Maceration

June 23, 2011 by · 1 Comment
Filed under: blister care, Foot Care, Health 
A BAD case of maceration

A BAD case of maceration

This weekend is the running of the Western States Endurance Run, a 100-mile race from Squaw Valley to Auburn, over the California Sierras. While around 375 will start the race, the finisher’s numbers will probably fall between 200 and 250.

The main reasons for not finishing will include being under trained, stomach issues, simply missing cutoffs, and injuries.

Injuries are big. There will be sprained ankles, cuts and scrapes from falls, possible wrist injuries from falls, tons of blisters, and this year – a lot of problems from maceration. With higher than normal snow levels, and this week’s hot temperatures, runners will be in the snow more than normal. Plus runoff from the snow will affect trails and stream crossings. These wet conditions will affect many of the runners – leading to maceration.

The picture above shows a severe case of maceration. With maceration this bad, the runner usually cannot continue because of the pain.

Maceration at Western States

Maceration at Western States

So, what is maceration and what can you do about it?

Dermatology.about.com give the following definition: Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected with bacteria or fungi. The photo, taken at the Western States finish line years ago, shows a good case of maceration. The runner’s son asked me to look at his dad’s feet because he had huge painful blisters on the bottom of his feet. There were no blisters – only the skin as shown.

Wet conditions can have a negative effect on our feet. Blisters may go from being minor inconveniences to major problems. Maceration can happen. In severe cases, trench foot can become a real medical issue. When these conditions set in, you will be at the mercy of your hurting feet.

So what happens when your feet are wet and cold and how can that affect your racing? As your skin becomes wet, it softens and becomes more susceptible to blisters. If a blister forms, it is more likely to rupture. The skin then separates further. Maceration happens when skin becomes soft and wet for long periods of time. When you take off your socks and find your feet look like prunes, this is what has happened. The skin is tender and can fold over on itself, separating and creating problems. As layers of skin separate, blisters spread, the skin becomes whitish in color, and it can split open and bleed. It is very hard to patch feet when this has happened. Feet become so tender that every step is painful. The first photo shows such a case.

Many athletes with macerated feet feel as if the whole bottom of their foot is blistered, as I mentioned above. In fact, there are often no blisters. The skin is so soft and tender that every step is painful. Many times the skin had folded over on itself or has lifted to form deep creases. These feet need to be dried as much as possible by removing them from the moisture source, applying drying powders, and exposing them to air. There is no quick fix for macerated feet.

Tips for maceration

Maceration of the skin can cause a great deal of pain and interfere with walking and running. These steps should be taken prior to exposure for the best effect:

  • Apply a beeswax and lanolin preparation such as Pro-Tech-Skin from Atsko or Kiwi’s Camp Dry, or Hydropel Sports Ointment, which is used by many adventure racers because of its moisture-repelling capabilities.
  • Coat your feet with Desitin Maximum Strength Orginal Paste.
  • Reapply the skin protectant at frequent intervals or when changing socks.
  • Warm your feet when stopping, resting, or sleeping.
  • When resting or sleeping, remove footwear, dry your feet, and allow them to air.

Tips for moisture

  • For high-intensity, fast-paced sports, lightweight and fast-drying shoes are the best bet.
  • If you wear shoes with a Gore-Tex fabric, remember your feet will sweat and create moisture inside the shoe-therefore moisture-wicking socks should always be worn. Note: Once a Gore-Tex fabric shoe has water inside from a stream crossing or other water source, it will stay wet inside for a long time.
  • Treat your shoes with a waterproof spray to protect the shoes from the elements and, in turn, keep your feet warmer.
  • If your shoes have a breathable upper, layers of duct tape over the upper can keep the wind and moisture out.
  • Wearing shoes that do not have adequate draining capabilities will subject your feet to extended periods of moisture. Use a heated nail or a drill to make a few small holes where your upper attaches to the lower part of your shoe or boot. Make one on each side of the heel and one on each side of the forefoot. Some athletes prefer holes in the sole of the shoe for faster draining.
  • Wear socks that are have moisture-wicking capabilities. Whatever socks you wear, change them frequently and dry the old socks.
  • Consider wearing waterproof socks. The best choice is SealSkinz socks.

