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Tuesday, June 29, 2010

Supinators: Help with Lateral Shoe Wedging

     There is really no great shoe for people whom overly supinate (roll their feet to the outside like spraining their ankles). One way that podiatrists, pedorthists, and shoe repair people handle this problem is with lateral (or valgus) shoe wedging. The wedging can be placed on the outersole or into the midsole as demonstrated by these photos. With excessive supination (aka lateral instability) accounting for 17 known symptoms, including ilio-tibial band strain, low back pain, ankle sprains or strains, cuboid syndrome, etc., this common wedging process can greatly diminish symptoms caused by this motion.

     The photo above demonstrates the initial cut with an eleven or ten blade half way up the midfoot and half way through the shoe from lateral to medial. The cut goes from the ball of the foot to the back of the heel.

Once the scalpel has made the cut, barge cement is applied to the inside of the shoe.

     Depending on the size of the wedge needed, grinding rubber (I purchase from JMS Plastics) is beveled and then both sides are glued and left standing to dry. Here 1/4" wedges are being made for multiple shoes. The front end of the wedge (placed into the front part of the shoe) is slightly rounded before skiving to ease in the shoe placement.

     Here is a closer view of the shoe wedge with the beveled part that will be placed into the shoe first (go in the deepest) and the rounded front part.

Here is the wedge being shoved (yes, shoved!!) not so gently into the shoe as deep as possible.

     Here is the shoe wedge from the side view after initial sanding to make presentable.

     Here is the finish product of a 1/4" valgus or lateral midsole wedge to fight excessive supination tendencies. Super Glue or one of its knockoffs is normally used here to seal any gaps. It takes time working with the Barge Cement to know how long to wait before applying the wedge. The patient should never feel that the shoe now overly pronates them. If so, there is too much wedge. Normally when this happens, this wedge is removed and a new one one half that thickness is then applied.

Sunday, June 27, 2010

Acute Injuries:Begin Strengthening Immediately in Acute Injuries or Post-Operative

     Yes, that means right away!! 

     Golden Rule of Foot: As soon as an injury occurs, restrengthening of the muscles in the area involved should begin.

     As I have mentioned in an earlier blog, injury treatment normally begins with an Immobilization Phase (where muscles weaken). At some point after the acute pain has normally subsided, the Restrengthening Phase begins. Sports Medicine tries to blend those phases together so that there is less weakness setting in, and a shorter rehabilitation with less flareups. But what kind of strengthening exercises can you do when you are in pain???

     First of all, let us look at the types of strengthening exercises available. Starting with any of these, as long as they are pain free, can prevent or slow down muscle weakness. The 6 basic types from easiest to hardest are:

  1. Active Range of Motion--simply moving the muscles without resistance.
  2. Isometrics--the muscle tightens but goes through no range of motion.
  3. Isotonics--a fixed weight or amount of resistance is placed on the individual muscle/tendon
  4. Progressive resistance exercises--the resistance is not fixed and can be varied by tension or the strength of the person (usually against a stretch band).
  5. Functional/Dynamic Exercises--where the muscles/tendons are exercised in groups, normally with some weight bearing
  6. Isokinetics--muscles are strengthened around the same motion (speed) with variable resistances set (normally done in physical therapy offices, but has been less popular).
     When you have an injury, immediately think about how to keep strong. Before you actually see a therapist or trainor for advice, can you start moving the area alittle pain free? It must be pain free!! Can you at least move the muscles in the joints above and/or below the injury? With a sore ankle, you could at least start doing Active Range of Motion strengthening exercises at the toes (wiggle toes) and the knee (move the knee into flexion then extension). I will have many posts on these concepts.

Tuesday, June 22, 2010

Neuro-Eze for Nerve Pain

     Neuro-Eze is an over the counter product for nerve pain or neuropathy (abnormal sensations including burning, numbness, tingling, buzzing, pain, etc) that I have had some good luck. I first heard of it from renowned (and extremely bright) Dr Arlene Hoffman, podiatrist in San Francisco. If you are having nerve symptoms in your feet, buy a bottle online from and rub it in for several minutes 3 times daily to the affected area. Try for a month on one foot to test your response, even if both feet are bothering you. I have had just as much luck with Neuro-Eze in 50% of  patients, than with much more expensive creams/gels from a prescription compounding pharmacy. Please respond to this blog with comments or questions regarding its usage. It is a high concentration of an amino acid L-Arginine. I am unclear if it has any side-effects, especially if you are pregnant or nursing. See .

