Foot Taping For Heel Pain

 Low-Dye Foot Taping Technique:

A common practice in Podiatry is to tape the foot and support the arch when someone complains of heel pain (Plantar Fasciiitis).  This approach provides very good albeit temporary relief of pain.  This is a very useful tool if a big event is coming up and you’d rather not be limping through it.  If combined with other approaches such as supportive shoes, steroid injections and orthotics, this method can spring board you along the path of healing quickly.





Here is a demonstration video we put together for your enjoyment:

Some of the materials can be found online:  T-Strap, Tape etc…

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists


Posted in Low-Dye Foot Taping for Plantar Fasciitis | Tagged , , , , , | Leave a comment

Shin Splints

***  Here is a great video link I found demonstrating the in’s and out’s of shin splints…  enjoy.



Shin splints (also known as medial tibial stress syndrome (MTSS) is a familiar pain that most athletes in sports that involve high impact or large amounts of repetition have experienced.  Shin splints refers to pain along or just behind the tibia (shinbone).  This term is often used as a “catch all” phrase for numerous other causes of leg and ankle pain.

(Image Source)


Shin splints can happen during any physical activity but normally result from too much force on the shin bone (tibia) and associated connective tissues and  muscles.  Any activity that forces fast stops and stops can create injury to the tibia and connective tissues.  My personal experience with shin splints have been most often with running, playing soccer and occasionally with long hikes.  Most sources will implicate high impact activities and the type of terrain including hills and uneven surfaces.

There are many scenarios that can set you up for shin splints including: muscle imbalance (consider core muscles), tight calf and foot muscles, flat feet and/or over pronation, and sudden increase or excessive duration of physical activity.   Having poor form while running, such as leaning forward or backward too much, as well as landing on the balls of your feet and running with toes pointing outwards all contribute shin splints.  Any athlete who is constantly bothered by this problem should seek out a podiatrist or sports medicine doctor with a treadmill and camera system for gait evaluations.  Currently in the Salt Lake area, I know of only one such system in the office of Trevor Williams DPM.

Poor shoe gear (shoes that either are too flimsy or too thick and padded) can contribute to shin splints.  Shoes that offer too much padding (according to one study) can actually INCREASE the impact forces when running while very thin shoes or no shoes at all require careful changes to running and training techniques to avoid injury and to enjoy the hoped for benefits.

With the new wave of minimalistic shoes and/or barefoot running a lot of anecdotal evidence can be found around the internet supporting or detracting from these “new” running techniques.   A recent extensive scientific literature review performed by Jenkins et al yielded the following results:

“Although there is no evidence that either confirms or refutes improved performance and reduced injuries in barefoot runners, many of the claimed disadvantages to barefoot running are not supported by the literature. Nonetheless, it seems that barefoot running may be an acceptable training method for athletes and coaches who understand and can minimize the risks.”


Pain associated with shin splints can occur late in a sports season for athletes or after prolonged activity for active individuals. However, onset can occur during the initial rigors of exercise after an individual has been inactive for a long period of time. A typical presentation of this condition involves pain, palpable tenderness, and possibly swelling to the lower leg above the ankle about 5-10 inches. Pain can be described as a dull ache and may show up at the beginning of a workout.  The pain may go away by continued activity and then occur again at the end of the activity.  As the syndrome progresses pain may stay throughout the whole training or during low intensity activity and may continue at rest.  Joint motion in the ankle and foot should not cause pain or another diagnoses should be considered.

There are numerous conditions whose symptoms often mimic those of shins splints.  These can include compartment syndrome and stress fractures (see lecture on metatarsal fractures).   Compartment syndrome is often either caused by significant recent trauma or during strenuous exercise.  This is a serious condition that at it’s worst can cause permanent damage to muscle and bone resulting in disability and/or amputation.  Symptoms to look out for are loss of feeling, severe swelling and pain, and loss of pulses in the foot.  The worst cases are usually caused by some type of direct blow to the leg.   Patients should be seen immediately by an emergency room or lower extremity specialist (orthopedic or podiatric).

Stress fractures are much more difficult to differentiate from shin splints early on in the course of the problems because both have similar symptoms.  Often shin stress fractures occur closer to the knee than shin splints and have a very specific and consistent point of pain.  The pain from stress fractures normally progresses into constant  and then severe levels with findings obvious on xray developing.  Shin splint pain can also progress into constant pain if activity levels are not cut down, but xrays will not normally show any significant changes to the bone.  Bone scans, MRI and the new SPECT imaging techniques can offer more information and help the physician tell the difference between these problems.

To complicate things further, there are two different types of shin splints described in the literature.  The first type is called anterolateral shin splints where the pain is located on the front and outside of the shin. It is usually felt during running when the athlete’s heel touches the ground. The second type is called posteromedial shin splints where the pain in the leg is on the inside and lower part of the leg and can be triggered by standing on the toes or inverting (rolling in) the ankle.

