/2012/10/22/1-2-3-the-first-and-second-amend... . Published Oct. 22, 2012.

CBC's I-Team catches nail salon health violations on camera

The CBC I-Team visited two salons previously written up by Manitoba Health inspectors and found violations and unsafe practices continue even after they had been sanctioned.

Aloha Nails on Regent Avenue had previously been cautioned by provincial health inspectors for high bacteria counts in foot baths, for its "dirty and dusty" workstations and for reusing single-use tools like files and buffers.

The I-Team reviews what its secret shoppers saw in salons to Manitoba's Chief Health Inspector Mike Leblanc (CBC)

The I-Team's secret shoppers observed staff working again on work surfaces coated in nail dust and dead skin and reusing nail files and buffers on clients.  

The province's chief health inspector wasn't impressed.

"Not good," Mike LeBlanc said, when the I-Team presented its findings. "They should be doing better than that."

Public health inspectors have written up Aloha on Regent four times since 2012. The last inspection in March 2015, prompted by a complaint from a customer who believed she had contracted a foot fungus after a pedicure, found Aloha to be compliant with all regulations.

In Manitoba, inspections of spas and salons are only prompted by public complaint. The I-Team's secret shoppers visited Aloha in December, nine months after its last inspection.

"We would be revisiting them and reinforcing with them, encouraging them to maybe get more training and to follow their training and the guidelines," said LeBlanc.

The I-Team also visited Chic Nails, which was the subject of a complaint in September of 2015. During the I-Team's visit, the nail technician failed to sanitize the secret shopper's hands before starting the manicure and used a previously used single-use nail file and buffer.

"They should be disposing of the disposable ones in between clients, and they should be doing that in a public way to show, 'Look, we're throwing this away. We're not reusing it for the next person,'" LeBlanc said.

A worker at Aloha Nails uses a previously used emery board on I-Team secret shopper. (CBC)

As for sanitizing a client's hands before starting work, LeBlanc said: "They should be washing people's hands beforehand."

"We would take another look at them and to make sure that they're complying with our guidelines," he said.

Carter Chen speaks for Chic Nails. When told of the infraction caught on camera, he told the I-Team it was an isolated incident.

"Well, we do have some turnover within the salon," Chen said. "Sometimes you can't always check on each employee."

The salon keeps a list of salon rules in the back of the salon, which tell staff how to treat single-use items, Chen said.

The I-Team's calls to Aloha were not returned.

The Registrar of the College of Podiatrists of Manitoba said podiatrists occasionally have to deal with the after effects of poorly performed or unsanitary pedicures: ingrown nails, infections and fungus.

Martin Colledge is concerned after a sales consultant contacted him about buying advertising on the RateMDs website. (CBC)

"Forty to 60 per cent of the population over the age of 50 has clinical evidence of fungal infections in the nail.  The questions is, is that something that is transmitted through spas and pedicures?" Martin Colledge asked.

Colledge also worries about the ways some spas and salons advertise their services.  Some are advertising that they have "master pedicurists" on staff who claim to be able to treat people with health problems as opposed to offering cosmetic services

"The competency of what they are offering is unclear," Colledge said, "As a regulator I have some concerns about that."

In particular, Colledge worries about pedicure clients with diabetes.

"What may appear to be a callous can actually be underneath that quite a deep ulcer," Colledge said. "So if you have someone who despite their best intention starts cutting away at a callous in someone who has that what they may reveal is a whopping great hole in the foot which they probably wouldn't be competent to deal with."

Colledge cautions people looking for serious foot care to seek a regulated health care provider like a podiatrist, rather than an esthetician.

 'If it's too good to be true, it probably is.' - Jocelyn Diamond, esthetician

But if you're just looking for a straightforward pedicure, how can you be sure your salon or spa is compliant with regulations?  Esthetician Jocelyn Diamond said price can often be a good indicator of whether a spa is following the rules.

