FitSugar

Get on the Ball: Calf Raises

FitSugar — Tue, 09 Dec 2008 14:30:00 -0800

There are tons of exercises that work your booty and thighs, but what about your calves? It's important to tone these muscles because not only do they look sexy in your gym shorts, but strong calves will help you run faster and tackle hills with ease. Here's an exercise that you can even do while at your desk. All you need is an exercise ball or chair, and a light set of dumbbells.

To learn how to do this calf toner read more.

Sit on a ball, chair, or workout bench. Hold a three to five pound dumbbell on your lower quad, just above your knee.
Slowly lift both heels off the ground as high as comfortable, so you are on the balls of your feet. Then slowly lower them back to the floor.
Repeat 15 to 20 times, for a total of three sets, doing this calf stretch after eat set.

No Equipment Necessary: Calf Raises

FitSugar — Thu, 13 Dec 2007 09:30:00 -0800

A lot of us do a lot of leg work to develop our lower body muscles, but completely forget about the calves (or neglect them for fear they'll get bulky). Calf Raises develop flexibility and strength in the ankle joint and calf, and all you need to do them is your body and a step/curb or any uneven surface. Here's how:

Stand with balls of feet on a curb/step, heels hanging off. Keep knees soft, not locked.
Slowly let heel fall below the curb/step, then slowly move weight to toes and lift your heel back up.
Repeat this up and down action 12-15 times. Do three sets.

Fit's Tip: You may want to be close to a wall or something in case you need to get your balance. If you don't have a stair accessible you can do calf raises on flat ground, just go up to your tiptoes and back down. To make it more challenging, you can lift one leg behind you and do one leg at a time.

Get on the Ball: Seated Calf Raises

FitSugar — Wed, 16 Apr 2008 11:00:00 -0700

The calves are one of the most neglected muscles in the lower body, but in the Summer they also happen to be one of the most visible muscles of the leg - think capris, shorts, dresses, skirts, etc. People love to work their quads, hamstrings, hip flexors, and glutes but when it comes to working our calves, most of us fall short. This exercise on the ball really targets the muscles of the calves while also giving the core a little workout, too. Here's how to do it:

Start by sitting on a stability ball and resting dumbbells on top of thighs. Thighs should be parallel to the floor and knees should be about hip width apart.
Slowly lift heels off floor to contract your calf muscles and hold for one second.
Then slowly bring heels back down to the floor to complete one rep.
Do three sets of 10-12 reps. Start with 3 to 5 pound weights, and increase weight if that feels easy.

Fit's Tip: To make this move extra challenging, bring your legs closer together. This will challenge your core even more to keep you upright as well as working your calves.

Don't forget to stretch your calves after working them. Here's a bunch of calf stretches for you to try!

You Asked: Stretch For Sciatica

FitSugar — Wed, 14 Oct 2009 05:50:08 -0700

Hey Fit,
I've been having issues with my sciatic nerve lately, I was wondering if you could post some stretches and/or yoga poses that would help with sciatica? Thanks!
- Hitting a Nerve

I feel your pain. The sciatic nerve, when pinched or pressed, can cause tingling and numbness down the back of the leg. The pain can come from a nerve root being pinched in the lower spinal column - mostly at the last vertabra (lumbar 5) and the sacrum. Pain can also come from a tight piriformis muscle, since the nerve runs through this deep booty muscle. If you are experiencing sciatica from a degenerative or herniated disc, you should see an orthopedist to get a diagnosis and a recommendation for a physical therapist. When it comes to lower back injuries due to nerve compression, strengthening your core is elemental to getting rid of the tingling pain. It is important to strengthen your abs and spinal muscles in a way that won't compromise your injury further.

I do have two safe stretches to share with you. Learn them when you read more.

I have found this piriformis stretch to be safe and effective with Pilates clients experiencing sciatica. I call it the figure four, but it is a simplified variation of the yoga pose pigeon.

Lie on your back with both legs in the air. Place your right ankle on your thigh above your left knee. See the shape of the number four? It is there, just upside down.
Reach your right hand through the open space created by your right leg and grab your left hand that is reaching around the outside of your left thigh. Slowly bend your left knee. You should feel a stretch on the outside of your right hip. Hold for 30 seconds.

Another stretch that can relieve tension caused by an unhappy sciatic nerve is this simple hamstring stretch.

Lie on your back, bend your right knee and place right foot on the floor.
Raise your left leg as high as you can keeping your pelvis square (don't raise your left hip toward your ear).
Hold your lower thigh or place a strap over the arch or ball of your foot. Flex your foot to stretch your calf too.
Hold for 30 seconds, then switch legs.

On the Move: Commuter Workout

FitSugar — Thu, 03 Sep 2009 05:50:49 -0700

Do you feel like your commute is interfering with your gym time? Add some simple strength-training moves to your bus or train time. Michael Martin, a personal trainer at Equinox, developed a simple routine for you to take advantage of your commute. Check out the moves.

Strap-Hanger Pull-Ups: Didn’t get a seat? No problem. Work your biceps while you wait by holding onto the strap to engage your bicep. Keep your neck and shoulders relaxed while holding the bicep contraction for eight to 10 seconds and release. Repeat the move eight to 12 times or until muscle fatigue. Casually change arms and repeat on the other side. Another option: Try briefcase curls while waiting on the platform or stuck in line waiting for a train ticket.
Commuter Seated Calve Raises: Start with your feet hip-width apart and flat on the floor. Come up onto the balls of your feet and contract your calf muscles. Since you’re working without weights, squeeze the contraction tightly and hold it for eight to 10 seconds breathing normally, then slowly lower the feet to the floor using your own resistance. Lay your briefcase or backpack across your lap for added challenge and weight.

There are plenty more moves, so keep on reading.

Fittingly Green: Work Out Outside For Earth Day

FitSugar — Wed, 22 Apr 2009 06:00:00 -0700

Today is Earth Day, so celebrate with an outdoor workout. Yes you can run and walk outside, but you can also strength train while doing so. All you need is an empty park bench and a curb to strength train your entire body while on the move in the outdoors.

Here are some ideas:

Take your basic step up and do it on a park bench. You will work your legs while keeping your heart rate up.
Use the same park bench for push-ups. Put your hands on the back of the bench, walk your feet out until you're in a plank position, and begin doing push-ups. For more of a challenge, put your hands on the seat of the bench. To mix it up, place one hand on the arm of the bench and the other on the seat. Make sure to repeat the same number of reps after switching your hand configuration to the other side.
Curb your calf raises. Stand with balls of feet on a curb/step, heels hanging off, and raise both heels for 10 reps. For an extra challenge, try single-leg calf raises.

Do I have more ideas? You betcha! See them when you read more.

Single-leg squats on the bench will challenge your balance while toning your tush. Stand sideways on the bench with your right side toward the back of the bench and your left leg dangling off the seat. Bend your right leg into a squat position as your left leg moves lower than the bench seat. Do 10 on each leg.
Take your lunges for a walk in the great outdoors. Find an open space in the park, or a quiet stretch of sidewalk, and add some lunges into your run or walk.
Use the seat of a bench to tone the back of your arms with some triceps dips.

Don't forget to try the monkey bars next time you jog past a playground, too.

Source

Foot pain

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Treatment: Corns and Callus...
Treatment: Bunions
Treatment: Hammertoes
Treatment: Ingrown Toenails...
Treatment: Forefoot Pain...
Treatment: Heel Pain
Treatment: Flat Feet
Treatment: Abnormally High ...
Treatment: Tarsal Tunnel Sy...
Treatment: Foot Injury
Prevention
Shoes
Insoles and Orthotics
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Treatment for Ingrown Toenail:

Orthonyxia, a surgical technique that implants a small metal brace into the top of the nail, was as effective as traditional surgical techniques for preventing ingrown toenail from recurring, according to one study.
A nonsurgical method for treating ingrown toenail with chemicals uses either sodium hydroxide or phenol, but one study shows that sodium hydroxide procedures have a better outcome and faster recovery than phenol procedures.

Treatment for Forefoot Pain:

Ultrasound-guided injection of alcohol might provide relief from Morton's neuroma, according to one study. Symptoms improved in 94% of patients who had the treatment, a success rate comparable to that of surgery.

Treatment for Heel Pain:

NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.
Studies show that extracorporeal shockwave therapy provides a very small reduction in heel pain without side effects. It may be a good option for patients who haven't responded well to conservative treatment.

Work-related Foot Problems:

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

Introduction

Foot pain is very common. About 75% of people in the United States have foot pain at some time in their lives. Most foot pain is caused by shoes that do not fit properly or that force the feet into unnatural shapes (such as pointed-toe, high-heeled shoes).

The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of more than 120 muscles, ligaments, and nerves. It serves the following functions:

Supports weight
Acts as a shock absorber
Serves as a lever to propel the leg forward
Helps maintain balance by adjusting the body to uneven surfaces

Because the feet are very small compared with the rest of the body, the impact of each step exerts tremendous force upon them. This force is about 50% greater than the person's body weight. During a typical day, people spend about 4 hours on their feet and take 8,000 - 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.

Foot pain generally starts in one of three places: the toes, the forefoot, and the hindfoot.

The Toes. Toe problems most often occur because of the pressure imposed by ill-fitting shoes.

The Forefoot. The forefoot is the front of the foot. Pain originating here usually involves one of the following bone groups:

The metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe)
The sesamoid bones (two small bones embedded at the top of the first metatarsal bone, which connects to the big toe)

The Hindfoot. The hindfoot is the back of the foot. Pain originating here can extend from the heel, across the sole (known as the plantar surface), to the ball of the foot (the metatarsophalangeal joint).

