Shape Up! Your Guide to Lower Extremity Strengthening for Winter Activities

It’s no secret that your risk of injury decreases as your level of physical fitness increases. The older you get the less agile you become and the more important it is that you keep your body healthy, which includes eating right and exercising on a regular basis. Not only does a healthy lifestyle decrease your risk of injury with athletic activity, but also it decreases your risk of adult onset (Type II) diabetes, heart disease, high cholesterol…and the list goes on and on!

This guide will attempt to provide ideas for strengthening exercises to keep you going throughout the winter season. It will increase your ability to perform your best on the slopes and on the hiking trails while helping you to avoid injury. As always, it is important to consult your Primary Care Physician before engaging in any exercise routine in addition to staying hydrated and getting plenty of rest.

Cardiovascular Workout – Anything that can get your heart pumping and your body sweating constitutes as cardiovascular activity. “Cardio” workouts will increase your endurance and improve your overall strength, in addition to burning calories! Some easy and fun suggestions for this type of exercise include: walking with a friend around the neighborhood while catching up, taking your favorite “kick-boxing” class at the gym, or jogging with your dog after work. Twenty to thirty minutes, three times a week is an attainable goal.

Core Strengthening Exercises – Keeping a strong core will help increase you posture, place your center of gravity centrally in your body and improve your overall balance. Standard crunches on a mat and single or double leg-raises while lying on your back are great exercises for increasing core strength. Pikes and the use of an exercise ball for these core strengthening exercises increase the outcome, but are technically more difficult. Abdominal exercises have no minimum or maximum, so doing 3 sets of 25 in the morning and in the evening 6 days per week, will only make you stronger! For proper technique in performing the standard abdominal crunch and for other core strengthening exercises, click on the link below which will take you to a video from the MayoClinic.com (http://www.mayoclinic.com/health/abdominal-crunch/MM00725)

Thigh Strengthening Exercises – Step-ups, squats and lunges are all exercises that are great for strengthening your quadriceps, hamstrings and gluteal muscles and will help protect your knees from injury. It is important that you remember to stretch and strengthen both the anterior and the posterior muscle groups of the thigh equally. If one group overpowers the other it can lead to patello-femoral pain, which is pain in the anterior part of the knee or pain posteriorly located behind the knee. To see a video on how to properly perform these exercises, please click on the link, as it will redirect you back to the MayoClinic.com (http://www.mayoclinic.com/health/squat/MM00724)

Calf and Ankle Exercises – Increasing your calf strength and the strength of the muscles passing from the leg, across the ankle joint and into the foot will improve balance as well as decrease your risk of high-grade ankle injuries, plantar fasciitis and tendonitis among others. Simple exercises for the calf include jump-roping, single-limb heel raises with your heel hanging off the edge of a stair (3 sets of 15 reps each side), and a weighted toe raise. The weighted toe raise can be done with something as simple as a sack of potatoes hung from the mid-foot with the leg at 90 degrees and dangled over the edge of a table. Pull the toes up towards your head, hold for 3 seconds and then lower the toes back to neutral; repeat for 15 repetitions, 3 sets. Exercises for the ankle focus on stability and include a single-limb stance with the knee slightly bent held for 30-45 seconds. Balance boards, used under the instruction of a trainer can also be effective for increasing ankle stability and decreasing your risk of injury. For fun, lie on your back with one foot in the air and trace the alphabet with your foot. When you get to “z” switch to the other side.

The thigh and calf exercises can both be completed on the days in between your cardiovascular workouts, in sets of 3, 15 repetitions for each exercise. It is important that you give yourself at least one, if not two days a week for rest and recovery period so that you don’t fall victim to overuse injuries. Should you start to feel pains that feel out of proportion on one side of the body versus the other, consult your Podiatrist or Primary Care Physician for a referral and discontinue all exercise until further investigation can be completed.

“What Not to Wear”…5 Tips for Keeping Safe and Choosing Appropriate Winter Gear!

As temperatures drop and snow begins to fall across the country, winter snow gear, sleds, skis, snowmobiles and ice fishing gear are being pulled from the closets. So, what is it that you need to know this winter about keeping your feet safe, warm and properly outfitted?

1. Safety: The most important thing to keep in mind is safety and not just regarding your feet, but also protecting your head. Make sure that when you head out to engage in winter fun, you dress warmly, wear your helmet and follow safety guidelines. Know the temperatures, mountain conditions, weather forecast and your abilities all before leaving the house. If you are new to the sport, it is also important that you take a lesson to ensure your safety and the safety of others.

