Diabetes and Equinus – An Overlooked Combination
Diabetes patients are, according to pertinent studies, are more likely to suffer with equinus. I discussed these studies in a post at PodiatryToday.com entitled “Why Do We Overlook Equinus in Patients in Diabetes.”
Yet, it seems that too often diabetic patients are treated for mycotic toenails and we debride these nails and their calluses, thrust them into diabetic shoes and orthotics, while telling them to pay attention to their feet and beware wounds.
In the article I discuss these choices and challenge you to research, study your patients. See if you too find that too many diabetic patients are showing equinus symptoms which are being neglected. These patients deserve better and we as doctors of podiatric medicine have the skill and expertise to give them relief.
I again challenge you to read the articles:
Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. By WP Grant, R Sullivan, and DE Sonenshine, et al. J Foot Ankle Surg. 1997; 36(4):272.
Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. By LA Lavery, DG Armstrong, & AJ Boulton – J Am Podiatr Med Assoc. 2002; 92(9):479.
Tendo Achilles lengthening and its effect on foot disorders. By TE Sgarlato, J Morgan, HS Shane, A. Frenkenberg – J Am Podiatry Assoc. 1975; 65(9):849-71.
These studies have findings of the frequent combination of diabetes and equinus symptoms. More findings discuss treatment and relief for the diabetic patient. We have the opportunity to learn and improve our practices. We have the opportunity to put the patients into a brace and get them started toward recovery.
Four Ways to Care for Diabetic Feet in Cold Weather
Cold weather adds a different aspect for your feet if you are living with diabetes. As the weather cools off and you’re looking for warmer footwear you can make plans that will make foot care easier. Preventative care can avoid many sad issues.
Shoes: You are not defined by the way your shoes look – go for fit first. Remember that you look downward at your own feet, so maybe they look larger or not as pretty from your vantage point, but everyone else is more interested in you than your shoes. If they even look at your shoes, they have a different perspective and do not see large shoes. Shoes that fit your feet well will help you prevent the rubbed spots and blisters which can lead to infection and other issues of delayed healing that often goes with diabetes. Well-fitted shoes will help you feel like moving around to avoid problems with circulation as you maintain your exercise routines. You can get stylish shoes in designs and sizes that will not cause you foot problems.
You will benefit from more than one style of shoes. Have as many pairs of your favorite stylish shoes as you like. Then, some good walking shoes can be useful and appropriate for shopping and exercise. I suggest that you keep an open pair (casual, rugged sandals) that you can wear with cotton or other natural fiber socks which will help your feet stay warmer. The open shoes will permit freedom and air contact for your toes and heels while the socks still keep you warmer. You can wear your ‘granola’ shoes around the house evenings and weekends if your work style doesn’t encourage such casual footwear.
Socks: Lots of socks! I would recommend natural fiber socks because synthetic fibers can seem soft, but the threads can be irritating. They just don’t give. Clean dry socks are going to help you keep your feet warm while avoiding irritation from wet threads or avoid the excess moisture problems that can revive athletes foot and other fungal irritations. If your socks have gotten old and the threads are covered with little bumps that feel like gravel in your shoes, go get some new ones. They don’t have to be expensive, simply do what you need – keep your feet comfortable. Socks (and shoes) that are not too tight, but which permit your feet/toes to move will contribute to the warmth that you are seeking. They will work so well that you may not need the addition of heating pads that can get too hot or give you a chance to get tangled up in the cord, etc.
Moisturizers: Lotions can be a great comfort to help exfoliate the rough skin of summer when feet were bare. You will see many warnings about lotion leading to extra moisture. Try using just a little less lotion. Taking a moment more to massage the lotion into your skin helps avoid that issue and provides circulation stimulation that has more benefits for the diabetic foot beyond soft skin. Pat your feet with a dry towel after a session with lotion to absorb any excess lotion.
Toenails: Your toenails might seem to sneak a lot of extra during the winter when you don’t look at them several times a day peeping out of sandal toes. When they get too long, they are going to cause pressure issues in your shoes. They can grow over the end of the toe curving back to dig into the toe’s tip. Make an appointment with yourself to give your toenails a good looking over at least once a week. Even better, get a pedicure or trade pedicures with someone else. While you’re checking to see if those nails need a trim, watch for spots that are quietly being rubbed red (and moving toward raw). Those spots are a hint to you to get different shoes or socks.