Condition	Location	Symptoms	Recommended Footwear
Toe Pain
Corns and calluses	Around toes, usually little toe, bottom of feet or areas exposed to friction.	Hard, dead, yellowish skin.	Wide (box-toed) shoes; soft cushions under heel or ball of foot, or customized or gel insoles for calluses. Doughnut-shaped pads for corns.
Ingrown toenails	Toenails.	Nail curling into skin causes pain, swelling, and, in extreme cases, infection.	Sandals, open-toed shoes.
Bunions and bunionettes (tailor's bunion)	Big toe (bunions) or little toe (bunionettes).	The following can occur alone or in combination: Metatarsus primus varus. The first (big toe) metatarsal bone shifts away from the second, and the big toe points inward. Medial exostosis. This is a bony bump at the base of the big toe, which protrudes outward. Area next to bony bump is red, tender, and occasionally filled with fluid. Toe joint may be inflamed. Hallux valgus. This is a deformity in which the bone and joint of the big toe shift and grow inward, so that the second toe crosses over the big toe.	Soft, wide-toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings, if necessary. Avoid shoes with stitching along the side of the "bump."
Morton's neuroma (also called interdigital neuroma)	Inflammation of the nerve, usually between the third and fourth toes and bottom of the foot near these toes.	Cramping and burning pain, or electric-shock sensation. The condition may produce a thick protective sheath around the nerve that feels like a ball. This may be detected by pressing top to bottom on the top of the foot using one hand and moving the other hand from side to side. Morton's neuroma is aggravated by prolonged standing and relieved by removal of the shoes and forefoot massage.	Wide (box-toed) shoes. Orthotic or insole with pad that reduces stress on the painful area.
Hammertoe or claw toe	Usually second toe, but may develop in any or all of the three middle toes.	Toes form hammer or claw shape. In hammertoe, the first knuckle of the toe is mainly affected. In claw toe the entire toe is deformed. No pain at first, but pain increases as tendon becomes tighter and toes stiffen.	Wide (box-toed) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings are not for people with diabetes.)
Front-of-the-Foot Pain
Metatarsalgia	Ball of the foot.	Acute, recurrent, or chronic pain without a known cause.	Wide (box-toed) shoes. Orthotic with pad that reduces metatarsal pressure. Gel cushions. Metatarsal bandage.
Stress fracture	Most often in the area beneath the second or third toe.	Sudden pain (which persists) when injury occurs.	Low-heeled shoes with stiff soles.
Sesamoiditis	Ball of foot beneath big toe.	Pain and swelling.	Low-heeled shoe with stiff sole and soft padding inside.
Heel and Back-of-the-Foot Pain
Plantar fasciitis or heel spurs	Back of the arch right in front of heel.	At onset, some people report a tearing or popping sound. Pain is most severe with first steps after getting out of bed. Pain decreases after stretching, returns after inactivity.	Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.
Bursitis of the heel	Center of the heel.	Pain, with warmth and swelling. Increases during the day.	Heel cup.
Haglund's deformity (pump bump)	Fleshy area on the back of the heel.	Tender swelling aggravated by shoes with stiff backs.	Soft shoes. Heel pads. Possible orthotic to support heel.
Achilles tendinitis	Achilles tendon: area along the back between calf muscles and heel.	Pain worsens during physical activities (particularly running), after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg.	Insoles, tendon strap, heel cups.
Arch and Bottom-of-the Foot Pain
Tarsal tunnel syndrome	Anywhere along the bottom of the foot.	Numbness, tingling, or burning sensations, pain, most commonly felt at night.	Specially designed orthotics to relieve pressure.
Flat feet or posterior tibial tendon dysfunction (PTTD)	The arch.	No arch. Often no pain or discomfort. Three stages in PTTD: Pain and weakness in the tendon. The arch flattens but is still flexible. The foot becomes rigid and possibly painful at the ankle. Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back.	For children, possible custom-made insoles.
High arches (hollow feet)	The arch.	High arches. Lower back pain, possible tendency to lower limb injuries.

Causes

Nearly all causes of foot pain can be grouped under one of the following:

Ill-fitting shoes. Poorly fitting shoes are a frequent cause of foot pain. High-heeled shoes concentrate pressure on the toes and can aggravate, if not cause, problems with the toes.
Certain medical conditions. Any medical condition that causes a disturbance in the way a person walks can contribute to foot pain. This may include diseases or conditions that lead to pain or numbness in the feet (such as diabetes), leg and foot deformities, spinal problems, and neurological disorders such as Parkinson's disease or cerebral palsy.
High-impact exercise. High-impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.

Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.

Diabetes. Diabetes is an important cause of serious foot disorders. [For more information, see In-Depth Report #9: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.]

Obesity. Obesity can cause foot and ankle pain.

Pregnancy. Pregnancy can cause fluid buildup and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.

Medications. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.

Click the icon to see an image of foot inspection.

Risk Factors

A risk factor is anything that increases your chances of getting a disease or condition. The following are factors that increase your risk for foot pain:

Elderly people are at very high risk for foot problems. As you age, your feet widen and flatten, and the fat padding on the sole of the foot wears down. The skin on the feet also becomes dryer. Foot pain in older adults may be the first sign of age-related conditions, such as arthritis, diabetes, and circulatory disease. Foot problems can also impair balance and function in this age group.

Taking fashion to extreme limits, some people have turned to cosmetic surgery as a drastic way to fit into high-heeled shoes. Procedures include surgical shortening of the toes, narrowing of feet, or injecting silicone into the pads of the feet. Such methods may increase your risk for future foot pain. The American Orthopaedic Foot and Ankle Society (AOFAS) and other foot-related medical associations have expressed concern over this trend. The AOFAS strongly advises against cosmetic foot surgery and urges consumers to carefully consider the relative risks and benefits of undergoing unnecessary surgical procedures.

Women are at higher risk than men for severe foot pain, probably because of high-heeled shoes. Severe foot pain appears to be a major cause of general disability in older women.

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

For example, in a study of New York police officers who walked an average of 3 miles a day, 20% experienced foot pain at the end of their workday. (Insoles can relieve much of this pain.) No studies, however, have scientifically distinguished between injuries due to work versus those due to regular use. This is an important issue because of its potential impact on disability claims.

Pregnant women have an increased risk of foot problems due to weight gain, swelling in their feet and ankles, and the release of certain hormones that cause ligaments to relax. These hormones help when bearing the child, but they can weaken the feet.

People who engage in regular high-impact aerobic exercise are at risk for plantar fasciitis, heel spurs, sesamoiditis, shin splints, Achilles tendon, and stress fractures. Women are at higher risk for stress fractures than are men.

Gaining weight puts added stress on the feet and can lead to foot or ankle injuries. The added pressure on the soft tissues and joints of the foot in overweight people increases the likelihood of developing tendinitis and plantar fasciitis.

Treatment: Corns and Calluses

A corn is a protective layer of dead skin cells that forms due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. Corns can develop on the top of, or between, toes. If a corn develops between the toes, it may be kept pliable by the moisture from perspiration and is therefore called a soft corn.

Corns develop as a result of friction from the toes rubbing together or against the shoe. They often occur from the following:

Shoes, socks, or stockings that fit too tightly around the toes
Pressure on the toes from high-heeled shoes
Shoes that are too loose, due to the friction of the foot sliding within the shoe
Deformed and crooked toes

Calluses are composed of the same material as corns. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about 40 times thicker than the skin anywhere else on the body, but a callus can even be twice as thick. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.

Risk factors for calluses include the following:

Poorly fitting shoes
Walking regularly on hard surfaces
Flat feet

Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:

Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.
Wear thick socks to absorb pressure, but do not wear tight socks or stockings.
Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.
Use doughnut-shaped pads that fit over a corn and decrease pressure and friction. They are available at most drug stores.
Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for 5 minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. Unsterile cutting tools can cause infection, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are numerous over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritation, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following people should not use them:

Patients with diabetes
Patients with reduced feeling in the feet due to circulation problems or neurological damage
Patients who do not have the flexibility or eyesight to use them properly

Treatment: Bunions

A bunion is a deformity that usually occurs at the head of one of the five long bones (the metatarsal bones) that extend from the arch of the foot and connect to the toes. A bunion typically develops in the following way:

Most often it occurs in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as either a bunionette or a tailor's bunion.
A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
The underlying tissue becomes inflamed, and a painful bump forms.
As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle toward the rest of the toes. One important bunion deformity, hallux valgus, causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.

Several conditions can cause bunions:

Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
Injury in the joint may cause a bunion to develop over time.
Genetics play a role in 10 - 15% of all bunions.

Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:

Soft, wide, low-heeled leather shoes that lace up
Athletic shoes with soft toe boxes
Open shoes or sandals with straps that don't touch the irritated area

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary, particularly for more serious conditions, such as hallux valgus. There are more than 100 surgical variations, ranging from removing the bump to realigning the toes.

The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. This technique is not a cure, but patient satisfaction is high and results are long-lasting.

Click the icon to see an illustrated series detailing bunion removal.

More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:

Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% of patients are satisfied with the procedure.
Exostetectomy (removal of the large bony growth). This technique is only useful when there is no shift in the toe bone itself.
Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal). This is the gold standard procedure for very severe cases or when previous procedures have failed. Most patients report good results.
Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This technique offers symptom relief and faster rehabilitation than arthrodesis, but it can cause deformity and some foot weakness. Arthroplasty tends to be used in older patients. Biologic or synthetic implants for supporting the toes are showing promise as part of this procedure.
Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.

In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or damage from osteoarthritis.

Complications, though uncommon in even the most complex procedures, can include:

Continued pain
Infection
Possible numbness
Irritation from implants used to support the bone
An excessively shortened metatarsal bone

Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 - 8 weeks, and it can be that long before a patient can put full weight on the foot. In such cases, the patient will need to wear a cast or use crutches. Elderly patients may need wheelchairs.

Treatment: Hammertoes

A hammertoe is a permanent deformity of the toe joint, in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe shrink, and the toe stiffens into a hammer- or claw-like shape.

Hammertoe is most common in the second toe, but it can develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Risks include:

Lying down for long periods
Diabetes
Diseases that affect the nerves and muscles

Click the icon to see an image of a hammertoe.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.

