Hiking and your Feet Part 2 - Dr. Thomas Rambacher
Hiking and your Feet Part 2 - Dr. Thomas Rambacher
Hiking and your Feet Part 2 - Dr. Thomas Rambacher
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<strong>Hiking</strong> <strong>and</strong> <strong>your</strong> <strong>Feet</strong> <strong>Part</strong> 2<br />
<strong>Thomas</strong> <strong>Rambacher</strong><br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 1
Lower Extremity Injuries<br />
in <strong>Hiking</strong><br />
• Blisters!!!<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 2
Blisters:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 3
Blisters:<br />
• Foot blisters are among the most<br />
common injuries for athletes.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 4
Blisters:<br />
• Aside from being painful, blisters<br />
can alter an athlete’s running <strong>and</strong><br />
hiking form <strong>and</strong> lead to even more<br />
serious injuries of the leg <strong>and</strong> hip<br />
due to irregular gait biomechanics.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 5
Blisters:<br />
• Blisters result from frictional forces<br />
that mechanically separate<br />
epidermal cells at the level of the<br />
stratum spinosum.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 6
Blisters:<br />
• Hydrostatic pressure causes the<br />
area of the separation to fill with<br />
lymph-like fluid.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 7
Blisters:<br />
• The magnitude of the frictional<br />
forces <strong>and</strong> the number of times an<br />
object cycles across the skin<br />
determine the probability of blister<br />
development.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 8
Blisters:<br />
• The higher the frictional forces, the<br />
fewer cycles are necessary to<br />
produce a blister<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 9
Blisters:<br />
• Moist skin increases frictional<br />
forces, leading to blister formation<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 10
Blisters:<br />
• Very dry or very wet skin decreases<br />
frictional forces, preventing blisters.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 11
Blisters:<br />
• Other risk factors for foot blister<br />
formation include ethnicity (African-<br />
Americans are at lower risk than<br />
others)<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 12
Blisters:<br />
• Increased risk with flat feet <strong>and</strong> feet<br />
with structural prominences, such<br />
as bunions, hammertoes <strong>and</strong><br />
Haglund’s deformity.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 13
Blisters:<br />
• In order to prevent blisters, we<br />
need to minimize friction.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 14
Blisters:<br />
• This begins with shoe selection.<br />
Emphasize to patients that their<br />
shoes should fit comfortably, with<br />
about a thumb’s width (3/8-inch to<br />
1/2-inch) between the longest toe<br />
<strong>and</strong> the end of the shoe.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 15
Blisters:<br />
• Narrow shoes can cause blisters on<br />
the Great toe <strong>and</strong> fifth toe.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 16
Blisters:<br />
• A shallow toe box can lead to<br />
blisters on the tops of the toes<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 17
Blisters:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 18
Blisters:<br />
• Loose shoes often create blisters on<br />
the tips of the toes.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 19
Blisters:<br />
• Shoe fitting should take place in the<br />
afternoon or evening, since feet<br />
tend to swell during the day.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 20
Blisters:<br />
• Do not wear socks with large toe<br />
seams.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 21
Blisters:<br />
• Carry an extra pair of socks to<br />
change into if <strong>your</strong> socks become<br />
too damp.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 22
Blisters:<br />
• If you have areas of the feet that<br />
are prone to blistering, applying<br />
lubricants (like petroleum jelly, bag<br />
balm or even dry soap flakes)<br />
before you put on socks helps<br />
reduce friction.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 23
Blisters:<br />
• reapply large amounts of lubricant<br />
every 10 miles petroleum antichafing<br />
lubricants or BodyGlide (W.<br />
Sternoff, LLC) or Runner’s Lube<br />
(Mueller Sports Medicine, Inc.),.<br />
These products are waterproof,<br />
perspiration-proof, non-greasy, <strong>and</strong><br />
wash off with soap <strong>and</strong> water.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 24
Blisters:<br />
• Another recommendation is to<br />
massage both feet with lanolin<br />
every night for a month before a big<br />
walking or running event. It’s better<br />
than petroleum jelly since it doesn’t<br />
create heat when friction occurs.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 25
Blisters:<br />
Minimizing moisture on the feet by<br />
using drying agents is another way<br />
to reduce blister formation.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 26
Blisters:<br />
• In a double-blind study conducted at the<br />
U.S. Military Academy, cadets who used<br />
the prescription antiperspirant <strong>Dr</strong>ysol<br />