If you can take care of your own nails, make sure not to trim them too short. You don’t want to risk infection and irritation from even a tiny cut or snag from getting too close to the ‘quick’ on your toe. You may be able to use a file on your toenails regularly to keep them from ever getting long so long that they make you uncomfortable. If you must clip, work on toes that have been soaked in a shower or foot tub for a few minutes and are softer. Hard, dry nails can split and lead to the same infection problems.
Exercise: Moving around will help you keep your feet more comfortable because of the increased circulation. There will be blood flow, little or no tingling and more warmth from inside. “Inside warmth” is better than that achieved by socks, heating pads or drying hot water. Don’t let inclement weather keep you from moving around – you can lay out a path through your house to walk. It might not be ‘track and field’ activity, but it contributes to the exercise quota that you need.
In the event that you have a sore that doesn’t begin healing in a couple days, have tingling in your feet that doesn’t stop, have no feeling in your feet, call your doctor for an appointment. These things can be problems with diabetic feet. Neglecting them can lead to greater problems.
Equinus — “Root of All Foot Evils”
“Eighty percent of what we do is related to equinus.” was the focus of my presentation to the American Podiatric Medical Association Track I Surgery sessions in Boston during July.
Equinus is related to at least 21 foot problems that only increase if not recognized and treated properly.
Proper treatment would benefit from stable standards for the definition of angles in the foot both in diagnosis and treatment.
After suffering an injury that led to tendonitis for me, I invented the EQ/IQ brace which permits adjustment and movement. Additionally, this brace doesn’t have to be worn at night which gives the condition a chance to recover without pressure. Studies indicate that wearing other braces all night do not promote recovery, but certainly disturb the patient’s rest.
The EQ/IQ brace, intelligent management for equinus, does not need to be slept in. I recommend using it 30 minutes in the morning and 30 minutes in the evening with 15 minutes spent stretching the Gastroc-Soleus complex and 15 minutes spent stretching the Soleus.
As we look at features of the EQ/IQ brace from proximal to distal —
There is an above-the-knee extension with a hinge at the knee. The extension allows the knee to be locked into extension to stretch the Glastrocnemius muscle. The hinge can be released to allow for ease of application and isolated stretching of the Soleus. There is also a hinge at the ankle joint which allows the treating physician to set exactly the amount of dorsiflexion desired based on the patient’s biomechanical exam. I estimate 5 degrees the first month increasing to 10 degrees the second month, then if needed, 15 degrees the third month. The hinge goes from -30 degrees to +30 degrees, in 5 degree increments.
More about the EQ/IQ
Rocker Soles:
I designed the EQ/IQ brace to be ambulatory with a negative heel rocker sole, which allows ambulation with a fixed dorsiflexed position.
The rocker soles can be removed. Three different sizes (5, 10, and 15 degrees) are included with the brace to match the amount of ankle joint dorsiflexion.
Adjustable Wedges:
There is an adjustable wedge that goes under the hallux to engage the Windlass Mechanism. These wedges come in 35, 50, and 65 degree sizes and Velcro to the foot bed.
I designed varying degrees for the wedges to allow for patients with hallux limitus or rigidus.
Adjustable Uprights:
The femoral and tibial uprights are adjustable for leg and should be set by the physician
Foot Bed Sizes:
The standard foot beds will fit a small/medium size. However, the foot bed can be replaced by an extended version that will fit a large/extra large size.
Using the EQ/IQ Brace:
I am recommending time periods for wearing the EQ/IQ based upon recommendations for manual stretching, but doubled. Most manual stretching recommendations have the stretches done about 30 minutes per day. I think an hour a day is reasonable from a compliance stand point compared to 6-8 hours at night while disturbing the patient’s sleep.
The ambulatory component of the brace is an important factor. Patients can wear the brace during ther preparations for the day – after dressing the brace is working while they perform typical morning rituals. A similar scenario would play out for the evening stretching.
How to Get the EQ/IQ Brace:
The EQ/IQ brace is being prepared for production in the next few weeks. Treating professionals such as podiatrists, orthopedic surgeons, chiropractors, physical therapists, athletic trainers may pre-order the brace at an introductory discount of $170.00 per brace plus free shipping. Later the price will increase to $200.00 per brace.
To pre-order or get additional information, contact me at 317-660-2115 or you may use the contact/comment form at the Hoosier Foot and Ankle website, available 24/7 for your convenience.