Surgery. Patients with severe cases of hammertome may need surgery. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes require only a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks, and then the pin is removed. One study reported that 92% of patients who had arthroscopy were still pain free after 5 years.

Treatment: Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes. They usually develop when tight-fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. Other causes are:

Fungal infections
Injuries
Abnormalities in the structure of the foot
Repeated impact on the toenail from high-impact aerobic exercise

An ingrown toenail is a condition in which the edge of the toenail grows into the skin of the toe. The big toe is most commonly affected. Symptoms include pain, redness, and swelling around the toenail.

Caring for Toenails. Trim toenails straight across and keep them long enough so that the nail corner is not visible. If the nail is cut too short, it may grow inward. If the nail does grow inward, do not cut the nail corner at an angle. This only trains the nail to continue growing inward. When filing the nails, file straight across the nail in a single movement, lifting the file before the next stroke. Do not saw back and forth. A cuticle stick can be used to clean under the nail.

Treatments. To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water solution of Domeboro or Betadine can help. People who are at increased risk for infections, such as those with diabetes, should have professional treatment.

Antibiotic ointments can treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily, and use the antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removing the nail bed, or removing a wedge of the affected tissue. One study found that orthonyxia, a newer surgical technique that implants a small metal brace into the top of the nail, is as effective as traditional surgical techniques for preventing ingrown toenails from recurring.

Nonsurgical methods can also treat ingrown toenails. One technique uses chemicals to remove the skin. Both sodium hydroxide and phenol may be used, but research shows that sodium hydroxide produces a better outcome and faster recovery than phenol. Other nonsurgical methods include using cauterization (heating), or lasers, to remove the skin.

Treatment: Forefoot Pain

Forefoot pain refers to pain and discomfort felt toward the top of the foot. The rate of forefoot pain and deformity increases with age. When a cause cannot be determined, any pain on the ball of the foot is generally referred to as metatarsalgia.

Forefoot pain may be due to:

Morton's neuroma
Sesamoiditis
Stress fractures

A neuroma usually means a benign tumor of a nerve. However, Morton’s neuroma, also called interdigital neuroma, is not actually a tumor. It is a thickening of the tissue surrounding the nerves leading to the toes. Morton’s neuroma usually develops when the bones in the third and fourth toes pinch together, compressing a nerve. It can also occur in other locations. The nerve becomes enlarged and inflamed. The inflammation causes a burning or tingling sensation and cramping in the front of the foot. Other causes of this condition include:

Tight, poorly-fitting shoes
Injury
Arthritis
Abnormal bone structure

Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toed shoes), pads of various sorts, and cortisone injections in the painful area are also helpful. A combination of cortisone injections and shoe modifications provides better immediate relief than changes in footwear alone. Ultrasound-guided injection of alcohol might also provide relief from Morton's neuroma, research finds.

If these treatments are not effective, the enlarged area may need to be surgically removed. In one long-term study of one surgeon's experience, 85% of patients reported good to excellent satisfaction nearly 6 years after surgery. About 65% were pain free. Some numbness is common afterward, but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another neuroma.

Sesamoiditis is an inflammation of the tendons around the small, round bones that are embedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact activities, such as ballet, jogging, and aerobic exercise.

Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all that is usually required. In severe cases, surgery may be necessary.

A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Women are at higher risk for stress fracture than men.

A fracture in the first metatarsal bone, which leads to the big toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern of normal walking and weight bearing.

Treatment for Stress Fractures. Patients should seek treatment if pain persists for 3 weeks. In a study of young athletes, treatment after that time reduced the chance that they could return to their sport. Surgery may be needed if conservative measures fail. In most cases, however, stress fractures heal by themselves if you avoid rigorous activities. Some health care providers recommend moderate exercise, particularly swimming and walking. It is best to wear low-heeled shoes with stiff soles. Occasionally, a health care provider may recommend wearing a special wooden shoe and a compressive wrap to make walking more comfortable.

Treatment: Heel Pain

The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. Types of heel pain include:

Achilles tendinitis
Bursitis of the heel
Excess pronation
Haglund's deformity
Heel spur syndrome
Plantar fasciitis

Each type of heal pain is described in more detail below. General treatment guidelines are as follows:

The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.
If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy. Surgery may be an option if other methods have failed.

Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury. This condition is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.

People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.

An inflamed or torn Achilles tendon causes intense pain and affects mobility.

Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), may help ease pain and reduce inflammation. It is also helpful to apply ice for 20 - 30 minutes, four or five times a day. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much, and they can pose a risk for rupture of the tendon.)

Gentle Stretching. Gentle calf muscle stretches may also help reduce pain and spasms. If the calf is swollen, elevate the leg. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.

Surgery vs. Nonsurgical Treatment. Chronic inflammation may lead to rupture of the Achilles tendon. If pain continues, the ruptured tendon will require a cast and perhaps surgery, called tendon transfer. Although some experts believe a cast without surgery is a sufficient treatment for such rupture, there is a chance the tendon may rupture again in the future, even after it heals. Some experts suggest surgery for active people and nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although surgery reduces pain and preserves foot function in the long term. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about 5 days and fitted with special footgear (Variostabil, which continuously raised the back of the foot). The footgear was effective for most patients, and the tendon ruptured again in only 5% of cases.

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.

Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.

Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it frequently occurs with high heels. (It can also develop in runners, however.)

Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for more than 30% of patients and, in fact, the condition worsened in 14% of patients who had surgery. A more recent study reported that surgery cured 90% of cases, but patients took 6 months to 2 years to fully recover. Experts advise patients to try all conservative measures before choosing surgery.

Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps serve as a shock absorber for the body.

The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch of the foot. The condition can be temporary, or it may become chronic if ignored. Resting can provide relief, but only temporarily.

Heel spurs are calcium deposits that can develop under the heel bone as a result of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.

Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports. Plantar fasciitis accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to be responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.

Treatment Goals. The three major treatment goals for plantar fasciitis are:

Reducing inflammation and pain
Reducing pressure on the heel
Restoring strength and flexibility

Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed can help relieve the problem. Pain that does not subside with NSAIDs may require more intensive treatments, including leg supports and even surgery.

Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:

Put the hands on a wall and lean against them.
Place the uninjured foot on the floor in front of the injured foot.
Raise the heel of the injured foot.
Gently stretch the injured leg and foot.

With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.

Treatment. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen. NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.

Corticosteroids are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relief in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.

Several non-drug approaches can relieve pressure on the heel, including:

Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics.
Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients. Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, one study found they are equally effective in improving pain.
Elevated Heels. Some people report relief from mild symptoms with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate-to-severe condition. (Heel cups have not been proven to be very useful.)
Orthotics. For severe conditions, such as fallen arches or structural problems that cause imbalance, insoles, called orthotics, molded from a plaster cast of the patient's foot may be needed. (See "Insoles and Orthotics" section).
Extracorporeal Shock Wave Therapy (ESWT). ESWT may be used as an alternative to surgery for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which is believed to trigger healing of the tissues that are causing the pain. Studies show that the treatment provides a very small reduction in heel pain without side effects. It can be considered as an option for patients who haven't responded well to extensive conservative treatment.
Surgery. Surgery may be needed for some patients, typically those who have disabling heel pain that does not respond to other treatments for at least a year. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia. A less invasive method uses a procedure called endoscopy, which requires smaller incisions. Wearing a below-the-knee walking cast after surgery for 2 weeks may reduce the need for pain relief and speed recovery time compared to the use of crutches.
Botox. Small studies show that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduces pain and improves patients' future ability to walk. More research is needed on this treatment.

Treatment: Flat Feet

Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over age 50, but it can occur in anyone. The following are risk factors for PTTD:

Wearing high heels for long periods of time is a particular risk for flat feet. Over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down, and the arch falls.
Some studies have indicated that the earlier a person starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.
Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or the use of corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet pose any significant problems in adults is unknown. For example, one study on athletes with flat feet indicated that they had no higher risk for leg or foot injuries than did athletes with normal arches.

Treatment for Flat Feet in Children. Doctors usually can't diagnose flat feet until a child is 6 years old. Children with flat feet typically don't have symptoms, and often outgrow the condition. Children who are experiencing symptoms might need to change shoes or wear arch supports. In rare cases, minimally invasive joint insert surgery may be an option.

Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression.

In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis that typically lengthen the Achilles tendon and adjust tendons in the foot. One procedure uses an implant to support the arch. These procedures have potential complications. Conservative methods should be tried first.

Treatment: Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.

Claw toe is a deformity of the foot in which the toes are pointed down and the arch is high, making the foot appear claw-like. Claw toe can be a condition from birth or develop as a consequence of other disorders.

Treatment: Tarsal Tunnel Syndrome

Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot. It can occur with:

Diabetes
Back pain
Arthritis
Injury to the ankle
Abnormal blood vessels
Scar tissue that press against the nerve

Magnetic resonance imaging (MRI) and the dorsiflexion-eversion test can diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Specially designed shoe inserts called orthotics can relieve pain from tarsal tunnel syndrome, because they help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are a matter of debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than tarsal tunnel syndrome of unknown cause. It can take months after this surgery for a person to recover and resume normal activities. Only experienced surgeons should perform tarsal tunnel syndrome surgery.

Treatment: Foot Injury

If you suspect that you have broken or fractured bones in a toe or foot, call a doctor, who will probably order x-rays. Even if you can walk, you still might have a fracture. People are often able to walk even if a foot bone has been fractured, particularly if it is a chipped bone or a toe fracture.

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat mild pain caused by muscle inflammation. Aspirin is the most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin (Tolectin). A gel containing ibuprofen can be applied to sore joints. Acetaminophen (Tylenol) is not an NSAID, and although it is a mild pain reliever, it will not reduce inflammation. It is important to note that high doses or long-term use of any NSAID can cause gastrointestinal disturbances with sometimes serious consequences, including dangerous bleeding. No one should take NSAIDs for prolonged periods of time without consulting a doctor.