Monday, June 21, 2010

Shin Splints Part II: An Anatomy Lesson

As I discussed in Part I of Shin Splints, the pain is from below the knee to above the ankle. It is a large area with many possible structures involved. In most cases the pain is self-limiting, but with some use of the 10 basic treatments (see Part I)  you are guaranteed that the rehab will be quicker than with just REST.

Let us review the anatomy of Shin Splints. The 4 basic types of shin splints are Medial (most common), Anterior (2nd), Lateral (3rd), and Posterior (4th). The medial group of muscles (function) are the posterior tibial (controls over pronation), flexor hallucis longus (stabilizes the big toe), and the flexor digitorum longus (stabilizes toes 2 to 5). Photo below shows where medial shin splints occur. Since over pronation, bunions (unstable big toes), and hammertoes (unstable lesser toes) are all common problems, this type of shin splint is the most common. More specific treatments of these problems include various methods in controlling pronation (there will be a series of posts on this topic), stablizing the big toe area or stablizing the lesser toes.These include toe separators/spreaders, shoe inserts with Morton’s extensions, and big toe spica taping to stabilize the big toe area, and toe crests, toe taping, reverse Morton’s extensions all to stabilize the lesser 4 toes.

Many patients purchase shoes too wide in the toe box leading to marked instability, especially when they have bunions. Too much room with resultant sliding around is just as bad on bunions and hammertoes as having too little room with resultant crowding.

The 2nd most common form of shin splints is anterior shin splints (see photo above). The muscles (functions) involved all help to control foot slap after heel strike, and then to help lift the foot off of the ground at toe off. Overuse situations can easily occur with hill running and increases in the speed of workouts. The muscle/tendons involved are the anterior tibial (controls over pronation and stabilizes the first metatarsal), extensor hallucis longus (stabilizes big toe and lifts toe up at toe off), extensor digitorum longus (stabilizes lesser toes and lifts these toes up at toe off), and the peroneus tertius (stabilizes the outside of the foot including the cuboid , 4th metatarsal and 5th metatarsal).

This muscle group is normally the weakest of the 4 groups and has to constantly pull against the more powerful Achilles tendon. As the calf/Achilles gets too tight/too strong with vigorous exercise, it is hard for the anterior group to keep up. These muscles will strain under the added stress of working against the tight Achilles. Hopefully, you can see, when someone has anterior tibial shin splints, treatment should be directed towards:
• Stretching of the calf

• Decreasing hills/speed for awhile

• Stabilizing pronation (medial support) or stabilizing supination (lateral/cuboid area support)

• Stabilizing any digit appearing unstable (with toe separators, taping, toe crests, etc.)

The 3rd most common form of shin splints is lateral shin splints (see photo). The muscle/tendons (functions) involved are the peroneus longus (stabilizes the lateral ankle against excessive supination and stabilizes the cuboid and the first metatarsal), and the peroneus brevis (stabilizes the lateral ankle against supination and stabilizes the cuboid and fifth metatarsal). So they stabilize the lateral ankle, and both sides of the midfoot area. Ankle braces, ankle proprioceptive exercises (see post on flat footed balancing), power lacing, and stable shoes if you pronate or supinate too much can all be part of the treatment.

The 4th common form of shin splints is posterior shin splints (see photo). The upper 2/3 of the calf is considered a shin splint if the pain is deep. This is normally a stress fracture on the posterior aspect of the tibia (very common in runners) and often misdiagnosed as calf muscle strain. It may also be a strain of the soleus muscle (deep part of the calf) where it originates on the tibia. The gastrocnemius (or gastroc) is the bigger, more superficial, muscle of the calf. The soleus muscle starts deep to the gastroc and becomes the other ½ of the Achilles tendon below. Therefore, the soleus functions to lift the heel. It also attempts to slow down pronation at heel contact, so over pronators may strain the muscle. It is harder to strengthen the soleus then the gastroc, so weaknesses may develop and muscle strains can occur with relatively minor overuse situations.