Wet and cold feet can lead to long-term and even permanent disability. Even at temperatures above freezing, the combination of cold and moisture can lead to serious injury. Trench foot can occur even in mid 60-degree temperatures. The care of your feet in wet and cold weather is crucial.

Hydration, Dehydration, & Sodium – and Toenails

June 14, 2011 by · Leave a Comment
Filed under: blister care, Foot Care 

As long as we are on the topic of toenails, we need to review the effects of dehydration on our skin, which includes toenails. This subject is often overlooked by athletes.

Dehydration and the loss of important electrolytes can have a negative effect when hours of physical exercise cause stress to the extremities as fluid accumulates in the hands and feet. Fingers and toes often swell as they retain fluid because of low blood sodium (hyponatremia). This causes foot problems as the soft, waterlogged tissues become vulnerable to the rubbing and pounding as we continue to run and hike.

Make sure that you replace electrolytes, especially on long events. Drinking water or even sports drinks may not provide the proper replacement of sodium and other important electrolytes. The popular energy bars and gels may also be low in the electrolytes needed by the body.

Karl King, developer of the SUCCEED! Buffer/Electrolyte Caps, points out that the maintenance of proper electrolyte levels will reduce swelling of hands and feet even after many hours of exercise, and reduce “hot spots” and blisters on the feet. “When there is heat and humidity, the sweat rate is high and sodium is usually lost in significant amounts,” he says. “The sodium comes from the blood stream, and when the plasma gets too low, the body reacts to maintain the minimal tolerable level by pushing water from the blood into extracellular spaces. Thus, hands and feet swell. When the tissue on the feet swells, the feet become soft and more susceptible to blisters and damaged toenails. The feet swell inside the running shoes, putting extra pressure on the tissues, and those tissues can be rubbed to the point of physical damage. We see blisters form as layers of skin separate, and we see toenails move more, damaging the weakened tissues that normally anchor them.”

Ultrarunner Jay Hodde, a Badwater veteran, notes, “Proper hydration and well hydrated should not be used interchangeably. Being well hydrated with fluids says nothing about the sodium content of the fluid; both are important.” When you are well hydrated yet have low sodium, extra fluid accumulates in the tissues of the feet and the likelihood of blister formation increases. When you become fluid-deficient, the skin loses its normal levels of water and in turn loses its turgor. Then it easily rubs or folds over on itself, which leads to blisters.

Ultrarunner Rod Dalitz says, “I am convinced that electrolyte balance may be a big factor in blisters. With too much or too little salt, the layer just under the skin swells, and your skin is easier to disconnect from underlying tissue – which makes a blister.” Many athletes have found out the hard way that simply drinking a fluid replacement drink often will not provide the necessary electrolytes in the proper concentrations that the body needs. The use of a sodium replacement product in prolonged physical activity can help in the prevention of blisters.

Electrolytes and Black Toenails

Karl King emphasizes, “Black toenails are often a result of insufficient electrolyte management. Too little sodium makes hands AND feet swell. You can see your hands, but you can’t see it happening with your feet because they are in your shoes. When the tissues swell because they have excess water, the mechanical strength of the nail footing goes down. Then any movement will do tissue damage. Most of the damage is done in the second half of an ultra when electrolyte status is often thrown off if you don’t take care of it. Not many people get black toenails from a 15-mile run. Before I figured out electrolytes, I had black toenails like all of my ultra friends. After improving the way I handled electrolytes, my toenails gradually healed and black toenails were a thing of the past.”

Whether you have a 100 mile race on your calendar, or a 50 miler, or a marathon, make sure you manage your electrolytes and hydration level.