The acronym RICE stands for rest, ice, compression, and elevation -- the four basic elements of immediate treatment for an injured foot.

Rest. Patients should get off injured foot as soon as possible.
Ice. This is particularly important to reduce swelling and promote recovery during the first 48 hours. Wrap a bag or towel containing ice around the injured area on a repetitive cycle of 20 minutes on, 40 minutes off.
Compression. Lightly wrap an Ace bandage around the area.
Elevation. Elevate the foot on several pillows.

Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE is helpful for remembering how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours, and gentle movement may be beneficial, but don't put pressure on a sprained joint until the pain is completely gone (one to several weeks).

Prevention

The American Podiatric Medical Association offers the following tips for preventing foot pain:

Don't ignore foot pain -- it's not normal. If the pain persists, see a doctor who specializes in podiatry.
Inspect feet regularly. Pay attention to changes in color and temperature. Look for thick or discolored nails (a sign of developing fungus), and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete's foot. Any growth on the foot is not considered normal.
Wash feet regularly, especially between the toes, and dry them completely.
Trim toenails straight across, but not too short. (Cutting nails in corners or on the sides increases the risk for ingrown toenails.)
Make sure shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest, and replace worn out shoes as soon as possible.
Select and wear the right shoe for specific activities (such as running shoes for running).
Alternate shoes. Don't wear the same pair of shoes every day.
Avoid walking barefoot, which increases the risk for injury and infection. At the beach or when wearing sandals, always use sunblock on your feet, as you would on the rest of your body.
Be cautious when using home remedies for foot ailments. Self-treatment can often turn a minor problem into a major one.
It is critical that people with diabetes see a podiatric physician at least once a year for a checkup. People with diabetes, poor circulation, or heart problems should not treat their own feet, including toenails, because they are more prone to infection.

Skin creams can help maintain skin softness and pliability. A pumice stone or loofah sponge can help get rid of dead skin.

Taking a warm footbath for 10 minutes two or three times a week will keep the feet relaxed and help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom salts increases circulation and adds other benefits. Taking footbaths only when the feet are painful is not as helpful.

In addition to wearing proper shoes and socks, walking often -- and properly -- can prevent foot injury and pain. The head should be erect, the back straight, and the arms relaxed and swinging freely at the side. Step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe.

Exercises specifically for the toe and feet are easy to perform and help strengthen them and keep them flexible. Helpful exercises include the following:

Raise and curl the toes 10 times, holding each position for a count of five.
Put a rubber band around both big toes and pull the feet away from each other. Count to five. Repeat 10 times.
Pick up a towel with the toes. Repeat five times.
Pump the foot up and down to stretch the calf and shin muscles. Perform for 2 or 3 minutes.

Early Development. The first year of life is important for foot development. Parents should cover their babies' feet loosely, allowing plenty of opportunity for kicking and exercise. Change the child's position frequently. Children generally start to walk at 10 - 18 months. They should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts.

Shoes. Children should wear shoes that are light and flexible, and since their feet tend to perspire, their shoes should be made of materials that breathe. Replace footwear every few months as the child's feet grow. Footwear should never be handed down. Protect children's feet if they participate in high-impact sports.

Shoes

In general, the best shoes are well cushioned and have a leather upper, stiff heel counter, and flexible area at the ball of the foot. The heel area should be strong and supportive, but not too stiff, and the front of the shoe should be flexible. New shoes should feel comfortable right away, without a breaking-in period.

Well-fitted shoes with a firm sole and soft upper are the best way to prevent many problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. There should be 1/2 inch of space between the longest toe and the tip of the shoe (remember, the longest toe is not always the big toe), and the toes should be able to wiggle upward.

Stand when being measured, and have both feet sized, buying shoes that fit whichever foot is largest. Wear the same socks as you would regularly wear with the new shoes. Women who are accustomed to wearing pointed-toe shoes may prefer the feel of tight-fitting shoes, but with wear their tastes may adjust to shoes that are less confining and properly fitted.

Ideally, the shoe should have a removable insole. Thin, hard soles may be the best choice for older people. Elderly people wearing shoes with thick inflexible soles may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling.

High heels are the major cause of foot problems in women. Although people believe that foot binding is a problem limited to Chinese women of the past, many fashionable high heels are designed to constrict the foot by up to an inch. Women who insist on wearing high-heeled shoes should at least look for shoes with wide toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also keep the amount of time they spend wearing high heels to a minimum.

The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and a looser fit for wider feet. If, after tying the shoe, less than an inch of tongue shows, the shoes are probably too wide. Adjust tightness both at the top and bottom of the shoe. When shoes with high arches cause pain, skip eyelets when lacing them to relieve pressure.

If shoes need breaking in, place moleskin pads next to areas on the skin where friction is likely to occur. Once a blister occurs, moleskin is not effective. Change shoes during the day, and rotate between different pairs of shoes. As soon as the heels show noticeable wear, replace the shoes or their heels.

Avoid extreme variations between exercise, street, and dress shoes.

Exercise and Sports. Shoes purchased for exercise should be specifically designed for a person's preferred sport. For instance, a running shoe should especially cushion the forefoot, while tennis shoes should emphasize ankle support. Athletic socks are almost as important as shoes. Experts often recommend padded acrylic socks.

Occupational Footwear. Because a number of occupations put the feet in danger, workers in high-risk jobs should be sure their footwear is protective. For example, non-electric workers at risk for falling or rolling objects or punctures should wear shoes with steel toes and possibly other metal foot guards. Electric workers should wear footgear with no metal parts (or insulated steel toes) and rubber soles and heels. Chemical workers should wear shoes made of synthetics or rubber, not leather.


Aerobic Dancing	Sufficient cushioning to absorb shock and pressure, which should be many times greater than shock from walking. Arches that maintain side-to-side stability. Thick upper leather support. Box toe. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combo hiking/cycling shoes may be sufficient for the casual biker. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance the forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Enough traction on the sole to prevent slipping. Consider insole or orthotic with arch support for problem feet.
Tennis	Allows side-to-side sliding. Low-traction sole. Snug fitting heel with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch anklebone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Insoles and Orthotics

Insoles are flat cushioned inserts that are placed inside the shoe. They are designed to reduce shock, provide support for heels and arches, and absorb moisture and odor. In general, they can be very helpful for many people.

People respond very differently to specific insoles. What may work for one person may not for another. Consider the thickness of socks when purchasing insoles to be sure they do not squeeze the toes up against the shoes. Insoles can be purchased in athletic and drug stores. Shoe stores that specialize in foot problems often sell customized, but more expensive, insoles. In general, over-the-counter insoles offer enough support for most people's foot problems. Most well-known brands of athletic shoes have built-in insoles.

Brands and Materials. There are many types of insoles available. They are composed of various materials, such as cork, leather, plastic foam, and rubber. Very effective insoles are now made from viscoelastic polymers (such as Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel, and others), which are gel-like materials that act both as liquids and solids.

Heel Cushions for Shortened Achilles Tendons. People who have developed short, tightened Achilles tendons (usually women who have worn high-heeled shoes for prolonged periods) should consider using heel cushions. Like insoles, heel cushions are inserted inside the shoes. They should be at least 1/8 inch thick, but not more than 1/4 inch thick.

For severe conditions, such as fallen arches or structural problems that cause imbalance, podiatrists or physicians may need to fit and prescribe orthotics, or orthoses, which are insoles molded from a plaster cast of the patient's foot. Orthotics are usually categorized as rigid, soft, or semi-rigid.

Before seeking prescription orthotics, people with less severe problems should consider testing the lower-priced, over-the-counter insoles.

Types of orthotics include:

Rigid Orthotics. Rigid orthotics are used to control motion in two major foot joints that lie directly below the ankle. They are often used to prevent excessive pronation (the turning in of the foot) and are useful for people who are very overweight or have uneven leg lengths. Some experts warn that rigid orthotics may cause sesamoiditis or benign tumors from pinched nerves.
Soft Orthotics. Soft orthotics are designed to absorb shock, improve balance, and remove pressure from painful areas. They are made from a lightweight material and are often beneficial for people with diabetes or arthritis. Soft orthotics need to be replaced periodically, and because they are bulkier than rigid orthotics, they may require larger shoes.
Semi-Rigid Orthotics. Semi-rigid orthotics are designed to provide balance, often for a specific sport. They are typically made of layers of leather and cork reinforced by silastic.

Resources

www.apma.org -- American Podiatric Medical Association
www.aofas.org -- American Orthopaedic Foot and Ankle Society
www.acfas.org -- American College of Foot and Ankle Surgeons
www.aapsm.org -- American Academy of Podiatric Sports Medicine
www.apta.org -- American Physical Therapy Association
www.diabetes.org -- American Diabetes Association
http://ndep.nih.gov/campaigns/Feet/Feet_overview.htm -- National Diabetes Education Program
www.arthritis.org -- Arthritis Foundation
www.podiatrynetwork.com -- Podiatry Network

References

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Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.

Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007;28:996-999.

Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007;46:348-357.

Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007;188:1535-1539.

Kruijff S, van Det RJ, van der Meer GT, van den Berg IC, van der Palen J, Geelkerken RH. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148-153.

Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, Heyman ER, Borowsky P, LeMay C. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006;45:196-210.

Review Date:
12/14/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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You Asked: Pulled Calf Muscle?

FitSugar — Fri, 10 Oct 2008 05:30:00 -0700

Dear Fit,
I overdid it running on the treadmill a couple of nights ago. I ran hard and was in a rush so I didn't stretch or cool down. Then I put my heels back on to go to a cocktail party. When I got home, my right calf was aching. It hurts a bit when I walk and feels really tight. I think I pulled it. What can I do to help it heal quickly? Do I ice it? Do I heat it? I haven't worked out in a couple of days and I miss the exercise.
Thanks,
- Kink in My Calf

Ouch! I hate exercise injuries and feel your pain, though I usually injure my hamstrings. I think it is good that you're staying off your calf. To see how I think you should treat this injury, just read more.