(Person & Covey, Inc.) for at least three<br />
nights before a 21km hike had a 21<br />
percent incidence of foot blisters, as<br />
compared to 48 percent for the placebo<br />
group.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 27
Blisters:<br />
• <strong>Dr</strong>ying foot powders, such as<br />
Zeasorb (Stiefel Laboratories, Inc.),<br />
<strong>and</strong> antiperspirant sprays (that<br />
contain aluminum chlorhydrate or<br />
aluminum chloride) are inexpensive<br />
ways to decrease moisture.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 28
Blisters:<br />
• Toughening the skin is another<br />
method of avoiding blister<br />
formation.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 29
Blisters:<br />
• Applying multiple coats of tincture<br />
of benzoin to sensitive areas or<br />
soaking feet in strongly brewed tea<br />
(tannic acid) are commonly used<br />
skin toughening procedures.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 30
Blisters:<br />
• Protecting or “shielding” areas of<br />
the foot with a high potential for<br />
blister formation is an excellent<br />
preventive approach. Some of these<br />
susceptible areas include bony<br />
prominences<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 31
Blisters:<br />
• B<strong>and</strong>-Aid Blister Block (Johnson &<br />
Johnson, Skillman, N.J.) <strong>and</strong> <strong>Dr</strong>.<br />
Scholl’s Cushion Blister Treatment<br />
(Schering-Plough Healthcare<br />
Products) are self-adhesive,<br />
silicone-like pads that act as an<br />
extra layer of skin to absorb<br />
friction.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 32
Blisters:<br />
• Cut slightly larger than areas of<br />
intense friction or sensitive skin,<br />
moleskin provides another<br />
inexpensive method of preventing<br />
blister formation.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 33
Blisters:<br />
• Liquid adhesives, such as Mastisol<br />
(Ferndale Laboratories, Inc.),<br />
promote adherence of moleskin to<br />
the foot.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 34
Blisters:<br />
• Alternatives to moleskin are the<br />
“liquid” b<strong>and</strong>ages such as New Skin<br />
(Medtech Laboratories, Inc.), which<br />
dries to form a tough protective<br />
covering on the skin.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 35
Blisters:<br />
• May also consider using lambswool,<br />
commonly used by dancers,<br />
between the toes in order to<br />
prevent <strong>and</strong>/or soothe blisters.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 36
Blisters:<br />
• Since it’s not always possible to<br />
prevent blisters, it is important to<br />
relieve pain, prevent enlargement<br />
or infection, <strong>and</strong> promote a speedy<br />
recovery when they do occur.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 37
Blisters:<br />
• Small, intact blisters that don’t<br />
cause discomfort usually don’t need<br />
treatment. The best protection<br />
against infection is a blister’s own<br />
skin or roof.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 38
Blisters:<br />
• To protect the roof, you can cover<br />
this type of blister with a small<br />
adhesive b<strong>and</strong>age or blister guard.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 39
Blisters:<br />
• However, you should drain larger or<br />
painful blisters that are intact<br />
without removing the roof. Proceed<br />
to apply an antibiotic ointment <strong>and</strong><br />
cover it with a b<strong>and</strong>age. Remember<br />
to change their dressings daily.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 40
Blisters:<br />
• If you’re dealing with blisters that<br />
have large tears, you should<br />
“unroof” them <strong>and</strong> cleanse the base<br />
thoroughly with soap <strong>and</strong> water or<br />
an antibacterial cleanser. Then<br />
cover it with an antibiotic ointment<br />
<strong>and</strong> b<strong>and</strong>age.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 41
Blisters:<br />
• Additional padding may be<br />
necessary for continuing sports<br />
activity. Ring-shaped pads made of<br />
felt will protect small blisters.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 42
Blisters:<br />
• Larger blisters may require<br />
dressings.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 43
Treating Blisters-On The Trail<br />
• Small blister<br />
• Cover with tape<br />
• Do not De-roof<br />
• Do not Lance<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 44
Treating Blisters-On The Trail<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 45
Treating Blisters-On The Trail<br />
• Large intact blister<br />
• Lance<br />
• Do not De-roof<br />
• Cover with antibiotic ointment<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 46
Treating Blisters-On The Trail<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 47
Treating Blisters-On The Trail<br />
• Large blister with multiple large rip<br />
• De-Roof<br />
• <strong>Dr</strong>ess as large open Wound (Abx <strong>and</strong><br />
DSD)<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 48
Treating Blisters-On The Trail<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 49
Toenail Problems:<br />
• Ingrown toenails <strong>and</strong> subungual<br />
• hematomas are the most common<br />
• toenail injuries.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 50
Toenail Problems:<br />