Footwear Professionals Speak out on Minimalist Shoes

June 4, 2011 by · 4 Comments
Filed under: Footwear, Footwear Products 

I subscribe to the Pedorthic Newswire newsletter. It is useful to keep me in the know about trends in the footwear industry from a pedorthist’s perspective. Here’s my description about Pedorthist in Fixing Your Feet:

Pedorthists work with the design, manufacture, fit, and modification of shoes, boots, and other footwear. Pedorthists are board certified (C.Ped) to provide prescription footwear and related devices. They will evaluate, fit, and modify all types of footwear. A C. Ped. can help find a shoe built on a last (the form over which a shoe is constructed) that best matches a person’s feet, and then construct a custom orthotic that meets his or her particular biomechanical needs and interfaces with the shoe in a way that improves its fit and performance.

In the June 1, 2011, issue of the Pedorthic Newswire, there were six answers to a question posed by a pedorthist. Here’s the question.

Question: I am seeing a lot of patients who are runners, wearing shoes like the Nike Free and New Balance Minumus. For many of these people, these shoes are completely inappropriate and actually causing problems, yet they insist on wearing them. Is anyone else encountering this and how are you handling it?

Now for an explanation about the answers. The first five are from pedorthists. They may or may not be experienced in working with athletes. But they know footwear and physical problems caused by wrong or bad footwear.

Response #1: We have also been seeing a great number of these athletes, as well as those wearing toning footwear that has been well marketed to the populous without consideration of the individual’s biomechanical needs. Video gait analysis has often been the answer. A talking head is quickly muted, and often overpowered, by marketing genius – however the visual of a flexible pes planus (flat feet) with huge torque through propulsion (and the resultant deformation of the foot and ankle in the patient’s eyes) is often the proof one needs to sway their opinion. For the blue Kool-aid runner who insists on wearing minimalist footwear in spite of their biomechanical challenges, assisting them with their training regime, or referring them on to someone who can, may be beneficial. Limiting their use to shorter runs could be suggested, and will keep them in the cool crowd.

Response #2: I would suggest telling your patients to try a pair of the Five Finger shoes or go barefoot when running. This exercises the feet and allows a more natural running gait.  We have seen in our practice that most running shoes, including the Nike Frees, give too much support and cause many tendonitis and fasciitis problems. If your runners usually run 6 or 7 days a week, have them run barefoot about 5 days and wear shoes only once a week for their long run.

Response #3: I like to take some history first. Usually, if we are seeing them, it’s because they are symptomatic in some way. The best approach is not to “attack” the shoe choice right away. Ask about the type of symptoms, the timeline, and what shoes they wore before and during their symptoms. As we know, runners can be some of the most challenging patients as far as treating them “between the ears.”

Some runners will listen, while others will kill themselves with a shoe if some expert, book or coach told them they were the best shoe for them. No shoe or style is a silver bullet for everyone. Unfortunately, like unstable toning shoes, minimal shoes are being presented as a great shoe for a large number of people. I use the eyeglass analogy. If I passed out 100 pairs of 1.75 corrective reading glasses to random people, I would get similar results. A certain percentage would have great results. Others would have marginal results. There would also be a given percentage that would have poor to awful results.

The good thing about eyecare is they have a standardized system of measuring and fabricating that doesn’t exist in our field. Some runners have the flexibility and biomechanics that allow them to adapt to minimal shoes. I may be over-simplifying it, but I chalk that up more to how they picked their parents and their DNA. On the other hand, some runners lack the ability to adapt to those shoes and that style of running. It’s also possible that some of the runners reporting amazing results could have simply been “over-shod.” Not bashing anyone, but about 90% of the runners I see who had an expert evaluate them, are in moderate to heavy pronation control shoes.

My experience with symptomatic runners shows that many of them should actually be in a neutral shoe. Perhaps these minimal shoes are nothing more than getting them closer (by default) to their actual prescription? If the runner is clearly doing harm with a minimal shoe, I ask them in a nice way why they are using them and what they are trying to achieve. Some responses make sense, but often it’s not a very valid reason, especially if it could be contributing to their symptoms. Again, runners can be quirky, so I rarely tell them something they are doing is terrible. If they are smart, they will put 2 and 2 together and make the right choice.

You can also wean a runner on or off those shoes (if they aren’t sure about them, or they are having poor results). One option is to suggest a traditional neutral cushion shoe instead. Some runners become symptomatic in a pronation control shoe with 250 miles on it. Imagine what can happen going from that to a minimal shoe, and one can see how some runners have awful results using these shoes. For the ones who are stubborn, I don’t lose breath arguing or trying to prove how smart I am. You will gain nothing by engaging in a circular debate with them. Wish them luck, and tell them to feel free to contact you if they develop any problems.