First off, it sounds to me like you strained your calf rather than pulled it. A strained muscle is when the muscle is overstretched while working and develops micro tears. Usually it happens when the muscle is being asked to simultaneously stretch and bear weight, like when running. In a pulled muscle, the size of the tears are larger and are considered partial tears. A pulled muscle is much more painful, and generally with a pulled muscle you feel the pain immediately upon injury, creating an "OMG! What have I just done?" moment. It doesn't sound like that happened your case.

The good news is that strained muscles heal much more quickly pulled muscles. It generally takes about two weeks for a strained muscle to completely repair. Initially you want to ice your strained muscle for no longer than 20 minutes at a time. But after 48 hours, transition to heat in the form of baths or heating pads. The initial icing will help keep down any swelling that has occurred in the muscle, then the subsequent heat promotes healing. To reduce the sensation of pain, you can take over-the-counter pain medication.

For healing purposes, the best thing you can do is rest the muscle by avoiding impact activity, like running, and don't try to stretch the muscle until the pain is gone. While I am not sure that wearing heels is what you want to subject your injured calf to, wearing flats with this kind of injury is not beneficial either. You want to keep the heel lifted a bit, so wearing running shoes would be ideal. If that is not your style, you can put a little heel lift in your shoe, but be sure to put one on the non-injured side to keep your legs even. Lifting the heel takes pressure off the calf muscle, and can help during the recovery process.

Once the pain is gone, be sure to stretch and strengthen your calves with some heel raises; I would also do some basic walking before hitting the treadmill again. If you allow the muscle to fully recover, you decrease the chances of reinjuring your calf. A proper warm-up will help prevent injury, too; do some light cardio, then stretch the muscle before running hard. If in two weeks you are still in pain, make an appointment with your doctor to make sure you haven't torn the muscle or tendon.

Sure do hope this helps.

Source

Another Reason to Exercise: Varicose Veins

FitSugar — Mon, 17 Sep 2007 12:30:00 -0700

Have varicose veins and looking for a way to keep them under check? Or worried about getting varicose veins in the future?

Well exercise is an easy and effective way to relieve and prevent varicose veins -- gnarled, enlarged veins. Exercise helps push stagnant blood from the bottom of the legs back to the heart. Furthermore, Luis Navarro, M.D., founder and director of the Vein Treatment Center and senior clinical instructor of surgery at Mount Sinai School of Medicine, suggests working your calf muscles more too. "When you exercise your calf muscles, they act as a pump, taking over for weak valves," Dr. Navarro explains. "So the stronger your calf muscles, and the more you move them, the better." Many women find that exercising on a regular basis helps to ease the pain and discomfort associated with varicose veins and can help prevent the condition from worsening.

So start moving ladies and hop on the calf raise machine at the gym or simply do a few standing calf raises (raise yourself onto your toes and lower your heels back down to the floor) at home to work those calves. Your legs will thank you!

Source

Peripheral artery disease and intermittent claudication

FitSugar — Wed, 08 Oct 2008 17:35:09 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Peripheral Artery Disease (PAD) Risks

Smoking, unhealthy cholesterol levels, and diabetes are the main risk factors for PAD. According to a 2006 study in Circulation, they affect PAD in different ways:

Smoking and high cholesterol are more likely to cause PAD progression in the large vessels of the legs. Painful cramps in the hips, thighs, and calves -- especially those that occur during exercise -- are the tell-tale symptoms.
Diabetes is more likely to cause PAD progression in the small vessels of the feet. Symptoms include foot ulcers that are slow to heal.

According to the American Heart Association, quitting smoking is the best way to prevent PAD and slow its progression. Patients should also control cholesterol through exercise, diet, and medications.

PAD and Heart Disease

Patients with PAD have a 1 in 5 chance of having a heart attack or stroke, or dying from a heart-related event, within the course of a year, indicates a 2007 study in the Journal of the American Medical Association (JAMA). Blood clots in other arteries (brain, heart) further double this risk.
PAD also increases the risk of dying from heart surgery or other interventional heart procedures, suggests a 2006 Journal of the American College of Cardiology study. Surgeons should take extra care when treating patients with PAD.

Exercise is Essential

Exercise is important for preventing PAD, and essential for those with the disease. According to a 2006 Circulation study, patients with PAD who are the most physically active have a third of the chance of dying than those who are inactive.
For patients who have difficulty walking, arm aerobics may be a helpful alternative and can actually help improve walking ability, suggests research presented at the 2006 American Heart Association Scientific Sessions.

Introduction

Peripheral artery disease (PAD) occurs when the arteries in the extremities (feet, legs, hands, and arms) become clogged with a fatty substance called plaque. It most often occurs in the legs. The build up of plaque causes the arteries to become narrow and hard, which obstructs blood flow. This hardening of the arteries is called atherosclerosis. (Atherosclerosis that affects arteries to the heart and brain is the major process leading to heart disease and stroke.)

PAD is also called peripheral arterial disease and peripheral vascular disease.

Atherosclerosis of the extremities is a disease of the peripheral blood vessels. It is characterized by narrowing and hardening of the arteries that supply the legs and feet. The narrowing causes a decrease in blood flow. Symptoms include leg pain, numbness, cold legs or feet, and muscle pain in the thighs, calves or feet.

Symptoms

People with peripheral artery disease (PAD) may or may not have symptoms. Because of silent symptoms, many cases of PAD go undiagnosed.

Claudication comes from the Latin word "to limp." Claudication is crampy leg pain that occurs during exercise, especially walking. The pain is due to insufficient blood flow in the legs (caused by blocked arteries). Intermittent means the pain comes and goes. Intermittent claudication is the most prominent symptom of PAD. About a third to a half of patients with PAD have this symptom.

The most frequently affected artery in intermittent claudication is the popliteal artery. This artery leads off from the femoral artery (the major artery in the thigh). It continues below the knee where it branches off and carries blood to the muscles in the calf and foot. You should be sure to talk to your doctor about any leg or thigh pain you are experiencing.

PAD-related leg pain is relieved only by rest. Leg pain occurs in one leg in 40% of patients and in both legs in 60% of patients. Patients may also experience fatigue or pain in the thighs and buttocks.

There is also some evidence that people with PAD have blood cells that are prone to forming clots.

In advanced cases, the arteries are so blocked that even rest does not help. Leg pain that continues when lying down is called ischemic rest pain. Ischemia is the medical term for insufficient blood flow to tissues.

People with ischemic rest pain are at risk for ulcers and gangrene. In severe cases, amputation may be required.

Symptoms of advanced PAD can include:

Calf muscles that shrink (wither)
Hair loss over the toes and feet
Thick toenails
Shiny, tight skin
Painful non-bleeding ulcers on the feet or toes (usually black) that are slow to heal

In some cases, blood clots form in the arteries in the legs, producing abrupt symptoms.

Risk Factors

About 10 million American adults have peripheral artery disease (PAD). Although it was once believed that PAD occurs more often in men than women, current research now indicates that both genders are equally susceptible. African-Americans have twice the risk for PAD as Caucasians.

The most important risk factors for PAD and intermittent claudication are the same as the major risk factors for heart disease and stroke. People with a combination of these conditions (including PAD) are at increased risk of a more severe form of the heart or circulatory disease. Smoking and high cholesterol levels may increase the risk for PAD progression in large blood vessels (such as the legs), while diabetes increases the risk for PAD in small blood vessels (such as the feet). Quitting smoking and controlling cholesterol are the two best ways to slow PAD progression.

The most important risk factors for PAD include:

Smoking. Experts believe that smoking is the number one risk factor for PAD and that smoking even a few cigarettes a day can interfere with PAD treatment. Smoking increases the risk for PAD by 2 - 25 times, with the danger being higher when other risk factors are present. One study reported that 90% of patients with PAD were current or former smokers. [See In-Depth Report #41: Smoking.]
Diabetes. People with type 2 diabetes have 3 – 4 times the normal risk for PAD and intermittent claudication. In fact, their risk for PAD is higher than their risk for heart disease. People with type 2 diabetes also tend to develop PAD at an earlier age and have more severe cases. Patients with both diabetes and PAD are at high risk for complications in the feet and ankles. In one study, people with diabetes and intermittent claudication had a 30% chance of developing skin ulcers on their legs. [See In-Depth Report #60: Diabetes - type 2.]
Unhealthy cholesterol and lipid levels. The risk for PAD increases by 10% with every 10 mg/dL increase in total cholesterol levels. Low levels of high-density lipoprotein (HDL, the so-called good cholesterol) and high triglyceride levels also increase the risk for PAD. [See In-Depth Report #23: Cholesterol.]
Hypertension. High blood pressure doubles the chances for PAD. [See In-Depth Report #14: High blood pressure.]

Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.

Family history of heart and artery disease. Genetic factors that cause specific lipid and cholesterol abnormalities may increase the risk for PAD.
Artery inflammation and damage. High levels of C-reactive protein can indicate persistent inflammation in the arteries. Such inflammation can cause significant damage in blood vessels, and is highly associated with PAD
Age. PAD occurs more frequently in people over age 50 and affects 12 – 20% of Americans age 65 years and older.
Ethnicity. African-Americans are at highest risk for PAD. They are twice as likely to develop PAD as Caucasians.

Homocysteine. Abnormally high blood levels of the amino acid homocysteine have been linked to an increased risk of heart disease, stroke, and PAD. Excessive levels occur with deficiencies of vitamins B6, B12, and folic acid. Scientists are continuing to research connections between homocysteine and heart and vascular disease. Some experts believe that high levels of homocysteine are only indicators, not causes, of heart disease.

Click the icon to see an image of vitamin B12 sources.

Click the icon to see an image of sources of folate.

Infectious Organisms. Some microorganisms and viruses may be able to trigger the inflammation and damage in the arteries that contribute to heart disease and peripheral artery disease.

