THE CLINIC

Stubbornly Hardened Heels

On both my heels I have hard tissue that I have attempted to treat to no avail. It also appears on the area just below my toes on the bottom of each foot. Both physicians and podiatrists have advised me to apply moisturizing cream three times a day, put cushioned insoles inside my shoes, soak my feet in hot water with Epsom salts, and rub them regularly with a pumice stone. This last treatment in particular was a lot of effort and yielded almost no result. The only treatment that has had any results worth noting was rubbing vitamin E oil into the hard areas three times a day. While this appeared to soften my feet, it was such a mess that I deemed it not worth it. The oil got inside my shoes, socks, bed sheets, etc. and there was simply no way to contain it. I would greatly appreciate any additional solutions to this problem. Thanks!

Kyle San Giacomo
Fort Stockton, TX

I have had success treating excessively hard skin (known medically as hyperkeratosis) with the following regimen:

1. Apply Carmol-40 lotion twice a day to all areas. This is a prescription-only lotion with 40% urea, vitamin E, lactic acid, and zinc.
2. Wear cushioned insoles, as you have done, but also non-leather soled shoes.
3. Wear socks at all times.
4. Do not walk barefoot.
5. See a podiatrist every two months initially for paring of the legions with a blade; after this you might be able to lower the frequency of the visits.

This is a hereditary and non-curative condition but if you are diligent it can be managed well. With this treatment you will also have the peeling of skin—which can’t be avoided until the condition gets better. Later you can also use a lotion with only 20 percent urea if you so choose.

David A. Lief, DPM
Irving, TX

In addition to Carmol-40, there are over-the-counter lotions or creams, such as Eucerin Plus, that contain alpha hydroxyls (lactic acid and uric acid). Alpha hydroxyls are gentle acids that soften the dry, hard skin.

Paul Langer, DPM
Minneapolis, MN

Don't Ignore Clotting Problems

I am a fitness walker, age 56, 215 lbs. I average 10 to 20 miles per week. My marathon PR is 5:38. Recently, after long excursions (10 to 24 miles) my medial shins have irregularly shaped, dark red splotches on them. They last for a few days and are not painful. It looks like blood under the surface of the skin. I take an 81-mg aspirin, 10 mg of Lipitor, 25 mg of a prescription NSAID, and 8 mg of Cordura daily along with multiple vitamins. My other regular exercise is light weightlifting and a short swim one day a week. I suffered a myocardial infarction seven years ago and have no symptoms today. I have excellent blood work from one month ago.

Frank Pirelli
Dover, DE

The combination of low-dose aspirin, a daily NSAID, and heavy physical activity are probably enough to cause a tendency toward bleeding into the skin, which means these areas are likely bruises. I would consider trying acetaminophen in lieu of the NSAID, and see if your bruising ceases. If it continues, further evaluation by a hematologist is probably indicated.

William M. Simpson, Jr., MD
Charleston, SC

Obviously without seeing the splotches there are limitations in what I might be able to reliably diagnose. However, I also suspect that the splotches are due to bleeding under the skin related to the trauma of your long workouts. NSAIDs and aspirin interfere with the function of platelets, the cells that make blood clot. They may further contribute to this problem. If the splotches are due to trauma, their appearance should evolve from a dark red purple to a more yellowish green-brown over a several day period, similar to the changes in appearance someone with a black eye goes through.

There are some uncommon medical disorders associated with splotches over the shins or that can predispose people to bleeding, so make sure you check with your doctor just to be certain that something else is not the cause. If your doctor determines that there is no other cause, there is no reason to alter your exercise program if these splotches are only cosmetic and are not causing any discomfort.  Although your aspirin use may be contributing to the appearance of these legions, you should keep taking aspirin since you have had a heart attack in the past.

Todd Miller, MD
Rochester, MN

Although the condition you describe could very well be the result of bruising of the tendons in your shins, it is certainly important, as noted above, to see a doctor to be sure there are no clotting problems with your blood.