A further post will discuss various ways to strengthen the gastroc versus the soleus. In general, soleus strengthening is done with the knee bent 45 to 90 degrees and the ankle is then plantarflexed with resistance (pointed downward like a ballerina on her pointe shoes). Treatment of this type of shin splints must initially rule out tibial stress fracture which requires more modifications. Once tibial stress fractures are ruled out, functional changes include decreasing ankle plantarflexion (extension) and stabilizing pronation. Also, avoiding activities that produce a negative heel effect (see separate post), like getting off your seat in cycling. A slight biomechanical change in activities to minimize heel lift (ie. walking more flatfooted even when going up hills, or lowering the seat on your bike) can greatly speed up treatment.

Sunday, June 20, 2010

Foot Orthotics: Best for Water Sports with Shoe Recommendations

     Water shoes and sandals have become very popular and important as the summer months, hot weather, and beach or pool activities have arrived. For those of you that wear orthotic devices for foot and leg problems, the thought of going without this protection while around water can bring great concern. First of all, I tend to prefer water shoes over sandals for better protection and stability for my patients. But, with proper water resistant orthotic devices (only the plastic part of the device), water sandals with an enclosed heel to hold the orthosis can be very stable. See the photo of an orthotic device without any material that water would effect with the Merrell water shoe it was designed to fit. If you have a good fitting orthotic device, any orthotic lab could make these off the original cast.

     Common water shoes that I recommend are (in no particular order):
  • Ahnu Muir--Men
  • Teva Sunkosi 2--Men
  • Salomon Techamphibian 2--Men and Women
  • Merrell Water ProSable--Women
     Common water sandals that work well with orthotic devices (in no particular order):
  • Teva Dozer--Men and Women
  • Teva Cardenas Fisherman
  • Keen Mystic--Women
  • Keen Commuter Rockaway--Men
  • Merrell Chameleon 3Maze--Men

Monday, June 14, 2010

Shin Splints Part I

Shin Splints (Part I): What are they? What is the basic treatment?

More Inspirations from Italy: this time Monterrosso al Mare (see photo above)

Shin Splints literally means pain somewhere between below the knee joint and above the ankle joint. There are a lot of structures that can produce pain in that area, so the treatments range from simple to complex. Mostly, shin splints is an overuse of one group of muscles/tendons that start (originate) in the leg, and end up (insert) into part of the foot. Each one of these muscle/tendon has various functions around various joints. It can be one of these muscle functions that has been forced to work in an overuse fashion that produces pain. Podiatrists, physical therapists, orthopedists, and physiatrists (rehab specialists) tend to be the most qualified to recognize the exact muscle/tendon involved when treatment is stalling.

Shin splints is so common, and normally responds so well to basic treatment, that most clinicians do not get too involved in its complexities. The basic treatment of shin splints involves:

  1. Reduce activity to pain free levels for at least one week.
  2. Ice the involved area for 30 minutes 3x/day.
  3. Change your athletic shoes if they may be worn down.
  4. Minimize your speed workouts and hill workouts.
  5. Consider if levels of Calcium and Vitamin D may be low.
  6. Attempt 3 to 4 days/week alternative exercises as long as it is pain free (i.e. cycling, elliptical, walking, swimming, court sports, etc.)
  7. Stretch the achilles tendon 2 positional (knee straight and knee bent) for 1 minute each 3x/day.
  8. Experiment with an ankle brace or ankle taping if it is painful to walk.
  9. Wear tie-on supportive athletic shoes full time while the shin is healing (although you may experiment with clogs as an alternative).
  10. Attempt pain free muscle strengthening of the muscle group involved. More on this in a later post.

As your symptoms get better, gradually increase your activity back to normal levels (normally 20% increase per week if you were still able to exercise, and 10% per week if you had to shut it all down). A walk/run program may be appropriate (see separate post).

The next part of this topic in the next blog post will talk about the various muscle groups in the leg, and the various functions they perform in these amazing bodies of ours. Talk to you soon.

Saturday, June 12, 2010

Compromises Made in Medicine

Inspiration from the Campo dei Feuri in Roma, Italy

Campo dei Fueri is a great people-watching square. When my wife and I arrived on a sunny, hot Italian Sunday, a flood of people in Italy passed us by. Sipping our drinks (see photo of my wife Patty in the middle in blue) thousands passed the tiny outdoors cafĂ©. Their individual stories would have been so fun to hear. The square has many historical points, but the large central statue of Giardano Bruno (see photo), burned at the stake for his beliefs in 1600, dominated the scene. What got him into trouble you may ask? Bruno believed the world was round. He felt strongly enough that he could not keep it secret. He died for what he believed in!!