Remembering Richard O. Lundeen, DPM
The late Richard O. Lundeen was my mentor. His teaching, guidance and example are largely responsible for the mission at Hoosier Foot and Ankle to be passionate about delivering innovative foot care solutions to you, our patients.
I was honored to have Dr. Lundeen as a podiatry patient….finding him to be an ‘impatient’ patient with his own surgery recovery. He was typical of doctors in that aspect.
I wrote a memorial blog post about Dr. Lundeen’s leadership in podiatric medicine – making the field so much better for patients with that leadership. You can read more about his contribution to podiatric medicine as well as to my own practice and life at Podiatrytoday.com.
The post is entitled “In Memory of Richard O. Lundeen, DPM”. Again, I have benefited from knowing and learning from Dr. Lundeen and you have benefited from that mentorship as well. Please take a moment and read about a great man.
Congratulations – Linda James and Thank You, Everyone
We want to congratulate Linda James who won the 42 inch LG LCD Television as the top referrer to Hoosier Foot and Ankle this summer.
From June through early September, we asked patients and friends to recommend the foot care at Hoosier Foot and Ankle to their own family and acquaintances who needed treatment. We had a system were chances for the TV were given for referrals. A ticket was made out for the office records and a copy given to the patient. The office tickets were put into a drawing box.
On September 2, we held the big drawing which produced Linda James’ ticket.
This has been a busy summer with this active referral program, plus we welcomed Dr. Shirley Catoire to our staff and began marketing the EQ/IQ brace for the treatment of equinus.
The Very Important Patient appointment time slots continues at our clinics. Patients who refer FIVE or more other patients will be eligible for the next-to-no-wait appointment times. The clinics offering appointments beginning at 2 PM will have two ten-minute time slots from 1:30pm to 2:00pm.
For early risers with full schedules, we have clinics with morning hours. When the appointments begin at 8:30 am, the VIP time slots will be from 8:00am until 8:30am.
If you have questions, please call our office — toll free 877-207-9557. Or you can use the online contact form at Hoosier Foot and Ankle to leave a message. I appreciate your help and want the new VIP time slots to help you and your foot care.
Equinus | Intelligent Management | EQ/IQ Brace No. 4 in a Series
In an attempt to get stability in the treatment of equinus, I have been trying to establish a definition. Previous posts have discussed research regarding the definition numbers. The definition standards would be helpful both in diagnostic evaluation and treatment of equinus.
When it comes to the treatment of equinus, the current non-surgical modalities have been effectual at best. I have invented equipment that I believe is a superior non-surgical treatment for equinus. The design process is based entirely on evidence based medicine and the references are readily available — please contact me if you want to see them.
First, I would like to discuss night splints and why they are ineffective. I have had personal experience using night splints during which I realized their flaws first hand.
I developed Posterial Tibial tendonitis in my right ankle from running; the condition was not improving with orthosis. I did not want to stop running because the activity had helped me lose 40 pounds. I had equinus like many of the population, which was worsening with the running. I started using night splints to help. One night, I woke up at 3:00 am to take the splints off and looked down at my legs. I sleep on my side with my knees bent, like most adults; especially when wearing night splints. I realized the night splints were doing nothing. It is well documented that the Gastrocnemius muscle is the muscle that is tight as it crosses the knee, ankles and subtaler joints. My Gastrocnemius muscles were not being stretched at all; a complete waste of time. Additionally, I was not sleeping well due to the night splints. I was ready to burn them.
The proverbial light bulb went off — I would have to have an above the knee extension to lock the knee in extension. The solution I came up with is the EQ/IQ brace.
The EQ/IQ brace, intelligent management for equinus, does not need to be slept in. I recommend using it 30 minutes in the morning and 30 minutes in the evening with 15 minutes spent stretching the Gastroc-Soleus complex and 15 minutes spent stretching the Soleus.
I will discuss features of the EQ/IQ brace from proximal to distal.
There is an above-the-knee extension with a hinge at the knee. The extension allows the knee to be locked into extension to stretch the Glastrocnemius muscle. The hinge can be released to allow for ease of application and isolated stretching of the Soleus. There is also a hinge at the ankle joint which allows the treating physician to set exactly the amount of dorsiflexion desired based on the patient’s biomechanical exam. I estimate 5 degrees the first month increasing to 10 degrees the second month, then if needed, 15 degrees the third month. The hinge goes from -30 degrees to +30 degrees, in 5 degree increments.