Dennis Daly, MD
Camillus, NY

Skip the Juice: Drink Water and Eat Fruit

For the last 16 years, I've run 30 minutes three times a week. I 'm now 53 and have been wondering whether it's better to have fruit juice or a daily sports recovery drink. I notice there are between 38 and 48 grams of sugar per serving in most juices, and only 14 grams in most sports drinks—but the latter is of the sucrose type rather than fructose. My blood sugar level is in the normal range (105 to 110, 12 hours fasting), though it has been creeping up in the last few years. I have no health problems except borderline hypertension for which I take 25 mg daily of the beta blocker atenolol.

Hal Toth
Forest Hills, NY
 
Sugar does not cause diabetes; while your blood sugar levels may be creeping up, drinking juice is not likely the cause. Exercise and weight management are the proper tools to keep blood sugar levels under control. Sports drinks have fewer grams of sugar than juices because they are designed to be consumed during exercise, a time when the body prefers diluted liquids. Fifty to 70 calories of an eight-ounce sports drink get absorbed faster than juices with 100 to 150 calories per eight ounces. While a sports drink is appropriate during runs lasting 60 to 90 minutes, you’ll do your overall health a favor by drinking juices, which have things like phytochemicals that you won’t find in sports drinks. Among the best choices are orange and grapefruit juices, which are rich in vitamin C. But getting these nutrients from the whole fruit will also give you a healthy does of fiber, provided you stay hydrated above and beyond the juice in the fruit.

Nancy Clark, MS, RD
Chestnut Hill, MA

With your present exercise program it would be best for you to drink water and eat fruit. Fruit has soluble fiber that helps with blood sugar regulation and weight control. I agree with the above assessment that maintaining an appropriate weight through diet and exercise is the best strategy for blood sugar control—better than simply looking at the sugar content of beverages. If you have two to four servings of fruit daily and enough water to quench your thirst then sports drinks or fruit juice are not necessary.

Ann Manzi, MS, RD
Beverly Farms, MA

Diabetes and Surgery

I am a 63-year-old male runner, 5’ 11”, 188 lbs, who hasn’t done much of it in the last six months due to persistent pain along my left heel. My DPM took an x-ray and found a calcium build-up where the Achilles attaches to the heel. He recommended a device called a silicone sock, Tylenol, and stretching (toes on stairstep, drop heel, hold for 10 seconds). Because I am diabetic, he did not recommend surgery due to possible complications and the added time to heal. I would like other opinions on this recommendation. Is there a history of successful surgery for problems like this in people over 60 with diabetes?

George Ronin
Montgomery, AL

These Achilles tendon spurs are very painful and difficult to resolve. Diabetes further complicates things by reducing blood flow, decreasing nerve sensation, and lowering immune response. If your blood sugar is managed well and you have good circulation you may do fine with surgery and its relatively long recovery. In addition to orthotics, PT, and rest, you might try a plantarfascial night splint to aid in stretching the Achilles tendon. Also, extracorporeal shockwave therapy has yielded promising results; check with physicians in your area to learn more about this procedure.

Lori Barnett, ATC, DPM, FACFAS
New Tripoli, PA

Surgery should be held out as a last choice, but I would not rule it out (assuming your primary doctor clears you). There are more conservative options to be explored, however. Aggressive physical therapy and a heel lift will usually do the trick. Note that even religious adherence to at-home exercise and an experienced physical therapist do not mitigate the fact that it can take up to six months to see results. The healing depends on many factors, including the control of your diabetes—high glucose levels impair healing, even with rest and therapy.

Surgery is an option if this fails, but there is increased risk of infection and almost certainly delayed healing afterward. A thorough discussion of these risks and a team effort among you, your primary doctor, and the surgeon should make surgery possible, however.

Bradley Wadington, DPM, FACFAS
Hendersonville, NC

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