Response #4: I wonder what you mean by “inappropriate,” and what problems they are causing. I think the running shoe manufacturers have injured an entire generation of runners by claiming cushioned shoes with elevated heels will propel you further and faster. My personal experience with minimal running shoes is that there is far less internal rotation on the tibia and excessive pronation when you reduce the heel height and softness of the shoe. The acceleration of the foot moving to foot flat caused by heavy heel striking is likely the cause. I agree with Christopher McDougal (Born to Run fame) that the shoe manufacturers are to blame for most of the injuries in the sport. BTW, I do use orthotics in my minimal running shoes.

Response #5: I have been in the footwear industry for close to 30 years, and have seen the “barefoot” versus running shoe debate raised several times. Back during the beginning of the first running boon in the 1970s, only skinny ectomorophic types like myself, too small for football, were destined to be runners. The were plenty of plimsoll shoes to provide the protection needed for our sport of running. The 1970s running boom inspired by Dr. Kenneth Cooper, aerobic fitness studies, and the international success of American distance runners such as Frank Shorter and Jeff Galloway, drew “less gifted” participants into the sport of running. Back then, we egotistical runners referred to them as joggers. However, there was a need to develop running shoes to accommodate to protective needs of the rapidly diversifying running population. The choice materiea during those days was sheet stock EVA. It was light weight, and provided a blend of cushioning but rapid compression under repetitive loads. The only reason that the 24mm heel to 12mm forefoot ratio was deemed optimal was to alleviate Achilles tendinitis, and knowledge that the material compressed close to 50% under impact loads typically experienced during foot strike during running.

The current minimalist running craze has me equally concerned. While I do advocate some barefoot running to help strengthen and “awaken” the intrinsic musculature of the foot and lower leg, minimalistic footwear only addresses about 10% of the running population.  Today’s average runner maybe more athletically gifted, but there are also mesomorphic types who have participated in other sports and are entering the sport for the first time in their 20s and 30s. Minimal footwear does not offer sufficient protection for average larger framed runners. In our Lab we have found that running barefoot does effect footstrike by increasing the angle of plantarflexion at the ankle joint, however there is no evidence that changing footstrike pattern will reduce injury. In fact, we are hearing of more metatarsal stress fractures from runners attempting to adapt to minimalist footwear. Minimalistic footwear has always existed; we called them racing flats. How many average runners can successfully train in racing flats without experiencing injury? A strong voice from the foot care and Sports Medicine professions is needed to tame this fad. Run Healthy!

Response #6: The minimalist footwear movement has traction, and is not going away anytime soon. Many athletes, runners especially, are eager to try these new shoes in the hope it will improve their race times, or simply help them “feel” the trail. For some of these athletes, the shoes work. For others, they cause problems. Most of the time, it is because they buy the new minimalist shoes and try to run the same miles they ran in their older, heavier, and more supportive shoes. Occasionally, there are people who buy the shoes because they want to start running. For all these folks, reducing mileage and starting slow is the best advice you can give. Almost like starting over. You’re right, they see others doing it and read about the movement everywhere, and so of course it will be OK for them. And they are not going to stop.

Many shoe companies are adding a minimalist shoe(s) to their line. New companies are starting up with footwear that may be fine for walking – but not for running. Yet runners see these new shoes and figure less is better so they can run naturally and have a better feel for the earth. Again, reducing mileage and starting slow is the best advice, and to be attentive for possible injuries. And of course, educate them on the warning signs of possible injuries. If you have the opportunity to do a gait analysis, it would be helpful. Last summer I provided foot care at a six-day stage race where a runner ran 115 trail miles in the Colorado Rockies in Vibram Five Fingers. He did fine because he had a high base mileage as conditioning. His feet were in better shape at the end than many runners who wore “normal’ supportive and cushioned shoes.

My response was #6. Could you tell? What are your thoughts?

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