2. Blended Wool not Cotton Socks: By design, cotton is a material that absorbs and retains moisture. With any activity, feet tend to sweat and those cotton socks you’ve been wearing won’t do anything to keep your feet dry. Wet socks lead to decreased foot temperatures and increased incidence of friction, blisters, and ulceration especially in the diabetic population. Wool has a tendency to wick away moisture, so that is a much better option over cotton. Polypropylene and other synthetic fibers also trump cotton in wicking away moisture.

3. Choosing the Right Boots: Whether your skiing, snowboarding or heading out to build a snowman with your family, you need to have boots that are designed and fitted for your sport. Make sure that when you try on a boot, it fits along the foot maintaining appropriate circulation but slightly snug so that when the boots “break-in” after several wears, they still fit. They should be properly padded around the ankle and they should never be too stiff. Finally, try boots on before you make the purchase!! It sounds ridiculous, but many patrons do not try on a pair of boots before they hand over their credit cards and are simply buying based on the style and color of the boots. This is a major no-no! Put them on, run around the store, kneel down and stress the boots as they will be stressed once you get them home. If they feel comfortable after all that, then its safe to add them to your closet.

4. Custom Foot-Beds: First and foremost, do not put custom orthotics, made for running and hiking into your ski and snowboarding boots. Your custom orthotics CAN be inserted into snow boots for shoveling and trekking to the convenient store and they CAN be transferred into your snowmobiling boots, and sledding gear. The reason they should not be inserted to skiing or snowboarding boots is that in those sports you are not moving through the traditional phases of the gait cycle. Skiing and snowboarding puts the body, legs and feet into mid-stance thus forces across the foot that occur with walking and running are completely different than those that occur during skiing. If you are having pains in the feet and/or knees with your winter activities, see your local podiatrist and bring your boots along with you. Custom orthotics can be fabricated to support your foot in mid-stance thus providing proper alignment while engaging in activity.

5. Keep in shape: Next week we will be discussing off-season and in-season strengthening exercises to keep you strong throughout the winter season. Staying in shape for the activities which you plan to engage in will keep you safe and allow you to engage up to your abilities without overshooting and injuring yourself.

Take Two: Common Winter Sports Injuries

1. Frostbite: Frostbite occurs when there is decreased blood flow and decreased heat delivery to the toes, but can also affect the fingers, nose and ears. Ice crystal formation takes place in the affected areas and depending on the severity of the injury can involved tendons, nerves, muscles or even bone. Symptoms include numbness, tingling, burning or loss of sensation to the area and color changes may be noted. Prognosis depends on the extent of the injury and determining this may takes weeks. In some cases amputation may be necessary or in less traumatic cases, increased prevention for reoccurrence is the only treatment. To prevent frostbite, make sure to take frequent hot-chocolate breaks from being out in the cold temperatures and investing in foot warmers to be placed between your socks and your boots will also be helpful!

2. Ankle Fractures: Ankle injuries, including sprains, strains and fractures are very common in the winter months as icy and snowy conditions lead to increased incidence of falls. According to Lauge-Hansen, an Ankle Fracture classification system, there are 4 main categories of ankle fractures classified by the position of the foot and the motion that takes place as the fracture occurs. The most common ankle fracture is classified as “Supination External Rotation” fracture (SER); meaning there is inward rotation of the ankle while the leg and body move in the opposite direction. In the most severe SER ankle fractures the tibia and fibula (bones of the leg) are broken and the ligaments surrounding the ankle are ruptured resulting in dislocation of the ankle joint. Patients suffering this type of injury will need surgical intervention to realign and stabilize the bones with internal hardware (pins and screws) in addition to repairing the ruptured ligaments. Be prepared for at least 6 to 8 weeks of complete immobilization. Preventing ankle fractures starts with wearing winter boots that have suitable traction on the bottom. Watch where you walk, and if it’s not necessary to leave the house during icy conditions, stay home and watch you’re favorite holiday movie!