We, as treating podiatrists, will measure everything from X-ray angles to forefoot varus position. Yet, we slap on a night splint and tell our patients, “Pull as tight as you can.” This makes not sense to me. We should have more control and precision over the treatment of equinus.
More about the EQ/IQ
Rocker Soles:
I designed the EQ/IQ brace to be ambulatory with a negative heel rocker sole, which allows ambulation with a fixed dorsiflexed position.
The rocker soles can be removed. Three different sizes (5, 10, and 15 degrees) are included with the brace to match the amount of ankle joint dorsiflexion.
Adjustable Wedges:
There is an adjustable wedge that goes under the hallux to engage the Windlass Mechanism. These wedges come in 35, 50, and 65 degree sizes and Velcro to the foot bed.
I designed varying degrees for the wedges to allow for patients with hallux limitus or rigidus.
Adjustable Uprights:
The femoral and tibial uprights are adjustable for leg and should be set by the physician
Foot Bed Sizes:
The standard foot beds will fit a small/medium size. However, the foot bed can be replaced by an extended version that will fit a large/extra large size.
Using the EQ/IQ Brace:
I am recommending time periods for wearing the EQ/IQ based upon recommendations for manual stretching, but doubled. Most manual stretching recommendations have the stretches done about 30 minutes per day. I think an hour a day is reasonable from a compliance stand point compared to 6-8 hours at night while disturbing the patient’s sleep.
The ambulatory component of the brace is an important factor. Patients can wear the brace during ther preparations for the day – after dressing the brace is working while they perform typical morning rituals. A similar scenario would play out for the evening stretching.
How to Get the EQ/IQ Brace:
The EQ/IQ brace is being prepared for production in the next few weeks. Treating professionals such as podiatrists, orthopedic surgeons, chiropractors, physical therapists, athletic trainers may pre-order the brace at an introductory discount of $170.00 per brace plus free shipping. Later the price will increase to $200.00 per brace.
To pre-order or get additional information, contact me at 317-660-2115 or you may use the contact/comment form at the Hoosier Foot and Ankle website, available 24/7 for your convenience.
Equinus | Intelligent Management| No. 3 in a Series
I’ve been discussing the need for a standard definition to apply to equinus conditions. I believe the condition is under diagnosed because of the vast variety of opinions about just what qualifies as equinus.
Last week, I covered research that I felt was based on low numbers which can lead to the opposite situation — over diagnosis. (Equinus | Intelligent Management No. 2 in a Series)
Referring to an article by J.F. Grady and A. Saxena; Effects of stretching the gastrocnemius muscle, in J. Foot Surg 30: 465, 1991 — a uniblind examination of ankle joint dorsiflexion with various times of stretching exercises performed once a day for six months:
- 30 seconds
- 2 minutes
- 5 minutes
The study used found the average pre-stretching measurements of the 25 participants to be 2.86+/-2.99 degrees of dorsiflexion with the knee extended and 9.02+/-2.35 degrees of ankle joint dorsiflexion with the knee flexed. Their study showed no statistical significance to the improved ankle joint dorsiflexion to recommend manual stretching.
The key point for this discussion is the pre-treatment numbers. The patients were measured with a goniometer in subtaler neutral with the midtarsal joint locked. This number is similar to Hill’s definition of 3-degrees as mentioned in the last post entitled Equinus | Intelligent Management No. 2 in a Series. Again, I think this is slightly off toward the low end.
C.W. Digiovanni, R. Kuo, N. Tejwani, et al wrote Isolated gastrocnemius tightness, in J Bone Joint Surg Am 84; 962, 2002, which examined the frequency of equinus in a symptomatic patient group and control group; and the reliability of clinical evaluation of equinus compared to an equinometer (this would be a computer measurement of ankle joint dorsiflexion). They used two definitions of equinus — 5-degrees and 10-degrees ankle joint dorsiflexion with the knee extended.
In the symptomatic group, the average ankle joint dorsiflexion with the knee extended was 4.5-degrees. In the control group, it was 13.1-degrees. The 5-degree group contained 65% symptomatic patients and 24% control group patients. In the 10-degree group, there were 88% symptomatic patients and 44% were of the control group.
The reliability of clinical exam compared to the equinometer for the 5-degree group was 76% for the symptomatic group of patients and 94% for the patients in the control group. For the 10-degree group, the reliability was 88% for the symptomatic group and 79% for the control group. The following quote from their article summarizes their findings.