The primary suspect has been Chlamydia pneumoniae, a non-bacterial organism that causes mild pneumonia in young adults. In one study, treatment with antibiotics in patients with evidence of a previous C. pneumoniae infection appeared to reduce PAD-related plaque build up. However, until better studies are conducted, experts do not recommend antibiotics to treat heart disease or PAD even in patients with evidence of C. pneumoniae.

It should be noted that many people have been infected with C. pneumoniae, and some studies have found no evidence that it increases the risk for heart disease.

Diagnosis

PAD is greatly under diagnosed. Many patients do not report symptoms, or may not even have symptoms. People should be checked for peripheral artery disease if they have risk factors for heart disease, leg pain during walking, or ulcers on their legs.

The doctor should perform a number of physical examinations to check for high blood pressure, heart abnormalities, blockage(s) in the artery in the neck, and abdominal aneurysms. The doctor should also examine the skin of the legs and feet for color changes, ulcers, infection, or injuries, and check the pulse of the arteries in the leg.

Intermittent claudication caused by peripheral artery disease is typically diagnosed using a procedure called Doppler ultrasound and a calculation called the ankle-brachial index. This method is also proving to be a helpful way to diagnose PAD in patients without symptoms of intermittent claudication.

The procedure is done as follows:

The doctor measures the systolic blood pressure of both arms while the patient is lying down. (The systolic pressure is the "top" number in a blood pressure measurement. It is the force that blood exerts on the artery walls as the heart contracts to pump out the blood. For example, in a blood pressure reading of 120/80, 120 is the systolic number.)
The doctor then puts blood pressure cuffs on four different locations on each leg. An ultrasound probe is passed over arteries in the foot. The signal emitted from the strongest artery is recorded as the cuffs are inflated and deflated. This is the ankle's systolic pressure.

The doctor divides the systolic pressure in the ankle by the systolic pressure in the arm. The result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API).

What the results mean:

ABI over 0.90. This result often rules out PAD, but if the patient has specific risk factors for artery disease, the doctor may still suspect PAD. In such cases, the patient takes a treadmill test and another ABI measurement. If the API index drops, then the doctor makes a diagnosis of peripheral artery disease.
ABI below 0.90. This is usually sufficient information to diagnose PAD. The lower the index the greater the risk for heart attack, stroke, or other serious circulatory or heart events. (In patients with diabetes, the doctor may perform additional tests, which may include ultrasound, pressure measurement in the first toe, or others that might confirm or dismiss a diagnosis of PAD.)
ABI less than 0.50. These measurements are highly associated with impaired leg function.
ABI less than 0.40. These measurements indicate very severe blockage in the leg arteries and a risk for gangrene.

MRA is a type of magnetic resonance imaging (MRI). It provides a non-invasive alternative to a traditional angiogram. The MRA uses a magnetic field and radiofrequency waves to provide pictures of arteries and blood vessels. An angiogram uses dye, which is injected through a catheter that is inserted in the groin. MRA patients are given gadolinium (a contrast material) through an IV to improve the image quality.

A new technology called computed tomography angiography (CTA) uses x-rays to visualize blood flow in arteries throughout the body. This technique is highly effective in diagnosing PAD.

A patient is often given a treadmill test if the ankle-brachial index is questionable. Patients with claudication have a 50 - 60% reduction in peak performance, which is comparable to that in patients with congestive heart failure. The treadmill test is also useful for determining the severity of the pain while walking and for assessing the effectiveness of treatments.

A test called a wave form analysis may be used to confirm an abnormal API or pressure reading. The patient lies on their back for at least 10 minutes in a warm room (so that the blood vessels will not narrow). The leg is turned outward, and the knee is slightly bent. The doctor passes a handheld scanner over the leg, which picks up sound waves coming from the arteries. These signals are recorded, and the wave forms are traced to detect abnormal blood flow.

Patients with suspected PAD should have an electrocardiogram (ECG) and other tests that would detect heart problems. Evidence suggests that heart disease may be under diagnosed in patients with PAD. In one study, a third of patients had silent ischemia, which is heart disease without angina, the chest pain that indicates blockage of blood flow to the heart.

The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. There are several different types of electrocardiograms.

A number of other tests may be ordered to rule out disorders with similar symptoms. Such disorders include:

Arthritis
Anemia
Spinal stenosis -- narrowing of the spinal canal causing leg or lower back pain

Click the icon to see an image of spinal stenosis.

Thrombophlebitis -- blood clots in the deep veins of the legs

Click the icon to see an image of thrombophlebitis.

Peripheral neuropathy -- nerve damage in the legs and feet, usually in people with diabetes
Night cramps in older people that are not due to problems in blood vessels
Muscle entrapment of the arteries or kinks in the arteries in the leg -- typically occur in young athletes
Adventitial cystic disease -- a rare disorder that produces cysts that block the popliteal and other arteries and typically occurs in young people

Complications

Patients with peripheral artery disease (PAD) have the same risk of death from heart events or stroke as people with heart disease. The risk increases as PAD gets worse. The worse the leg condition, the poorer the overall health of the patient.

According to a 2007 Journal of the American Medical Association study, patients with PAD have a 21% chance of having a heart attack or stroke, or dying from a heart event, within 1 year. If patients have blood clots and blockages in other arteries (brain, heart) as well as the legs, this risk doubles. Another 2007 study indicated that patients with PAD also have an increased risk of dying shortly after heart surgery or other interventional procedures, such as heart catheterizations.

Although signs of heart disease are detected in only 20 - 40% of patients with PAD after an initial diagnosis, studies suggest that when intense heart-diagnostic tests are performed (such as angiography or thallium stress tests) co-existing heart disease is detected in up to 90% of all patients with PAD.

The pain from intermittent claudication in the legs itself clears up in 40% of patients (although this does not eliminate any accompanying heart risks). Damage in the leg from oxygen loss progresses in about 35% of patients. Ischemic rest pain develops in about 10% of patients. This condition can lead to ulcers, gangrene, and, in extreme cases, amputation. People with diabetes are at highest risk for these complications.

In rare cases, blood clots can develop suddenly in a major artery in the leg -- a condition called acute occlusion. Symptoms include numbness, pain, coolness, pale color, lack of pulse in the artery, and weakness. This is a very serious event, which can lead to amputation or even loss of life. Treatment options include clot-busting drugs delivered to the blockage or surgery to remove the clot.

Peripheral artery disease can significantly impair daily physical functioning. Claudication pain severely limits physical activity. Even worse, intermittent claudication increases the risk for falling, usually because of unsteadiness, regardless of the severity of PAD. Intermittent claudication and PAD are also associated with mental decline.

Lifestyle Changes

There are two treatment goals for PAD and claudication:

Manage the pain of intermittent claudication, improve functioning, and prevent PAD from getting worse, so that gangrene does not occur
Reduce the risk for cardiovascular disease (heart attack and stroke)

Evidence indicates that even when patients are treated for PAD, they are frequently not given information or therapies to reduce the risk for heart disease.

Lifestyle changes are critical for every patient with PAD. Medication is often required to improve function and protect the heart. In very severe cases, surgery may be needed to improve blood flow.

People with type 2 diabetes have three to four times the risk for PAD and intermittent claudication. They also tend to develop PAD at earlier ages and to have a significant risk for heart disease. Patients with both diabetes and PAD should be screened for heart disease. In a 2003 study, aggressive reduction of blood pressure in patients with PAD who had diabetes significantly reduced their risk for heart attack and stroke. Aggressive reduction of cholesterol levels, usually with a statin drug, is equally important.

Patients who smoke should quit. Smoking is one of the primary risk factors for PAD and a major cause of complications. Quitting smoking may not make leg pain go away, at least not in the short term, but it certainly may keep blockages from getting worse. This reduces the risk to the heart.

In addition to quitting smoking, exercise is the most important lifestyle change patients with PAD and intermittent claudication can make.

Exercise to Help the Heart. The benefits of regular moderate exercise for the heart are undisputed. People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. And, patients with PAD who are physically active have death rates that are a third of those who are less physically active, according to a 2007 American Heart Association report. Some studies suggest it is not the length of a single exercise session that counts, but the total daily amount of energy expended. Several, short sessions of intense exercise can be particularly helpful for older people.

Exercise Training to Improve Blood Flow in the Legs. Exercise training improves blood flow in the legs and, in some cases, can work as well as medications and surgical procedures in increasing pain-free walking distance. To maintain benefits, exercise must be regular and consistent. A 2006 study suggested that a regular walking program can significantly slow the rate of functional decline associated with PAD. Patients in the study walked three times a week.

Some patients with intermittent claudication find that their leg cramps make it difficult to walk or participate in lower-extremity exercise. A 2006 study suggested that upper-body aerobic exercise can still provide benefits. By increasing oxygen and blood flow through the body, arm aerobics may help reduce leg pain and improve a patient’s ability to walk. Patients in this study used an arm ergometer, a table-top device similar to bicycle pedals that is operated with the arms rather than the legs.

The goals of a heart-healthy diet are to:

Reduce overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart
Increase high-density lipoproteins (HDL), which are beneficial for the heart
Reduce other harmful lipids (fatty molecules) such as triglycerides and lipoprotein(a)

Any diet should also help keep blood pressure and weight under control.

General Recommendations. Although there are many major dietary approaches for protecting health, experts generally agree on the following recommendations for heart protection:

Choose fiber-rich food (whole grains, legumes, nuts) as the main source of carbohydrates, along with a high intake of fresh fruits and vegetables.

Dietary fiber is the part of food that is not affected by the body's digestive process. Only a small amount of fiber is metabolized in the stomach and intestine. The rest is passed through the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber, soluble and insoluble. Soluble fiber retains water and turns to gel during digestion. It also slows digestion and nutrient absorption from the stomach and intestine. Soluble fiber is found in foods such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables, and whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight management. One of the best sources of fiber comes from legumes, the group of food containing dried peas and beans.