3. Calcaneal (Heel) Fractures: Calcaneal fractures are less common than other type of the injury to the foot, but in the event that they do occur, they are severely debilitating. This type of injury is caused by a high impact vertical force that can occur after jumping out a window or more realistically, a fall from a ladder while hanging holiday decorations and lights! Calcaneal fractures present with severe pain and “Mondors Sign:” severe bruising of the heel that extends to both the medial (outside) and lateral (inside) areas of the foot. Due to mechanism of injury, patients often suffer associated injuries including spinal fractures. The treatment for Calcaneal fractures is much the same as that for Ankle fractures: surgical repair is necessary with the use of internal hardware and long periods of immobilization. Make sure that when you are hanging decorations this holiday season, you have a helper with you that can stabilize the ladder you’re climbing, preventing a fall.

As mentioned last week, taking preventative measures will decrease the incidence of injury, especially during the winter months. Consult your Podiatrist if you have any concerns or need suggestions for selecting appropriate “winter gear.” If you do experience a traumatic injury, get yourself to the Emergency Room as soon as possible, or call your Podiatrist for an emergency appointment.

Weekend Winter Warriors

Thanksgiving marks the beginning of many holiday traditions including pick-up football games, hanging holiday lights and family ski trips. It is during this time of year that injuries commonly see in athletes playing high impact sports are seen in the everyday business man or woman: the “weekend warrior” type of individual.

The injuries that make the newspapers are unfortunately the more life-threatening injuries, but those suffered in the lower extremity can also be quite detrimental to a person’s quality of life. Over the next two weeks, I will break down some of the common injuries experienced in the winter months, how they are treated, and what can be done to prevent them.

1. 5^th Metatarsal Fractures: This is a fracture of a long bone in the forefoot that connects to the 5^th toe. This type of fracture is typically associated with an inversion ankle sprain, which occurs when the foot flexes downward and the ankle rolls inward. Inversion ankle sprains can occur with normal activities such as walking, and are common in pick-up sports such as football and basketball. There are five types of 5^th metatarsal fractures, but the most commonly seen is an Avulsion Fracture. Avulsion fractures occur when the tendon (proneus brevis) attached to the base of the 5^th metatarsal bone, sharply contracts during an inversion sprain and avulses, or pulls off a piece of bone. Treatment includes RICE* and immobilization for 4-6 weeks in a below knee cast, where the patient should remain non-weight bearing. Prevention for this type of injury can include strength training with a physical therapist as well as strapping or bracing of injury prone ankles prior to athletic activities.

2. Boot-top Fractures – Fractures of the Tibia from Ski Boots: “Boot-top” injuries occur when skis do not release from the ski boots during collisions. The skiers body continues forward while the boots remain fixed to the snowy surface. The tibia and often times the fibula (the bones of the leg) will fracture when enough force is applied. This type of injury often requires reduction, meaning the bone pieces need to be realigned, and often times surgery is required in order to stabilize the bone. The patient will be immobilized for at least 6 weeks in a below knee cast, where the patient must remain non-weight bearing. Taking care to have properly fitted and adjusted ski boots can help decrease the risk of “Boot-top Factures,” along with ensuring that the boot release is appropriate for the level of skill of the skier. Ski lessons for beginners are also a must!

Although these types of injuries are relatively rare, you should be aware of them and take preventative measures to ensure your safety! If you do experience injury to the lower extremity make sure to seek medical attention immediately, whether that be by going to the Emergency Room or by calling your Podiatrist to make an immediate appointment.

Don’t forget to check back next week for more “Winter Warrior” injuries explained!

*RICE: Rest, Ice Compression and Elevation

What is Diabetic Neuropathy?

In 2002, according to the National Institute of Diabetes and Digestive and Kidney Disease, approximately 65% of those living with Diabetes also had some degree of correlated neuropathy. In many cases it is the symptoms of neuropathy that lead to the diagnosis of diabetes, because these symptoms indicate to the patient that there may be a larger disease process occurring.

Neuropathy by definition is disease or dysfunction of one or more peripheral nerves that typically causes numbness, weakness, or both. It is thought that a combination of factors adds to the incidence of neuropathy in diabetic patients, but it is directly related to poor sugar control. Nerves are very sensitive to change and when blood sugars are high, the sugar molecules tend to glycosylate both the small blood vessels and the small nerves. This glycosylation compresses the nerve to some degree and results in the symptomatic representation of neuropathy.

