HbA1c and Me: How does my HbA1C Level Reflect upon my overall Diabetic Glucose Control?

The Hemoglobin A1c (HbA1c) blood test measures glycosylated hemoglobin, indicating your average blood glucose levels over a 90-day period. Hemoglobin carries oxygen through your body using your Red Blood Cells (RBC’s) as its vehicle. As your blood glucose levels rise above normal, sugar combines with the hemoglobin molecules and your blood cells become “glycosylated.”

The average life span of an RBC is 90 days, at which time they are shed from the body via the spleen and new RBC’s are formed. Once the hemoglobin has become glycosylated, it will remain that way for the entirety of its Red Blood Cells life span. Therefore, when your blood is drawn and an HbA1c level is tested for, it will show the average amount of glycosylation in your blood via the hemoglobin molecules. Essentially indicating your average blood glucose level and how well you have been doing in controlling your diabetes over a 3-month period (90 days).

In patients without diabetes, the normal HbA1c level is between 4% and 6%, with an average daily glucose level of 90mg/dL. For the diabetic patient remember: “7 and below is the way to go!” Your Podiatrist and your Primary Care Physician are looking for your A1c level to be below 7%, as that indicates that over a 90-day period your average daily blood glucose level has been around 170 mg/dL. HbA1c testing is a foolproof way for your doctor to gain an accurate picture of your sugar control over a longer period of time than just on the day they see you in their office. Thus, fasting or eating healthier and controlling your sugar levels the day or two before heading to the doctors for your blood test, will not be effective in lowering your HbA1c level. It is a more accurate way of gauging your glucose control and overall control of your diabetes.

The chart below outlines the average blood glucose levels that correspond to your Hemoglobin A1c level. As you climb the chart in your A1c percentage, it shows that your average blood glucose levels are increased over a 90-day period and the risk of complications from diabetes become greatly increased.

HBbA1c Average Blood Glucose Level
12% 345
11% 310
10% 275
9.0% 240
8.0% 205
7.0% 170
6.0% 135
5.0% 100
4.0% 65

The higher your A1c, the more glycosylated your RBC’s become, the more uncontrolled your diabetes has been, and the higher your risk of complications stemming from the disease becomes. Some of those complications include diabetic neuropathy, retinopathy, kidney complications and decreased blood flow to the hands and feet! Control of your blood glucose level is the best tool as a diabetic patient that you have in decreasing your risk of long-term complications, and it is something that once you pay close attention to long enough, maintaining your levels will become second nature. Over the next 3 months I challenge you to control your glucose levels so that on your next HbA1c testing, your “day- of” glucose level will match that of your 90 day average!

As an aside, it is important to remember that Hemoglobin A1c levels are not to be confused with standard blood hemoglobin levels, which indicate your body’s ability to transfer oxygen from the lungs to the tissues, and carbon dioxide from the tissues back to the lungs for expiration.

Hammering Out Your Hammer Toe!

Last week we discussed 3 types of digital deformities: Hammer toes, Mallet toes and Claw toes. They are very similar and treatment for each is much the same, but they can be distinguished from one another by the involved joints. The most common complaint with these deformities relates to areas of increased pressure and formation of a corn with resultant pain. Eliminating pressures on the top of the toe is usually the goal of treatment and there are various ways in which to have success. Conservative treatments can include periodic trimming down of the corns, padding of the toes and strapping the affected digit to a “neighboring” toe in attempt to straighten out the deformity. Wearing shoes with a roomier toe box can also be effective making hammer toes easier to manage and live with. When conservative treatment fails or is not an option, surgical options are available.

Much the same as surgical correction for bunion deformities, hammer toe surgical correction involves a choice between a soft tissue, boney or fusion procedure. The selection of one procedure over the other is a decision that your Podiatrist will make based on their clinical judgment and your level of discomfort. Each procedure aims to bring the joints involved in the deformity back into correct alignment resulting in straightening of the toe and reduction of pain.

Soft Tissue Procedure: A soft tissue procedure used for surgical correction of a hammer toe attempts to release the capsule surrounding the joint as well as release the tendons entering the toe so that the bones are free to straighten out into their correct position. Often times the digit contracts due to muscular imbalance, thus releasing the tendons of the involved digit essentially eliminates the imbalance. It is common practice during these procedures to have the corn, located on the top of the toe, removed decreasing pressure and reducing pain. Soft tissue procedures are used alone in the presence of mild deformity where the patient complains of pain without significant boney involvement. However, when a more aggressive boney or fusion procedure is used for surgical correction, as described below, a soft tissue procedure is also performed.

Bone Procedure: A boney procedure is one that requires cutting the bone and eliminating a portion of the bone involved in the deformity. Depending on the joint affected (whether you’re dealing with a hammer, mallet or claw toe), one or two of the three bones within the toe will be cut and a portion of that bone removed. In the classic hammer toe where the middle joint is affected, a portion of the bone closest to the body of the foot will be removed, decompressing the joint and allowing the toe to straighten. A pin will be placed into the toe for 4 to 6 weeks holding the corrected position until the surrounding soft tissues have healed. Keep in mind that because a portion of the bone within the toe is being removed, the toe will end up a little shorter than it started out.