Avoid saturated fats (found mostly in animal products) and transfatty acids (found in hydrogenated fats and many commercial baked products and fast-foods). Choose unsaturated fats (particularly omega-3 fatty acids found in vegetable and fish oils).

Click the icon to see an image of saturated fats.

Click the icon to see an image of trans-fatty acids.

When selecting proteins, choose soy protein, poultry, and fish over meat.
Weight control, quitting smoking, and exercise are essential companions of any diet program.

[See In-Depth Report #43: Heart-healthy diet.]

In general, no vitamins have been proven to reduce the risk for PAD or heart disease. Deficiencies in the B vitamins folate and B12 have been linked with elevated levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease and PAD. This association led researchers to examine the effects of vitamin B supplements on heart and vascular diseases. Results from several recent studies, however, indicate that while vitamin supplementation lowers homocysteine levels, it has no effect on heart disease outcomes.

Glutathione. Glutathione is a natural antioxidant produced in animal and plant cells. In one small study, patients who took it could walk with no pain, and there seemed to be an improvement in blood flow. More studies are needed.

Gingko. An analysis of eight studies reported that the herb ginkgo biloba has some modest effect on pain-free walking. The herbal remedy has blood-thinning properties. It is available over the counter.

Pine Bark Extract. Pine bark extract (Pycnogel) may help improve blood flow to muscles and reduce leg cramps, according to a small 2006 study of patients with intermittent claudication.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

The following is of special concern for people taking natural remedies for peripheral artery disease:

Ginkgo. Although the risks for gingko appear to be low, there is an increased risk for bleeding at high doses and interaction with high doses of vitamin E and anti-clotting medications. This is particularly important because patients with PAD often use these types of medications. Commercial gingko preparations have also been reported to contain colchicine, a chemical that can be harmful in pregnant women and people with kidney or liver problems.

Medications

Treatments for PAD help manage leg pain and improve function, as well as reduce the risk for heart attack and stroke. Drugs used for improving leg pain and function are generally those that either prevent blood clots (typically anti-platelet drugs) or open blood vessels. Such drugs also help protect the heart.

Experts now recommend that patients with PAD be given treatments for managing both heart risk factors and intermittent claudication.

Antiplatelet drugs thin the blood and reduce the risk for clots. They are used in mild PAD cases, for intermittent claudication, and to prevent blood clots after surgery.

Aspirin. Aspirin is the main antiplatelet drug used to treat chronic intermittent claudication, particularly in patients who also are at risk for heart attack and stroke. The drug improves leg circulation and, when used in early PAD, may prevent clots from forming in the veins.

Clopidogrel. Clopidogrel (Plavix) is a powerful type of drug called a thienopyridine. Some experts recommend it for patients with both PAD and intermittent claudication. In patients with PAD, it may protect the heart and arteries better than aspirin. Ticlopidine (Ticlid) is another effective thienopyridine that has been used for patients with PAD, but dangerous blood disorders, (particularly thrombocytopenia), have been reported in patients who had taken it for heart disease.

Phosphodiesterase inhibitors are drugs that help keep blood vessels open and blood flowing.

Cilostazol. Cilostazol (Pletal) is used to treat disabling intermittent claudication. A number of studies have reported that the drug helps improve walking distance and quality of life. It also helps improve HDL and triglyceride levels. Cilostazol works better than pentoxifylline, the first drug approved for claudication. It is expensive, however, and currently only recommended for patients who do not respond to aspirin or less costly treatments. Common side effects include headache, swelling in the limbs, and stomach problems such as diarrhea and flatulence (gas). It does not appear to have bad effects on the liver or kidney. Similar drugs have had serious side effects in patients with heart failure, so such individuals should avoid cilostazol.

Pentoxifylline. Pentoxifylline (Trental) reduces the sticky properties of blood, improving its flow. It is approved in the U.S. for managing claudication, although experts do not recommend its routine use. Studies regarding the drug's effectiveness have been mixed. Some studies have reported a small effect on walking ability; another found the drug significantly improved walking distance. Other research has found that the drug does not work any better than a dummy pill (placebo). The most common side effects include headache, nausea, heartburn, flatulence (gas), dizziness, blurred vision, and flushing.

Dipyridamole. Dipyridamole may help prevent complications of PAD when taken along with aspirin. Studies are mixed on the benefits of the combination. Without aspirin, the drug does not appear to have any advantages for patients with PAD.

Alteplase (Activase), also called t-PA, and reteplase (Retavase) are thrombolytic drugs. Such drugs are commonly called "clot-busters." They break up existing clots, and may be used in cases of acute vascular occlusion (the sudden development of a blood clot). They may also be used if a clot is present. Researchers are investigating whether thrombolytics are an effective alternative to surgery in severe cases of PAD. In severe cases, the drugs can be delivered directly into the artery.

Ramipril. The ACE inhibitor ramipril (Altace) improved blood flow to the legs, reduced leg pain, and helped maximize walking time in a small 2006 study of patients with intermittent claudication. Researchers still have to study whether this medication works best for specific patients (such as those with high blood pressure or diabetes).

Naftidrofuryl. Naftidrofuryl (Nafronyl) is available in Europe for intermittent claudication. It is not approved in the United States. Nafronyl is an anti-platelet drug that also blocks serotonin. This action helps damaged muscle tissue absorb more oxygen from blood. Nafronyl appears to improve quality of life and treadmill walking. However, one study found it did not improve overall walking distance.

Growth Factors. Growth factors help new blood vessels grow, an action called angiogenesis. Studies show that recombinant fibroblast growth factor-2 (FGF-2) improves intermittent claudication, even in low doses. The drug may have severe side effects, and long-term safety is unknown. A drug called vascular endothelial growth factor (VEGF) is also under investigation.

Mesoglycan. Mesoglycan has been studied for a few years. This drug breaks up blood clots, and studies have suggested that oral mesoglycan may improve walking distance.

Prostaglandins. Prostaglandins relax smooth muscles and open the blood vessels, which improves blood flow. These types of drugs are called vasodilators. Some may have anti-clotting activity.

Prostaglandin E1. Early studies on prostaglandin E1 in intermittent claudication have been promising. However, more recent studies have not reported significant benefits. The drug is injected.
Beraprost. Beraprost is a prostaglandin that can be taken by mouth. Early studies suggested that it might allow patients with intermittent claudication to exercise for longer periods of time. Subsequent studies have not confirmed these positive results. Side effects include headache, stomach distress, and anemia, although they appear to be mild.

Phlebotomy. Phlebotomy, the removal of blood from the body, is sometimes used to reduce the excess iron that accumulates in patients with PAD. However, a 2007 Journal of the American Medical Association study found that reducing iron stores did not significantly lower the risk of heart attack, stroke, or death in patients with PAD.

Reducing Heart Risks

If a patient cannot control heart risk factors with lifestyle measures, treatment may be needed.

It is very important for people with PAD to keep their LDL ("bad cholesterol") levels to below 100 mg/dL. If patients have serious heart disease risk factors (high blood pressure, diabetes, other unhealthy lipids) in addition to PAD, they may need to aim for LDL levels below 70 mg/dL. Aggressive control of cholesterol levels is known to reduce death rates in patients with peripheral artery disease (PAD). Unhealthy cholesterol levels are major contributors to atherosclerosis, the common factor in PAD and heart disease. Many experts now recommend that patients with PAD receive drugs to lower cholesterol.

A number of medicines are available for lowering cholesterol. Those discussed in this report may have particular benefits for patients with PAD. [See In-Depth Report #23: Cholesterol.]

Statins. Statins are the most effective drugs for the treatment of high cholesterol. Statins block the liver enzyme hMG-CoA reductase, which the body uses to make cholesterol. Statins are particularly effective for lowering LDL levels and triglycerides. They also raise HDL levels, but not as much as other anti-cholesterol drugs.

Statins include:

Lovastatin (Mevacor)
Pravastatin (Pravachol)
Simvastatin (Zocor)
Fluvastatin (Lescol)
Atorvastatin (Lipitor)
Rosuvastatin (Crestor)

Statins reduce the risk of heart attack and stroke. Evidence strongly suggests that statins have specific benefits for patients with PAD. In a 2003 study, statin use was associated with improved leg function, regardless of the patients' cholesterol levels.

Statins improve the function of the lining of blood vessels, which improves blood flow.
Statins appear to reduce inflammation in the arteries, which is now believed to be a major factor in blood vessel injury.
Some evidence suggests that statins might promote growth of new blood vessels and help prevent intermittent claudication.

Side effects of statins include headaches, skin rashes, muscle aches, sexual dysfunction, drowsiness, dizziness, nausea, constipation, and peripheral neuropathy (numbness or tingling in the hands and feet).

Statins can also cause an uncommon condition called myopathy. Myopathy can cause muscle damage and, in some cases, muscle and joint pain. The risk for myopathy increases with higher doses. The following increases one's risk of myopathy

Older age
Small size or frailty
Alcohol abuse
Hypothyroidism
Use of multiple medications

There is also a higher risk of myopathy if statins are used before surgery.

Statins also can affect the liver, particularly at higher doses, so periodic liver function tests should be done. Statins should not be taken by anyone with liver problems or by women who are pregnant or breast-feeding.

Nicotinic Acid (Niacin). Nicotinic acid is the active compound found in niacin (vitamin B3). It raises HDL levels more than any other anti-cholesterol drug, and is the first choice for patients with low HDL levels. Nicotinic acid is also extremely effective in reducing triglyceride levels. It may be beneficial for some patients with PAD.

Brands of nicotinic acid include Niacor, Nicolar, and Slo-Niacin. An extended-release form (Niaspan), taken at bedtime, may have fewer side effects than other types of niacin. Although niacin is available over-the-counter, the active form used for cholesterol is given in much higher doses and is available only by prescription. It is important to take this medication under a doctor's direction in order to ensure its safety and effectiveness. Combinations with other drugs, particularly statins, may add significant benefits.