Several categories of neuropathy affect the diabetic population, but the most common type is Peripheral Neuropathy. Peripheral Neuropathy is also known as distal symmetric neuropathy, meaning symptoms present first in the toes and fingers on both the right and left sides of the body. As the neuropathy progresses it continues along the foot and hand towards the arms and legs. The sensory changes are minimal and at first may go unnoticed, but as the neuropathy progresses symptoms become more discernable. The best was to prevent and control the progression of diabetic neuropathy is to keep your blood glucose levels within normal range, thus protecting your nerves from glycosylating.

Comprehensive foot examinations by your Podiatrist can help diagnose peripheral neuropathies in the early stages and it is important to remember that if you are experiencing any changes in sensation to your toes or feet, you see your doctor immediately. Your Podiatrist will look for changes in light and sharp touch, vibration, reflexes and your ulceration risk. All of these components can hold clues to an early diagnosis of peripheral neuropathy.

If you have already been diagnosed with neuropathy it is still very important to follow-up with your Podiatrist for routine care, but more importantly to be doing your part at home. You must check your feet on a daily basis for any open areas, especially between the toes and for any color changes that may indicate problems. The largest complication associated with having diabetic neuropathy is the patients inability to feel, thus injuries that would be painful in a non-diabetic go unnoticed in a diabetic and can lead to ulceration, infection, and loss of digits. If you notice something unusual or different from the previous day, contact your Podiatrist for an appointment.

Get A Move On!

Exercise regimens are important for any individual, but are of increased importance in the diabetic population. It has been shown that exercise lowers blood sugar levels and improves the body’s ability to use glucose.

During exercise in the non-diabetic individual the muscles of the body demand increased fuel sources, thus they turn to glycogen stores in the muscles themselves. If additional fuel sources are needed, the muscles will use glucose from the blood stream and eventually the liver, where glycogen is converted to glucose or stored proteins and fats will be used to supply energy.

In the diabetic patient this process isn’t as efficient. This by no means gives you a ticket out of exercising, but must increase your awareness in selecting exercises that are most appropriate.

Your exercise regime should be focused on increasing flexibility and maintaining proprioception. Proprioception is the body’s ability to feel that the ground is beneath your feet. When proprioception is lost, which occurs often in the diabetic patient, the risk and incidence of falls increases. Below are several exercises that will both increase flexibility to decrease deformity as well as increase proprioceptive reflexes to decrease risk of injury.

• Cardiovascular Exercise – this is exercise that makes you sweat and increases your heart rate, but should be low impact. Good options for “cardio” include walking, stationary bike, swimming or jumping rope. (20 minutes)
• Sit to Stand – Sitting in a chair with your knees bent at a 90-degree angle raise yourself from the chair without using your hands. Lower yourself down and repeat. If you feel unsteady, try to use just one hand for support. (3 sets of 10 repetitions)
• Seated Single Leg Raise – Sitting forward in a chair with your knees bent at a 90-degree angle, straighten the right leg at the knee elevating the foot off the floor, hold for 3 seconds and return to the start position. Repeat on the left leg. (3 sets of 10 repetitions)
• Calf Stretching – Facing the wall, place your hands onto the wall in front of you, place one foot forward with knee bent and one foot back with the heel touching the ground. Lean into the wall keeping the back leg straight and the heel on the ground. Hold for 10 seconds, relax and repeat. After 10 repetitions switch legs. (3 sets of 10 repetitions on each leg)
• Tandem Repeats – Standing close to a wall with feet shoulder width apart, place one foot in front of the other and hold for 5 seconds, return to start. Repeat on the other side to complete 1 repetition. For increased proprioception, close your eyes and try to complete this exercise. (3 sets of 10 repetitions)

The U.S. Government recommends a minimum of 5 days per week of appropriate exercise, but 3 days a week, or even 2 days a week are better than none. Remember to do as much as you can without overdoing yourself! If you experiencing calf pain, referred to as claudication pain, during exercise and you find yourself traveling shorter and shorter distances daily, you need to see your Podiatrist immediately. This could indicate decreased blood flow to your lower extremities and demands further vascular investigation.

So, get out there and get exercising!

Do I Really Need to Wear Those Ugly Diabetic Shoes?