Fusion Procedure: A fusion procedure is used when there are multiple joints (remember there are 3 joints within each toe) involved in the deformity and when the hammer toe is considered to be rigid, or non-flexible. A fusion removes any material within the joint space that is destroyed and allows the bones within the toe to be straightened out and brought together by pin fixation over 6 to 8 weeks. Fusions eliminate motion at the joints within the toe, so it is important to remember that after the procedure you will no longer have a contracted digit, but you will also no longer be able to bend the toe as you were prior to the surgery.

The risks and benefits of surgery must be weighed and discussed with your Podiatrist prior to consenting for a procedure, and it’s always wise to attempt treating your hammer toe conservatively first. If you decide to move forward with surgical intervention your period of recovery will range anywhere from 2 to 8 weeks with the ultimate goal being reduction of pain and straightening of the toe to prevent excessive pressures.

HAMMER, MALLET OR CLAW, OH MY!

Hammer toes, Mallet toes and Claw toes are three types of digital deformities of the foot that are extremely similar, yet vary from one another depending on the joint within the toe that is most affected. The term “hammer toe” is often used to encompass all three deformities, but they are distinct entities. To make the distinction relatively simple, remember that each of your toes, numbers 2 through 4 have three joints. In a hammer the middle of those three joints is the cause of the deformity, where as in claw toes it is both the middle and end joints and for mallet toes it’s only the end joint.

Digital deformities of this type are typically a result of muscular imbalance within the foot. What does that mean? Each of us is made with a different foot type and although some of us are perfect, or have perfect feet, we only make up about 20% of the population. That means that the other 80% of the population have a foot type that predisposes them to some type of deformity during their life; whether that be hammer toes, bunions, flatfeet etc. If you think about those statistics, abnormal is normal and normal is abnormal when talking about our feet! Either way, your body and more importantly your toes attempt to compensate for the muscular imbalances within the foot to increase foot function, and as a result they hammer, or contract at one or several of the joints within the toe.

Some less common causes of hammer, mallet or claw toes include joint diseases, such as rheumatoid arthritis, spinal cord or nerve injuries which weaken the muscles within the foot, decreased blood flow and decreased feeling in the toes, and a history of trauma to the toe such as fracture.

Prevention of digital deformity is much the same as preventative methods for development of bunions (hallux abducto valgus), which we discussed over the last two weeks. The etiology of the deformity must be identified early and corrected so that the foot never needs to compensate for that abnormality. Certainly wearing comfortable and supportive shoes, contrary to shoving toes into “pointy-toed” stilettos will decrease your chances of developing hammertoes, but it is a deformity that is much less predictable for occurrence than some other more debilitating and noticeable deformities of the foot.

The primary patient concern with this type of deformity includes corns that develop on the top of the affected digit and increased pain while wearing shoes due to increased pressure over the toe. It is likely and prudent that your doctor will suggest conservative treatments prior to any surgical interventions, although both are viable options. To decrease such symptoms conservatively and make the deformity more manageable, your Podiatrist can trim the corns down. By taking down the dead skin, the pressures over the toe will become less and pain will also decrease. Your Podiatrist will also recommend padding of the toe to eliminate pressure created between your toe and the shoe. They may use a strapping device that will “buddy” the toe to a more stable digit, bringing it down into line with the other digits. Of course, wearing shoes with a wider and roomier toe box will alleviate pressures and decrease pain as well. Injection therapy is not a conservative treatment that is offered due to the size of the digit and the minimal degree of relief that it may provide.

If patients can tolerate padding in their shoes and occasional trimming of their corns, conservative care of the deformity can provide a long-term result. It is likely that decreasing such pressures will decrease symptoms and hammer toes can become quite manageable conservatively! If all conservative treatments fail and you are ready to consent for a surgical approach to fixing your hammer, mallet or claw toe, your Podiatrist can certainly recommend something that will reduce pain and pressures. Next week we will discuss the surgical options for treating your deformity including what to expect after surgical correction.

Should I Have My Bunion Repaired?

This week we will focus on the types of surgical procedures used to correct painful bunion deformities that have not responded to conservative care. To reiterate, conservative treatment options should be considered and exhausted when possible before surgery becomes a reality. Types of conservative care include injections, padding/offloading and orthotic therapy. When conservative therapy fails your Podiatrist may recommend surgical correction through one of the procedures described below in attempt to realign the big toe and decrease the level of pain you have been experiencing. It is important to keep in mind when reviewing these procedures that your Podiatrist will select the right procedure for you based on the severity of your deformity.

Soft Tissue Procedures: A soft tissue procedure used for bunion correction is one that attempts to release any tendons and tighten the capsule around the involved joint, both of which are involved in deviating the big toe towards the lesser toes. By releasing these pieces of soft tissue the bones within the big toe will straighten out, align with the lesser toes and decrease the space that has been created between the first and second long bones in the foot. Typically, these procedures are used on patients who have mild deformities and minimal pain over the bump on their big toe. Soft tissue procedures can be performed alone, but are always performed when more corrective procedures are also performed.