This would never happen in medicine in the 21st Century. But, you do see a subtle selling out by medicine to the dictates of insurance companies. It is usually a subtle undertone in the treatment plan when the healthcare providers chose for their patients only tests, products, etc. that are covered by the insurance. The patients are getting sometimes a small view of all their treatment options.Providers must sit back and look at their practice. Are they compromising too much?? With all of the changes in health care technologies, and the added experience of those practicing medicine, every clinician should be practicing at a higher level with better outcomes than 5 to 10 years ago. Is this so? If not, what can be done to change things about the practice? Is too little time being spent with patients?  Are all the treatment options been carefully explained to the patient, especially when there are many choices?

And what about the patient’s role? Patients are getting more and more squeezed with higher premiums. If they can choose between two treatment plans, one cheaper than the other, cheaper sounds gooood! But is it appropriate to help?

As I mentioned in my post on the K.I.S.S. principle, keeping things simple is normally a great starting point. Simple is normally less expensive since it is more patient-time involved, and less doctor/therapist-time involved. However, with office visits getting shorter, patients may not be getting a good picture of their choices. Only one treatment plan may be presented. In my business, treatment plans can often be numerous, based on many factors. Patients must speak up and ask for their options. Be more vocal. Express when money is of great, or of no concern (usually when the initial treatments are not effective, and the patient begins to feel very vulnerable). Definitely, the way medical reimbursement is going, all patients will be asked to pay for more. Doctors and patients must become well versed in the K.I.S.S principle with cost-effective treatments that have good positive outcomes. We are a wee-bit overly tech happy, which definitely costs more.

So what have I learned from Bruno. He gave me more resolve to not sacrifice any treatment for any reason. He reminded me to fight for my patients by standing up for what I believe. I won’t be burned at the stake, but I must daily feel joy in my ability to help patients the best I can. This way I will enjoy practicing medicine, and all its sacredness.

Wednesday, June 9, 2010

B.R.I.S.S. Principle of Tendinitis Treatment

B.R.I.S.S. Principle for Tendinitis Treatment

Having experienced my first writer’s block since starting this blog, and risking great personal sacrifice, my wife Patty and I went off to Italy for inspiration (on 5/18 to 5/31/10). The following posts were written in beautiful places along the Italian Riviera, with this one from San Remo. The photo above shows the view from our hotel room as we ate breakfast. What sacrifice I make, and will continue to make occasionally, for my readers.

What does B.R.I.S.S. stand for?

• B---Biomechanical Changes

• R---Rest or Activity Modification

• I----Ice or Anti-Inflammatory Measures

• S---Stretching or Flexibility

• S---Strength Training

Treatment of tendinitis (also called strains) should be done as soon as symptoms develop. The BRISS principle helps doctors/therapists/athletes stay focused on needs to be accomplished. Common tendinitis conditions treated by a podiatrist include Achilles tendinitis, posterior tibial tendinitis, various ankle tendinitis, patellar tendinitis, hamstring tendinitis or strain, piriformis strain or syndrome, and hip tendinitis.

B ---Biomechanical changes try to eliminate motions that cause or, at least, aggravate the problem. Each problem treated may have 3 or more biomechanical changes necessary to heal the problem quickly. For example, common biomechanical changes necessary to treat Achilles tendinitis include attaining greater heel heights in shoe gear, avoiding negative heel positions (see the separate post on negative heel stretch) like getting off your seat in cycling, correcting rear foot pronation when the heel and ankle are misaligned walking or running, and avoiding full flexion of the ankle (like in a deep squat). Each problem treated has different sets of changes that may be needed. Usually changes are made over the course of time from most obvious to less obvious (less common cause), or from simplest change to more difficult change to accomplish.

R ---Rest is a four lettered word to many I treat, including myself. Like Behavior Modification is to Diet, Activity Modification is to Rest. Activity Modification for injuries sprang out of the Sports Medicine Movement. To successfully use Activity Modification, the concept of Good Pain/Bad Pain must be understood by the clinician and patient (see separate post on this topic). Rest implies weakness, tightness, and basic loss of function. Activity Modification programs allow alternative exercises (biking when you can not run), or changes in activities (avoiding hills for a runner for example).