• Ingrown toenails may<br />
• result from tight fitting boots or<br />
• socks or improper trimming of the<br />
• nail plate.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 51
Toenail Problems:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 52
Toenail Problems:<br />
• Subungual hematomas<br />
• may form from the repetitive<br />
• micro-trauma of the nail plate<br />
• hitting the front of the boot.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 53
Toenail Problems:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 54
Toenail Problems:<br />
• This often occurs when descending from<br />
• a climb or hiking downhill.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 55
Toenail Problems:<br />
• It is important during the boot fitting<br />
• process that one walks up <strong>and</strong> down<br />
• an incline board to make sure the<br />
• distal aspect of the toes are not<br />
• being compressed against the front<br />
• of the boot.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 56
Toenail Problems:<br />
• Toenail injuries can be<br />
• difficult to treat in the wild <strong>and</strong><br />
• therefore prophylactic<br />
• measures should be considered.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 57
Toenail Problems:<br />
• How to cut Toenail?<br />
• Depends on anatomical Toe type <strong>and</strong> active.<br />
• Straight <strong>and</strong> Short Usually<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 58
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• Plantar metatarsal pain may<br />
• result from a direct injury such as<br />
• stepping on a protruding rock.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 59
Metatarsalgia<br />
(Ball of Foot Pain):<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 60
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• May be due to the repetitive stress<br />
• placed on the sub-metatarsal area<br />
• when carrying a heavy backpack<br />
• over rugged terrain.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 61
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• The stress to the metatarsal region<br />
• may be further compounded by<br />
• heavy-weight hiking boots<br />
• that incorporate stiff shanks <strong>and</strong><br />
• outsoles.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 62
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• Podiatric intervention for this<br />
• type of metatarsal pain involves<br />
• the use of a metatarsal pad<br />
• proximal to the point of tenderness<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 63
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• These metatarsal pads can<br />
• also be incorporated<br />
• into a orthotic device.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 64
Metatarsal Pad<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 65
Metatarsalgia<br />
(Ball of Foot Pain):<br />
• Similar pain from<br />
• intermetatarsal space neuroma or<br />
• metatarsal stress fractures.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 66
Tarsal Tunnel<br />
Syndrome:<br />
• Compression of the posterior tibial<br />
• tendon nerve can occur from<br />
• irritation to the tarsal canal from the cuff<br />
• of a low or mid-height hiking boot.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 67
Tarsal Tunnel<br />
Syndrome:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 68
Pedal Prominences:<br />
Bone deformities such as (bunion) hallux<br />
valgus, hammertoes, <strong>and</strong> Haglund’s<br />
retrocalcaneal exostosis may<br />
become inflamed when subject to<br />
repetitive micro-trauma or shoe<br />
gear irritation.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 69
Bunion<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 70
Hammertoes<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 71
Haglund’s<br />
retrocalcaneal exostosis<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 72
Pedal Prominences:<br />
• These can be alleviated by the modification<br />
• of hiking footwear, the use of<br />
• accommodative padding or orthotic<br />
• devices, <strong>and</strong> surgery when necessary.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 73
Plantar Fascia Pain:<br />
• Inflammation in the plantar fascia<br />
• usually responds to RICE.<br />
• Treat with stretching <strong>and</strong> rigid shoe insert.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 74
Plantar Fasciitis<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 75
Achilles Tendon Pain:<br />
• Usually from irritation of shoe heel counter<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 76
Achilles Tendon Pain:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 77
Ankle Sprain:<br />
• Usually from improper shoe selection.<br />
• Treat with wrap <strong>and</strong> ice.<br />
• Follow up with podiatrist upon return.<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 78
Ankle Sprain:<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 79
Ankle Sprain:<br />
• Outcome <strong>and</strong><br />
treatment<br />
• based on areas of<br />
injury<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 80
Questions? Thank You<br />
<strong>Dr</strong>. <strong>Thomas</strong> <strong>Rambacher</strong> 949-637-0038<br />
More info on foot conditions<br />
with free downloadable brochures at<br />
dr.rambacher.com<br />
<strong>Thomas</strong> <strong>Rambacher</strong> DPM 949-637-0038 81