"Price says a lot," Diamond said. "If it's too good to be true, it probably is.  They're probably not throwing away their disposable items and their service provider may not be paying a fair wage."

Diamond estimates a basic pedicure should be between $35 and $45 which would factor in the cost of using new single-use tools like emery boards and quality sterilized re-usable tools.  She said a basic manicure should cost at least $25.

Diamond urges consumers to be wary of bargain prices on esthetics services because those businesses could be "cutting corners with products, cutting corners with your health, cutting corners with their staff, not using good, quality product."

Sports compression garments: the expectations vs the evidence

Research suggests that compression garments can be effective for improving muscle recovery after fatiguing exercise, but has shown little to indicate an athletic performance benefit.

A World Cup soccer player, a National Basketball Association point guard, a National Football League wide receiver, an Olympic gold-medal-winning short-track speed skater, a mixed martial artist, a professional wake-boarder. These are examples of elite-level athletes who wear compression garments with expectations of enhanced performance or muscle recovery.

These expectations are driven by compression gear companies who target professional and recreational athletes alike with website messages advising that the products will “take their sports performance and recovery to the next level,” as one site puts it. Published studies of compression garments, however, don’t fully support these claims.

In theory, sports compression garments improve performance during exercise and speed recovery afterward by improving vascular circulation, thus increasing oxygen delivery to muscles and removal of metabolic waste products such as lactic acid.

Research does indicate that compression can be effective for improving muscle recovery after fatiguing exercise, such as running a marathon. But, although multiple studies have looked at the effect of compression garments on sports performance, they have found little evidence of a performance benefit. And some researchers have found that the advantages of the garments primarily have to do with the wearer’s perception—raising the possibility of a placebo effect.

The degree to which marketing impacts the wearing of compression garments cannot be underestimated, according to Australian researchers in human movement science.

“There is little doubt that sports compression garments exploded on the scene and the ‘trend’ grew much faster than the scientific evidence,” said Peter Clothier, Ph.D, a lecturer in the School of Science & Health at the University of Western Sydney in Australia. “As with many trends in sports performance, the onus on the usage of devices such as compression garments is an individual one.”

Focusing on fit

The question of fit, or more specifically, the degree of compression provided by compression garments, is a common issue that has been raised in the peer review process and literature regarding the variable results. Specifically, a large majority of studies have not measured the exact amount of compression participants are receiving.

Experts say the fit is fundamental: If compression is not optimized, then the garment can’t do what it is proposed to do, regardless of whether that compression can actually make any physiological difference to an athlete. “It is possible that there may be an optimal degree of pressure that elicits beneficial or better effects,” Clothier said. “However, there is a lack of a valid and reliable scientific method to measure the pressure at the garment-skin interface. Several studies report attempts to quantify the degree of compression. However, these studies often fail to report the reliability of these measurements. Attempts to measure compression have occurred at a small number of easily accessible sites that are not representative of the net compression over the entire limb.”

Amitabh Gupta, PhD, a lecturer in Allied Health at the University of Western Sydney in Australia who coauthored a study on compression garments with Clothier, said a valid and reliable system would need to be developed to accurately measure total limb compression.

“To date, there are no such systems available,” Gupta said. “Therefore, the approach in our study1 was to follow manufacturer guidelines, which are the only method a consumer has to purchase an appropriately fitting garment.”

Jessica Hill is a PhD candidate studying recovery from muscle damage in endurance exercise and a sport and exercise physiology senior lecturer in the School of Sport, Health and Applied Science at St. Mary’s University in Twickenham, UK. She was the lead author on another compression garment study that appeared earlier this year in International Sports Engineering Association.2 The study addressed the variation in pressures exerted by commercially available compression garments.

“There was large variability in the way that the compression garment fits an individual,” Hill said. “They will not all be getting the same amount of compression. For me the biggest issue surrounding compression is whether the garment fits, and unfortunately, unless an athlete goes bespoke, it is going to be difficult to know if the garment fits properly. The fit of the garment is likely to be an important factor in how effective the garments are.”