When I tell my Diabetic patients that I would like to prescribed them a pair of Diabetic Shoes, they automatically get that look on their face, as if to say, "no way am I going to wear Diabetic shoes." I can assure you, the choices on Diabetic shoes have drastically improved over the past 10 years, and some pairs are quite stylish. The question that comes into play, is why do I have to wear Diabetic shoes, when my everyday sneakers are comfortable and stylish? The answer: Everyday sneakers that are not specifically made for Diabetic patients don’t offer enough support nor enough cushioning in the areas necessary to help prevent ulcerations and other complications in the Diabetic foot.
Your Diabetic shoes will be specifically sized to fit and accommodate you and your foot type. Adjustments can be made to accommodate for depth and width of both the insole of the shoe and the toe box area. You can rest assure that your pair of Diabetic shoes will be one of a kind made especially for you!
Adequate cushioning is another added benefit of specially made Diabetic shoe gear. Typically, your shoes will come outfitted with a removable insole that has been made to accommodate your plantar foot shape. This increases the comfort of the shoe with walking and standing, but also decreases pressures on the bottom of your foot, which other types of shoes cannot provide. Ultimately, this decreases your ulceration risk.
Airflow in and throughout your Diabetic shoes is an extremely important aspect that they can provide. Breath-ability prevents the feet from becoming hot, sweaty and damp. Damp and sweaty skin is something that we want to prevent in Diabetics because those areas of the skin can blister easily and lead to breakdown underneath.
Finally, the lining in your diabetic shoes will be seamless. This is important because again, it provides fewer areas for irritation and pressure on the foot and reduces your risk of ulceration. It should be emphasized that wearing Diabetic socks, those that are more wool than cotton and seamless, is important to the success of ulceration prevention and increased Diabetic foot health.
Most patients are covered through their Insurance carriers for one pair of Diabetic shoes per year, so it’s important to take advantage of this benefit. Wearing properly fitting and adequately off-loaded Diabetic shoes, which are much more stylish these days than they used to be, is extremely important in improving your foot health and decreasing your risk of Diabetic foot complications.

5 Daily Steps to Decrease Your Risk of Diabetic Foot Complications

Prevention is by far the best option patients have in protecting themselves from diabetic foot complications. The nature of the disease predisposes patients to decreased neurovascular signs (decreased blood flow and decreased sensation) in the small vessels and nerves. Through daily management, many of the complications of Diabetes in the lower extremity can be prevented and/or minimized. So, what things can you do on a daily basis to decrease your diabetic foot complication risks?

1. Proper Nutrition and Exercise: Maintaining a healthy diet and exercise routine (30 minutes 3 times per week) not only makes you feel good, but also keeps your weight down, and ensures that you are taking in all the necessary nutrients. There are many vitamins in your healthy diet, including A, C and D, that will increase the integrity of your skin decreasing your chances of breakdown and increasing your chances of healing.
2. Checking your blood glucose levels at least once, if not twice daily: It is important to maintain your blood glucose levels within a healthy range to prevent complications of Diabetes. You want to ensure that your pre-meal glucose levels are between 90-130 mg/dl and your post-meal glucose levels are less than 180 mg/dl.
3. Take your medications as directed: Medications prescribed by your doctors are important in controlling your co-morbidities, which may have a tendency to increase your diabetic complication risks. By maintaining your cholesterol, blood pressure, and glucose levels through prescription medications, diet and exercise, you can decrease your risk of ulceration and future complications related to Diabetes.
4. Daily examinations of your feet: You are your best resource for catching early signs of skin breakdown, ulceration, and infection. The earlier you detect areas of concern and make an appointment with your Podiatrist, the faster you will receive treatment and the less likely you are to have an increased risk of associated complications. Make sure you are never walking around the house without supportive shoes, you are washing all areas of your feet, including in between your toes, and drying those same areas thoroughly. Do not soak your feet in warm or hot baths, as this increases the chance that bacterial will grown on your feet and in between your toes, leading to future complications. Do not attempt to perform "bathroom surgery" for trimming of corns, calluses or nails. Leave the trimming and nail care to your Podiatrist.
5. Quit smoking: Smoking has a tendency to increase your heart rate and your blood pressure, while decreasing the amount of oxygen traveling with your blood cells to your extremities. The decreased flow of oxygen to your extremities decreases healing and increases your risk of complications should an ulceration arise.

Be sure to follow-up with your Primary Care Physician every 3 to 6 months for monitoring of blood glucose levels, HbA1c levels, and of your cholesterol and blood pressure. Make sure you check in with your Podiatrists every 6 months, or every year if you are a low-risk Diabetic patient, for prevention and management of any complications that may present in the lower extremity.