Bone Procedures: There are two types of bone procedures that can be used to correct your bunion deformity. There is one procedure where cuts are made into the first long bone of the foot and another procedure where cuts are made in to one of the two bones in the big toe.

Procedures that make cuts into the first long bone of the foot are used for moderate deformities where there is a more significant deviation of the big toe towards the lesser toes. Patients who require such procedures typically have moderate pain that would not adequately reduce with only a soft tissue procedure. In bone procedures, a “V-shaped” cut is made in the first long bone of the foot allowing the bone to be shifted over, aligned with the lesser toes and held in place with a pin or screw.

Procedures that make cuts into one of the two bones in the big toe are used when one of those two bones are a contributing factor in the deformity. A wedge cut is made in one of the bones in the big toe and the bone is de-rotated and properly aligned with the long bone in the foot as well as with the lesser toes. It is stabilized with a pin or screw; the same pin or screw being used for fixation of the bone cut made in the long bone of the foot as described above.

Fusion Procedures: A fusion procedure is used when patients have big toe joints that are arthritic and destroyed, thus they cannot function even if the bones are placed in a corrected position, as would be done with a bone procedure. A fusion procedure removes any material within the joint space that is destroyed and places the long bone in the foot and the first bone in the big toe together, end-to-end. A pin or screw is used for fixation and after 6-8 weeks of healing, the joint is fused and motion is permanently eliminated. Elimination of movement at the joint significantly decreases pain in patients with such conditions.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist. Complications with any of the bunion procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. Patients should expect anywhere from 2-8 weeks of recovery depending on the procedure selected and they should expect pain during recovery; although pain is a personal thing and depends on the patients tolerance!

Bunions are Genetic, Aren’t They?

This question can be heard multiples times per week in a Podiatrists’ office, and the answer to the questions is: No, not exactly! Bunions have a variety of etiologies that can act alone or in combination with one another causing deformity of the first ray (1^st metatarsal and bones of the 1^st toe). Just because Mom or Pop may have a bunion, you didn’t inherit your bunions from them, you inherited their abnormal foot type.

Lets take a step backwards for a minute and talk about what exactly a bunion is. Hallux Abducto Valgus (bunion) is a triplanar, progressive deformity of the first metatarsal in which the hallux (great toe) is deviated towards the lesser toes (abducted) and rotated (valgus). HAV is one of the most common pathologies found in the lower extremity and is found in females more often than males by about a 4:1 ratio.

The most common etiology can be classified as a biomechanical abnormality: any condition whereby the 1^st ray cannot function optimally in comparison to the normal or rectus foot. This encompasses a variety of pathologies including a hypermobile first ray (excessive motion of the 1^st metatarsal and its articulations within the foot), inflammatory conditions of the 1^st joint, neuromuscular diseases, an elevated first ray (met primus elevatus), and metatarsus adductus (medial deviation of metatarsals 2-5), to name a few. These inherited conditions prohibit the foot from functioning optimally and your body is forced to compensate for such abnormalities leading to the formation of a bunion. Thanks Mom and Dad!!

Some other less common etiologies of Hallux Abducto Valgus include post-surgical malformation, equinus (inability to dorsiflex the ankle greater than 10 degrees past neutral), limb length discrepancies, and a history of trauma to the hallux.

To prevent the occurrence of bunions, one of the predisposing conditions must be identified and corrected early on, or avoided all together. Unfortunately, this is not typically the case with inherited biomechanical abnormalities. The conditions go unnoticed or are brushed-off as something that the child will “outgrow.” Most pediatric foot abnormalities will not be outgrown and early evaluation and identification of a pathology by a Podiatrist can allow the child to be monitored and/or treated conservatively throughout their development.

Treatments options include a vast array of choices from conservative to surgical and the choice depends largely on the patients pain and discomfort in combination with a physical and clinical examination of the condition. Your Podiatrist will ask you a variety of questions to determine how fast the deformity is progressing and what methods of treatment, if any, you have previously tried. They will examine the deformity clinically to determine where the pain is localized, the degree of soft tissue involvement, the condition of the joint, the rigidity of deformity, and the underlying etiology. Your Podiatrist will also take bilateral radiographs of your feet to evaluate the joint and bone positions in comparison to “standard” radiographic angles.

Once all the pieces of the examination have been considered together, it is most likely that conservative options will be exhausted prior to surgical intervention. Conservative treatments include: injections to decrease inflammation and alleviate pain; padding of the toe to decrease pressure with shoes; physical therapy to increase the range of motion at the joint and eliminate muscular imbalances that may be a causative factor; and orthotics, which attempt to realign the foot in a more optimal position decreasing the biomechanical abnormality that may be the root etiology of your HAV.

If the deformity is rigid and severely progressed, or if conservative treatments have been exhausted without resolution of pain, surgical options become a consideration. Next week we will discuss the types of surgical procedures that may be performed in treating your bunion, the pros and cons of such surgeries and the pre-operative and post-operative courses that should be expected.

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.