“We have selected <5° of maximal ankle dorsiflexion with the knee in full extension as our definition because it allowed us to diagnose the problem in those who were at risk (symptomatic patients) with fairly good reproducibility (76%) and, more importantly, we were able to reliably avoid (in 94% of the cases) unnecessary treatment of those who were not at risk (asymptomatic people).”
When examining this literature, it is clear to me that the standard definition of equinus should be 5-degrees of ankle-foot dorsiflexion with the knee extended. It is important to have the subtaler joint in neutral postion and the midtarsal joint locked.
Readers who are experienced with foot conditions will be more familiar with some of the terms than patients or people who have foot pain but who haven’t found someone who can offer relief. If you have questions about your condition, I recommend that you contact a professional with your questions and seek a professional evaluation. As this post reports, standard definition and professional evaluation can both deliver adequate treatment and/or avoid over-treatment.
Equinus | Intelligent Management| No. 2 in a Series
The concerns and issues of Equinus treatment are faced by patients first, then their podiatrists and other professional contacts. I am suggesting some standard definitions for diagnosis and treatment so that we can help patients ‘get back in step’
Informational literature has Equinus definition ranges between -10 and +22 degrees of ankle joint dorsiflexion for normal ambutlation. I found a consensus of 13 different studies for10-degrees. Having a firm definition range should make communication between specialties and among practitioners much easier when discussing equinus.
For example, I am the team podiatrist for both the Indiana Pacers team and the Indiana Fever team. Within my determination of the measurement degrees, I think every player has equinus. The trainers use different measurements which lead them to think none of the players have equinus. It is a matter of definition and evaluation.
An article written by R.S. Hill; “Ankle equinus: prevalence and linkage to common foot pathology.” in JAPMA 85: 295, 1995, discusses the evaluation of 206 new patients from Kaiser Permanente clinics over a six-week period of time. This article helps establish a definition of equinus that we need.
Additionally, the information shows how frequently equinus is associated with the pathologies we see every day in our podiatry practices. Twenty-six patients were excluded because they didn’t meet criteria – ingrown toenails, onychomycosis, verrucae plantaris were involved among other similar conditions. Six patients of the remaining 174 had normal ankle joit dorsiflexion. Of the 168 patients left in the study, three had gastrocnemius equinus and 165 had gastrocsoleus equinus. Hill used a definition of 3-degrees of ankle joint dorsiflexion and normal ankle joint dorsiflexion. In the study, 96.5% of the patients with foot or ankle symptoms had equinus using these definitions. I think Hill’s definition was a little low and will use the remaining two articles to further discuss a definite definition.
Readers who are experienced with foot conditions will be more familiar with some of the terms than patients or people who have foot pain but haven’t found someone who can offer relief. If you have questions about your condition — perhaps your pain is connected to equinus — I recommend that you contact a professional with your questions and seek a professional evaluation.
Equinus | Intelligent Management | A Series
“Equinus deformity is the most profound causal agent in foot pathomechanics and is frequently linked to common foot pathology.” from Biomechanics of the First Ray Part V: The Effect of Equinus Deformity | CH Johnson and JC Christensen in J. Foot Ankle Surg. 44: 114-120, 2005
It is my opinion that this ‘profound causal agent’ receives too little attention from us – the practitioners. I’m further convinced that the lack of attention is connected to no absolute definition of equinus.
Through this series, I propose to provide an absolute definition of equinus based on three very profound articles and other research. I will also elaborate on a treatment protocol using an ‘intelligent brace’ that I have invented.
My interest in equinus was piqued beyond my patient roster when healthy exercise began to result in equinus symptoms in my own right ankle. Running was giving me trouble, yet that very exercise was connected to a significant weight loss. When we are counseling patients toward a healthier life-style, we owe to them to be prepared to guide them through the process. The perfect situation would be wise exercise with no injury. When injury occurs podiatrists have the opportunity to help patients through to healthier feet.
In the next posts, I will discuss research in the articles mentioned earlier, share my opinions and my justification for the equinus definition that I believe is applicable and describe the breakthrough of the EQ/IQ brace.
As you read you may have questions. As doctors, trainers, therapists, you wonder where and how to obtain the EQ/IQ brace. As equinus sufferers, you will be seeking information that you can share with your doctor. You can contact me at Hoosier Foot and Ankle. You can call 317-660-2115 with questions or you can leave your message/question on the Contact Form available in the sidebar of the Hoosier Foot and Ankle website.