Many patients can not tolerate the side effects of niacin. About a quarter of patients taking rapid-acting forms of nicotinic acid stop taking them. The most common side effects are flushing of the face and neck, itching, headache, blurred vision, and dizziness. They can occur between 5 minutes to hours after taking the drug and can last for varying lengths of time. The body does get used to these effects eventually, so they generally go away. Gastrointestinal problems are common. Other side effects include dry skin and mucous membranes and darkening of the skin.

About 3 - 5% of people taking nicotinic acid develop liver abnormalities, which go away after the medication is stopped. The extended form of Niaspan appears to be safe for the liver, but people with chronic liver disease should not use any form of nicotinic acid. People with gout should avoid nicotinic acid, since it elevates uric acid.

The role of nicotinic acid in people with diabetes is less clear. About 30% of patients who take niacin have a jump in blood glucose levels. But some studies have reported that diabetics who use niacin had little trouble with glucose control. Niacin's effects on HDL and triglycerides are especially suited for the lipid imbalances that are common in diabetes.

Fibrates. Fibrates (sometimes called fibric acid derivatives) break down the particles that make triglycerides. Gemfibrozil (Lopid) is the standard fibrate. Newer fibrates, including fenofibrate (Tricor) and bezafibrate (Bezalip), may be more effective in lowering cholesterol than gemfibrozil. Most fibrates have been shown to lower the risk of heart attack. A study on fenofibrate suggested that it reduced certain clotting factors (another risk factor for heart disease).

Fibrates may be good choices for many patients who need to lower triglyceride levels and increase HDL, but who cannot take nicotinic acid.

In one study, patients with PAD who took bezafibrate experienced fewer non-fatal heart attacks and the severity of intermittent claudication was reduced.

Side effects of fibrates may include gastrointestinal discomfort, aching muscles, sensitivity to sunlight, and skin rashes. Impotence has been associated with fibrates in less than 1% of patients. Fibrates have been known to cause gallstones, so people with gallbladder problems should not use these drugs. The drugs may cause abnormal heart rhythms and can affect the liver and kidney. They interact with a number of drugs including warfarin, some oral drugs used for diabetes, and certain antibiotics. Fibrates also interact with grapefruit juice.

Evidence suggests that best drugs for patients with high blood pressure and PAD may be angiotensin-converting-enzyme (ACE) inhibitors. These drugs block the effects of the angiotensin-renin-aldosterone system, which is thought to have many harmful effects on the heart and blood vessels.

ACE inhibitors include:

Captopril (Capoten)
Enalapril (Vasotec)
Quinapril (Accupril)
Benazepril (Lotensin)
Ramipril (Altace)
Perindopril (Aceon)
Lisinopril (Prinivil, Zestril)

They are important drugs for patients with PAD and diabetes who also have high blood pressure.

Side effects include an irritating cough, excessive drop in blood pressure, and allergic reactions. In some people, the cough is intolerable. Iron supplements or the drug picotamide may help reduce the frequency of coughs.

One rare, but severe, side effect is granulocytopenia, which is an extreme reduction in white blood cells.

In rare cases (0.3%), patients who take ACE inhibitors suffer a sudden and severe allergic reaction called angioedema, which causes swelling in the eyes and mouth and may close off the throat.

Although ACE inhibitors can protect against kidney disease, they also increase potassium retention in the kidneys. This increases the risk for cardiac arrest if levels become too high. Because of this, ACE inhibitors are generally not given with potassium-sparing diuretics or potassium supplements.

ACE inhibitors can harm a developing fetus and should not be used during pregnancy.

[See In-Depth Report #14: High blood pressure.]

Surgery

In severe cases, surgery may be needed to open blocked blood vessels. Many surgical procedures can be accomplished with minimally invasive endovascular techniques, such as angioplasty and stenting, which can help open small blocked arteries below the knee and prevent amputation. If there is extreme blockage in the leg artery, bypass surgery and vein grafting may be required.

For many years, leg bypass surgery was the main type of surgery used for extensive PAD. This procedure involves the creation of a tube (graft) that acts as a new blood vessel. Grafts can be made from synthetic material (artificial vein) or from a vein taken from a different location in the patient's leg (natural vein). The graft reroutes blood flow in the leg, around the blocked artery. In one study, the natural vein remained open after 4 years in nearly half of the patients, while the synthetic vein (made from polytetrafluoroethylene [PTFE]) had closed in all but 12% of patients.

Artificial veins tend to pose a much higher risk for blood clots, and the consequences of re-blockage are must more severe than when the natural vein recloses. To keep the artificial vein open, oral anti-clotting drugs such as aspirin or warfarin, may be used. (Such drugs do not work at all with natural vein bypass.)

In general, less invasive surgical procedures such as balloon angioplasty and stenting are now more frequently performed.

Percutaneous transluminal angioplasty (PTA) is an approach that has several variations. The object of the procedure is to open the blocked blood vessels that are causing intermittent claudication. Angioplasty is being increasingly used, especially in patients who have other medical conditions. Some experts believe that it is less expensive and more effective than leg bypass surgery.

The PTA procedure requires only a local anesthetic. Patients can return to normal activity in 24 - 48 hours. Complication rates are low. The effects are not permanent, but the procedure can be repeated without any greater risk than with the original one.

Anticoagulants such as warfarin or heparin and antiplatelets such as aspirin may used to prevent blood clots occurring during surgery. All of these drugs increase the risk for bleeding. Thrombolytic drugs may be used before, during, or after angioplasty if a blood clot is present.

Reclosure of the blood vessels from blood clotting, even long after surgery, is an important complication. Repeat surgery may be needed. Major complications following surgery include pneumonia, stroke, kidney failure and heart attack.

Balloon Angioplasty. The standard procedure is balloon angioplasty. A thin tube is inserted through an artery in the groin and passed through the blocked artery. A wire is threaded through the tube. A deflated balloon is passed over the wire to the blockage. When inflated, it opens the artery.

Because of the risk for reclosure from blood clots after balloon angioplasty, various other procedures are used or are being investigated.

Stenting. More recent angioplasty techniques use an expandable metal mesh tube (stent). A self-expanding stent called the SMART stent was approved in late 2003. The SMART stent is used specifically for patients whose PAD is caused by a blockage in the iliac artery, which runs through the pelvic area. Stents can be effective in opening arteries, but 20 - 30% of patients have new blockages within a year of surgery. In 2005, researchers began testing a drug-eluting stent coated with paclitaxel. They hope that the drug may prevent blockages from recurring in the leg arteries. A paclitaxel-eluting stent is already approved in the U.S. for treating coronary artery disease.

Drug-eluting stents may not be recommended for patients who had recent heart surgery, or women who are nursing or pregnant. Patients who receive a drug-eluting stent may need blood thinning drugs for at least several months.

Drug-Coated Balloon. A new technique uses a drug-coated balloon instead of a stent. The balloon is sprayed with paclitaxel. When the balloon is inflated inside the leg artery, the drug is transferred to the plaque that is causing the blockage. Doctors think that this type of minimally invasive angioplasty surgery might provide an important alternative to stents. Although stents have been very useful in heart surgery, they can sometimes cause later complications in PAD.

Brachytherapy. Another approach uses radioactive implants (brachytherapy) in combination with PTA, which help prevent the arteries from closing after angioplasty. In a major 2002 analysis, this approach produced greater benefits compared to PTA alone, at least in the short term.

Laser Treatment. Laser light pulses are being investigated as a way to vaporize cholesterol plaque and blood clots from the blood vessels. A 2004 report suggested that laser therapy may be particularly useful in patients with PAD who are not good candidates for bypass surgery.

PolarCath. A new type of angioplasty treatment called PolarCath opens blocked arteries by cooling and dilating them with a nitrous oxide-filled balloon. A 2004 study showed that this procedure, also called CryoPlasty therapy, has a 9-month failure rate of less than 20%, which is significantly lower the 40 - 50% failure rate reported after angioplasty or stenting procedures.

Intermittent pneumatic compression (Arterial Flow, VenaFlow) is a mechanical technique normally used to treat leg ulcers or swelling from fluid build-up. The device is an inflatable fabric device that goes around the lower leg. The inflated device puts pressure on the limb. Some devices apply pressure in a wave-like motion that simulates the natural increase in blood flow during walking. A 2002 analysis of 26 studies suggested that this treatment may be beneficial for patients with PAD who cannot undergo surgery. It may even prove to be a viable alternative to medical treatments in some cases.

Resources

www.padcoalition.org/wp -- Peripheral Arterial Disease Coalition
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.americanheart.org -- American Heart Association
www.acc.org -- American College of Cardiology
www.diabetes.org -- American Diabetes Association
www.vdf.org -- Vascular Disease Foundation
www.sirweb.org -- Society of Interventional Radiology

References

Aboyans V, Criqui MH, Denenberg JO, Knoke JD, Ridker PM, Fronek A. Risk factors for progression of peripheral arterial disease in large and small vessels. Circulation. 2006 Jun 6;113(22):2623-9.

Ahimastos AA, Lawler A, Reid CM, Blombery PA, Kingwell BA. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial. Ann Intern Med. 2006 May 2;144(9):660-4.

Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Guralnik JM, et al. Physical activity during daily life and mortality in patients with peripheral arterial disease. Circulation. 2006 Jul 18;114(3):242-8.

Saw J, Bhatt DL, Moliterno DJ, Brener SJ, Steinhubl SR, Lincoff AM, et al. The influence of peripheral arterial disease on outcomes: a pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol. 2006 Oct 17;48(:1567-72.

Steg PG, Bhatt DL, Wilson PWF, D’Agostino R, Ohman EM, Rother, J. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. Mar 21 2007;29(11)7:1197-1206.

Zacharski LR, Chow BK, Howes PS, Shamayeva G, Baron JA, Dalman RL, et al. Reduction of iron stores and cardiovascular outcomes in patients with peripheral arterial disease: a randomized controlled trial. JAMA. 2007 Feb 14;297(6):603-10.

Review Date:
3/29/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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