Assessing performance

Clothier and his colleagues studied the effect of compression garments on motor performance parameters and leg mechanical characteristics during rapid and repeated loading of a limb to exhaustion—a lower limb dynamic rapid loading task that utilized the stretch-shortening cycle.1

They assessed 38 recreationally active male participants with a mean age of 22 years who performed single-leg, on-the-spot hopping at a frequency of 2.2 Hz for up to three minutes or to volitional exhaustion. Biomechanical measures included total duration of hopping time and individual hop cycle characteristics, including spatio­temporal variables and leg mechanics.

Each participant was tested under three conditions—garment, sham garment, and no garment—with the order of conditions randomized. The sham garment was designed to look and feel like the compression garment but did not actually provide compression.

Flight phase and contact phase duration, vertical displacement of the center of mass during the flight phase, and normalized vertical leg stiffness all were significantly different at the end of the hopping trial than at the start. However, there were no significant differences between conditions for any of the variables measured. The researchers concluded that commercially available compression garments, when fitted to manufacturer guidelines, did not enhance performance in a controlled, relatively short duration hopping task to exhaustion, compared with no garment and the sham garment.1

“There was also no influence of [the compression garment condition] on performance of a number of biomechanical measures as described by spatiotemporal characteristics and vertical stiffness,” Gupta said.

While compression garments did not improve performance, they also did not detrimentally affect performance, the researchers noted. Therefore, they said, the choice to use compression garments must be made based on the perceived cost-to-benefit ratio.

“The perceived benefits, such as comfort, may still sway the choice of whether to use a compression garment or not during their performance,” Gupta said. “This study did not demonstrate a change in leg mechanical characteristics, and interestingly did not demonstrate an increase in the duration of hopping. Although not surprising, it does add to the view that compression garments may not directly improve motor performance, however, and plausibly, they may play a role in comfort and recovery.”

Despite the lack of research supporting compression garments as performance enhancers, their popularity has been likened to the widespread appeal of kinesiology tape among athletes.

“The use of compression garments during sport is similar to the fashion of Kinesio tape,” said Stuart Armstrong, MD, a sports and exercise physician with Anglesea Sports Medicine in Hamilton, New Zealand, alluding to the fact that manufacturer claims about the physiological effects of elastic therapeutic tape also have proved difficult to substantiate (see “Elastic therapeutic tape: The search for evidence,” March 2015, page 37).

Possible placebo effects

Photo courtesy of Sigvaris

Armstrong, like others who have studied the sports application of compression garments, said that any performance benefit is an imagined one.

“It will have a placebo effect if [athletes] believe it is helping their game, but there is no clinical evidence above and beyond this,” he said.

Scientists have said the challenge of blinding participants makes conducting studies on compression garments difficult, if not impossible. This leaves open the possibility of a placebo effect when measuring variables like subjective responses (eg, perception of muscle soreness) or subsequent exercise performance.

“That said, if evident, a positive effect is a positive effect,” said researcher Braid MacRae, MSc, who published a study on compression garments and exercise in Sports Medicine in 2011 while with the University of Otago in Dunedin, New Zealand.3 MacRae, who is currently with the Swiss Federal Laboratories for Materials Science and Technology (Empa) in St. Gallen, Switzerland, said the placebo effect should not be discounted.

“I think it would be foolish to overlook a placebo effect as an effect,” MacRae said. “If what you’re after is getting out the door for your next training session, and wearing compression garments helps do that, then I don’t see anything wrong with that. My advice for athletes would be quite practical. I believe you shouldn’t underestimate personal experience.”

Researchers in the US and abroad expressed similar positions.