Golden Rule of Foot: If you can not run 5 miles, see if you can run 1 mile, or even 1 minute. There is a lot to be gained in running less than your normal amount, as long as you stay pain free, then not running at all. It can be part of a multi-factorial alternative Activity Modification program (say that backwards three times). It will allow you to get back to your normal running program faster than straight rest. Activity Modification programs produce less weakness, less tightness, less loss of function, and faster returns to full activity. It is definitely on the winning team!!

I ---Ice is the universal word for anti-inflammation. I have covered this thoroughly in 2 posts (Ice and Secrets of Contrast Bathing). 2 Golden Rules of Foot summarize this topic well:

• Heat before activity, Ice after activity.

• If swollen, soak whenever possible.

In treating tendinitis, a daily program done 2 or 3 times of Stretch, Strengthen, Stretch, Ice (SSSI) should be done. Stretch initially to gently warm up the injured tendon, strengthen the tendon by the prescribed program from doctor or therapist (but not through pain), stretch again to relax the tendon, and then ice to minimize any irritation/aggravation produced. This SSSI is the hallmark of most home tendinitis treatments.

S ---I put Stretching first over strengthening work because stretching is normally done first in the treatment of tendinitis. Golden Rule of Foot: Find a stretch that makes the muscle/tendon feel better and you are halfway home. Please see the post on the Generalizations of Stretching. Stretching is done for many reasons. Stretching should never be done through sharp pain, and you should never feel worse after stretching. Stretching is used to warm up a muscle/tendon before activity, to relax/cool down a tendon after activity (the most important time to stretch), and to gain flexibility when you are tight to begin with. There will be a separate post dealing with over-flexible tendons.

The typical stretching program for muscle strains/tendinitis conditions have the patients stretching 3x/day, pain free, whether they are exercising or not (yes, 20+ times/week). In cases of extreme tightness of the injured muscle/tendon, a minimum of 100 stretches may be necessary to begin to gain on flexibility, so why stretch once every other day!! (you will never get there). Golden Rule of Foot: If you feel the sore area when you stretch, you will get better a lot faster.

If I can get patients to feel that they are stretching the sore area, I know that they will heal faster than normal. If they can not feel the sore area while stretching, I need to find a possible variation of the stretch or measure to see if they are over-flexible (another problem).

S ---Strengthening or re-strengthening is vital to the treatment of tendinitis. It is last in the mnemonic BRISS, but the most important. One of the reasons it will always be last is that it is in the 2nd phase of rehabilitation called “The Re-Strengthening Phase”. Another reason it will always be last, it is the most often forgotten part of any rehabilitation program. Yes, that is correct!!

The 1st phase of rehabilitation is “The Immobilization Phase”. Immobilization has many forms/combinations including activity modification, braces, casts, orthotic devices, taping, and splints. The Immobilization Phase is when most anti-inflammatory measures are utilized. The Immobilization Phase is when most, if not all, of the pain disappears. The athlete and non-athlete feel great, or at least much much better. Why should they go through more rehab? Let’s Play Ball—or just get on with life!! But the injured tendon, now much weaker due to the period of immobilization, is in a very vulnerable position. It desperately needs more strength. It is very prone to re-injury if that strength is not regained.

We lose 1-3% of our strength daily in the injured tendon from the day an injury occurs. Within several months, all of the strength to do even normal activities is gone. Re-injury occurs often when the strength is never regained. Re-strengthening must be gradual and pain free. The art of re-strengthening is best done by physical therapists and personal trainers. I will have many posts on strengthening. Skilled sports medicine specialists try to strengthen injured areas almost the moment the injury happens. Patients can wake up from knee surgery with a muscle stimulator working the quads. I will leave you (and get back to sun-bathing on the Italian Riviera) with two more Golden Rules of Foot:

• The Immobilization Phase should be carefully merged with the Re-Strengthening Phase for quicker rehabilitation.

• Strengthening the injured area should begin as soon as possible, even right after surgery or if you are being placed in a cast.

Sunday, June 6, 2010

Pain: Giving a Good Medical History

Giving Good Historical Information: Helping to Steer the Course of Treatment

More Inspiration from Portovenere, Italy

I have been watching ships and boats sail through the narrow channel between Portovenere and the Island of Palmaria (as seen in the photo above). They perform this task so effortlessly since they have done it so many times. In the medical arena, an important time to steer the ship/treatment plan in the right direction is by giving good historical information. Come prepared with the information typed (unless you have great handwriting; typing in the best). Point your doctor or therapist along the right path/channel and it help you get better faster. Think over each question carefully when answering. The process will clear your head and keep you focused on the most important aspects. While many of these questions can be the most helpful clues, it may also free the doctor/therapist to ask the key specific questions related to your specific injury (for example, does your painful knee lock where you can not bend it?)