“While it doesn’t appear that there are quantifiable physiologic changes when you wear [compression] garments, anecdotally, people do feel better and more confident when they wear them,” said Samuel R. Ward, PT, PhD, who is a professor in the departments of radiology, orthopaedic surgery, and bioengineering at the University of California, San Diego in La Jolla. “They feel like they have more support around something that was either injured or they feel as though it’s predisposed to injury. I think many people downplay the second part of that, which is not right. There’s a significant component of performance that is between your ears—the better people feel, the better they’re going to perform.”

Evidence for muscle recovery

Despite the lack of evidence for performance enhancement, the research has generated some evidence of beneficial effect in terms of muscle recovery. Armstrong, in fact, was the lead author of a randomized controlled trial of compression socks and their effects on functional recovery following marathon running that appeared last year in the Journal of Strength and Conditioning Research (JSCR).4

The compression garments came up to the knee and had a moderately strong compression gradient. They were fitted to 33 uninjured experienced mara­thon runners based on shoe size and calf girth.4

“Essentially, my research showed that there is a benefit in the use of compression garments for recovery after an exhaustive sporting event,” he said. “Crucially, the compression garments weren’t worn during activity, but were worn following the completion of activity.”

The aim of the study was to show whether compression socks worn for 48 hours after running a marathon could improve functional recovery 14 days later. The runners were measured by a timed treadmill test to exhaustion two weeks prior and two weeks following each marathon. The group wearing the compression socks, which were designed to give a compressive value between 35 and 45 mm Hg when fitted per the manufacturer’s instructions, increased the runners’ time to exhaustion by 2.6%. The placebo group, wearing the sham garment—a no-seam diabetic sock designed to be in the 4- to 5-mm Hg range (enough com­pression to keep the sock up)—decreased their time by 3.4%.4

“I was surprised I was actually able to show a difference in running performance two weeks following a marathon in the compression group versus the noncompression group,” said Armstrong, who noted that compression garments need to be medical grade rather than fashion-accessory grade. He recommended a level between 35 and 45 mm Hg for athletes. He also noted the importance of fit.

“Fit of the garments is incredibly important, and I know from the study I did, even though the compression socks were fitted to the participants, they were off the shelf and there was a wide variety of actual compressive values obtained in the athletes,” he said.

Another study investigating the effects of compression on recovery following marathon running indicated perceived lower levels of muscle soreness. Hill was the lead author on the study that appeared last year in JSCR.5

“Compression garments appear to reduce the severity of symptoms associated with muscle damage and have been indicated to accelerate recovery of muscle function,” she said.

Twenty-four runners were divided into two groups. One group wore lower limb compression tights for 72 hours after completing a marathon. The other group received one 15-minute treatment of sham ultrasound after the marathon. Perceived muscle soreness, maximal voluntary isometric contraction (MVIC), and serum levels of markers for muscle damage (creatine kinase [CK] and C-reactive protein [C-RP]) were assessed at various points. Perceived muscle soreness was significantly lower in the compression group than the sham group 24 hours after the marathon. There were no significant group effects for MVIC, CK, and C-RP.5

The study concluded that, while the use of a lower limb compression garment improved subjective perceptions of recovery, there was neither a significant improvement in muscular strength nor a significant attenuation in markers of exercise-induced muscle damage and inflammation.5 The other factor Hill said should be noted is that the individuals who took part in this study were experienced runners completing high weekly training volumes. Therefore, they were unlikely to experience very high levels of muscle damage, even after a marathon, and were likely to recover more quickly than less intense runners.

“If we had used a more inexperienced group of individuals we may have found different results,” Hill said. “We conducted a systematic review and meta-analysis of studies investigating the efficacy of compression and identified that the use of compression appears to reduce the severity of symptoms associated with exercise-induced muscle damage following strenuous exercise.”

That meta-analysis was published in the September 2014 issue of the British Journal of Sports Medicine.6 Hill and her researchers used an electronic search of the literature, ending in August 2012. They used three online databases (MEDLINE/PubMed, SportDiscus, and ISI Web of Knowledge) using a combination of terms.

Caveats and considerations

While sports compression garments aren’t a magic bullet and likely won’t help an athlete run faster or jump higher, they may enhance performance through perceived benefit and they may help in recovery.

“As a general rule in medicine, particularly in orthopedics, when people have pain or instability, compression provides some improvement in symptoms,” Ward said.

Additionally, Clothier and Gupta pointed out that, while their study concluded compression garments did not promote performance in a controlled short-duration hopping task, their findings did not necessarily translate into a lack of efficacy.

“In no way do we suggest that the wearing of commercially available [compression garments] could not enhance sporting performance, especially in relation to other movements, sporting activities or from a thermoregulatory, neuromuscular, physiological, or psychological perspective,” Clothier said.

He added that, because it’s possible that garments may affect other parameters than those measured, it is also plausible that the reported benefits of garments involve aspects of motor performance that do not directly relate to biomechanics.

By P.K. Daniel, Lower Extremity Review - August 2015

Practical tips to help parents spot children's foot problems

Just part of growing up vs. the sign of a problem—managing children's health and wellness is complicated for parents, who often struggle to know which signs and symptoms are temporary and those that point to more serious concerns. As parents transition back to the regular routines of fall with school and sports, the American College of Foot and Ankle Surgeons offers practical tips to help parents know what their children's feet are telling them.

"While many pediatric foot problems resolve themselves with growth and time, there are clear signs that tell parents when their children need medical help," says Suneel Basra, DPM, FACFAS, a New Jersey-based foot and ankle surgeon and a Fellow member of the American College of Foot and Ankle Surgeons.

Common pediatric foot problems can range from pediatric flat foot, toe walking, in-toeing, and flat or high arches to tarsal coalitions and extra bone growth. While these conditions and their treatments are different, they share some common signs that show parents there is a problem that needs addressing by a foot and ankle surgeon:

  • Pain, swelling and redness that does not subside
  • Development of thick calluses in one area of the foot
  • Problems with the way your child walks (gait)
  • Shins or thighbones that appear to turn inward
  • Ankles that are weak or easily give out

"Checking a child's foot health during a routine physical is just as important as any other part of the exam. Pediatricians and foot and ankle surgeons need to work together to ensure these conditions do not affect a child's overall growth and development," continues Dr. Basra.

There are a variety of treatment options for these conditions that parents can evaluate in partnership with their healthcare team. Whether a less invasive approach such as shoe modifications, orthotic devices and physical therapy or more intensive interventions such as bracing, steroid injections or surgery; a foot and ankle surgeon can advise parents on which treatment offers the best long-term prognosis for their children.

What is Charcot Arthropathy? Charcot foot, as it is commonly referred to, is a chronic progressive disease of the bone and joints found in the feet and ankles of Charcot Footour diabetic patients with peripheral neuropathy.

What leads to this Charcot foot? Having long standing diabetes for greater than 10 years is one contributing factor. Having autonomic neuropathy leads to abnormal bone formation and having sensory neuropathy causes the insensate foot, or foot without sensation and thus susceptible to trauma, this is another contributing factor. These bones in the affected foot collapse and fracture becoming malformed without any major trauma. One common malformation you see related to Charcot foot is the “rocker bottom” where there is a “bulge” on the bottom of the foot where the bones have collapsed.

Your patient with Charcot foot will present with a painless, warm, reddened and swollen foot. You may see dependent rubor, bounding pedal pulses, and feel or hear crackling of the bones when moving the foot. If a patient were to continue to bear weight on the Charcot foot there is a high chance for ulceration that could potentially lead to infection and/or amputation.

Continued, on-going weight-bearing can result in a permanently deformed foot that is more prone to ulceration and breakdown. Prompt treatment is necessary using total contact casting, where no weight bearing will occur on the affected foot for 8-12 weeks. Our job as wound care clinicians is good foot assessment with prompt identification and treatment of this acute Charcot foot to prevent foot deformity and further complications in the diabetic patient.





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