I would like to introduce you to a mnemonic that I used in medical school for asking a great history. The basic questions over the years have remained the same and the hallmark of great history taking. I hope you can take these questions and make them paint an accurate picture of your problem for the doctor/therapist you see next. If they are not impressed by your organizational skills, I will be amazed.

The mnemonic goes like this---

F Family History of similar problem? Frequency of pain (how often)?

A What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?

I How Intense (use Pain Scale) is the pain? What Irritates (makes it


L With one finger, point to the exact Location of the worse pain?

E What Eases the Pain? Does the pain have an Electric sensation with it

D What has been it’s Duration (how long has it been going on)?

O What were all the events surrounding the Onset of Pain? Are there

any Observable skin changes?

P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?

Q What is the Quality of Pain (burning, tingling, dull ache, sharp,

numbness, throbbing, pulsating, etc)?

R Is there Redness? Does the pain Radiate and where to?

S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?

T What have you done to Treat the problem? What Treatment has

helped? What Treatment has made it worse?

U Are there Underlying Health Issues (diabetes, osteoporosis,

arthritis, poor circulation, etc.)?

V Does the pain Vary (better at different times, worse at other times)?

W Can you Work? Were you injured at Work? Does this affect your Work


Good Luck and I hope this is really helpful to you. I hope your boat ride is enjoyable.

Thursday, June 3, 2010

Athletic Injury Rehabilitation: The Law of Parsimony

Deception Point
The Law of Parsimony: When multiple explanations exist, the simplest one is usually correct.

This is my first post being inspired by the Mediterranean Sea along the coast of the Italian Riviera (this time from Diano Marina, Italy).

As I watched the Mediterranean Sea and read Dan Brown's Deception Point thriller, on page 238 he mentions the Law of Parsimony. This is a common law utilized in medicine; a good starting point in the treatment of injuries. I will use the Law of Parsimony in this post to describe the common starting point of treatment based on the commonest cause for several injuries listed below. If you have one of the injuries mentioned below, make sure that your treatment is addressing this issue.

  • Achilles tendinitis--tight achilles tendons

  • Plantar Fasciitis--inadequate arch support

  • Recurrent Ankle Sprains--weak peroneal tendons

  • Chondromalacia Patellae or Patello-Femoral Dysfunction--weak vastus medialis

  • Ilio-Tibial Band Tendinitis--tight Ilio-Tibial Bands

  • Morton's Neuromas--tight front area of your shoe or boot

  • Posterior Tibial Tendinitis--excessive pronation

  • Bunion Pain--tight front area of shoes

  • Metatarsal Area Pain--development/increasing of hammertoes (see post on Budin Splint)

  • Peroneal Tendinitis--lateral instability in shoes

  • Generalized Arch Pain--weak intrinsic foot muscles
These are great starting points to treat these injuries. In many cases, it will take awhile to get weak areas strong, tight areas flexible, and correct biomechanical and shoe issues. Other treatments will be used to address anti-inflammatory concerns, and less common causes of the same injuries at the same time to hopefully sped healing along. See the post on Tips for Bunion Care as a good example. Thank you Dan Brown and the Mediterranean Sea for this inspiration. Now off to a great pasta or seafood dinner.

Wednesday, June 2, 2010

Heel Pain or Heel Blisters: Achilles Gel Pad to the Rescue

Silipos Achilles Gel Heel Pad, Large - Extra Large - Each #10395

If you develop pain in the back of your heel that possibly is caused or made worse by shoe pressure, Silipos Company has come up with a great help called Silopad or Achilles Gel Pad. A thin, but effective, gel pad is placed into a thin Nylon/Lycra sock which is normally worn under your regular socks. Backpackers, known to blister terribly the back of their heels, normally love this sock to prevent this problem from re-occurring. Many patients wear the sock even while wearing dress or other types of shoes. Even when the problem starts out as achilles tendinitis, irritation from the back of the heel counter of the shoe can greatly slow down the rehabilitation. More information can be attained at .

The outline of the gel has been highlighted in this photo above, and the side view seen below.

I hope some of the backpackers reading this post will consider this, especially if you have had previous blistering problems. I would like to refer you also to the separate post on Guidelines for Blister Care.