(Image Source)


Treatment of shin splints includes rest, ice, and non-steroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen.  It should be treated similar to most soft tissue injuries such as tendon or ligament strains.  Rest is the best way to treat shin splints as this gives the tissues the necessary chance to heal. This can be a couple of weeks in mild cases or up to about three months for severe cases. Acute therapy options for treatment include physical therapy modalities such as ultrasound, whirlpool baths, and electrical stimulation.

Patients may be advised to decrease the duration or intensity of their exercise and then build it up slowly, as well as to exercise caution on high impact surfaces until the muscles re-condition. Depending on the cause of the shin splints, specially fitted footwear or an orthotic may be used to prevent a re-occurrence of shin splints.  Some studies have shown calf stretching and over the counter arch supports to have fairly good value in the treatment of shin splints.

(Image Source)

Longer term considerations for persistent pain must include modifying the training routine until healing can occur. Stretching  and strengthening exercises (click here for a demonstration pamphlet) should be done on a daily basis.  Strengthening of the core hip muscles may also be beneficial.

Again, adequate and appropriate shoe gear is important and also the topic of much debate in the medical and sports world.  Below is demonstration on the basics of a good shoe.  Price is not the answer.  A simple, strong, protective shoe is the key.  If you are the barefoot/minimalistic type you must pay careful attention to the surfaces you are running on and running technique.  Shorter strides, mid-foot striking and soft running surfaces are recommended to reduce injury for all runners.

Other treatment options may include:

  • Extracorporeal shock wave therapy, which is used to treat various tendon problems of the lower extremity.  The evidence is weak at best for this modality at the time of this post.
  • Injection methods, which has been used to treat injuries of the lower extremity, including cortisone.  On a personal note, I have seen very successful podiatrists employ steroid/local injections with very good results.  Care must be taken not to numb up a new stress fracture accidentally and risk further injury.
  • Surgical options are for tough cases only that do not respond to conservative treatment. “Posterior fasciotomy” is the procedure performed. This may include cauterization of a ridge of the tibia, and results may not cause complete resolution but can improve the pain and function.


I hope this information is helpful.  Unfortunately anecdotal evidence is rampant with very few solid studies available out there.  Good shoes, simple arch supports, modifying activity levels until healing occurs and slow reintroduction of activities are the name of the game here.  For the persistent pain see a specialist for an injection and imaging to rule out possible stress fractures.

Best of luck to all you shin splint sufferers out there.  Please see a specialist if your pain isn’t responding to basic conservative treatments.

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists
Posted in Shin Splints | 1 Comment

Toenail Topics


Many of you who read this post will find it absolutely disgusting. 🙂  However, this information is based on questions I am asked everyday by people truly curious and wanting to know what can be done for their issues.  Some nail pathology is purely cosmetic and some can be deadly.

Nail Anatomy:

The nail matrix is where the nail is actually created and protrudes from as it grows.  The nail bed also creates the bottom layer of the nail.  On occasion, the nail root and nail plate  will be destroyed and the nail bed will go into overdrive creating a nail like structure leading the patient to wonder if their doctor missed the root.  This happens from time to time and cannot be predicted.


Ingrowing Nails:

Probably the most common procedures performed in the average podiatrist’s office are those concerning ingrown nails.   The photo below is a classic ingrown nail.  The nail is penetrating the skin along the edge allowing bacteria to enter tissue and start an infection.  Note the redness starting to appear around the nail border, this is early cellulitis and irritation.

Nails grow into the skin for a variety of reasons.  Some nails are shaped like the picture below, called “pincer nails”.  You can see below by the way the nail edge pushes on the skin, that it wouldn’t take much for the nail to penetrate the skin and become irritated or infected.  There are many nail shape types, the closer your nail gets to the shape below, the larger your chances of having issues.

Other patients have nails that grow more or less flat, but have excessive amounts of skin around the nail (seen below), also setting up the situation for the nail to penetrate the skin.  This may require removal of the excess skin to allow for normal and pain-free nail growth.

In the cases where the nail is clearly the problem, the edge of the nail is removed after a local block of lidocaine, marcaine or similar drug.  Once the offending portion of the nail is removed, the nail root/matrix is usually removed either surgically or with a chemical.  Quick applications of Phenol or Sodium Hydroxide are the most popular.  A bandage is placed and the patient is instructed on the follow-up care.  Commonly if chemicals are used, the patient will need to soak the foot in Epsom Salts or Iodine treated water 1-2 times per day for 15 minutes to allow the chemical burn to drain freely without creating an abscess.  If surgical resection is done, the bandage is usually left on for a number of days to allow the skin to heal in a sterile environment.  If done correctly, pain levels rarely exceed that controllable with ibuprofen or Tylenol.  In all cases, infection if very often associated with ingrowing nails and “bathroom surgery” is highly discouraged.  Also, don’t wait too long.  The longer you wait, the more difficult the issues become to fix.

Skin Cancer:

Toenails and skin cancer aren’t usually associated, but it does happen and often the results can be very scary.  Signs of concern are new dark-colored streaks in the nail itself.  Melanoma is a skin cancer that involves the pigment making cells in our skin.  People normally think of this kind of cancer occurring where sun damage has happened.  This is not true,  melanoma can appear anywhere in the body, even in places where “the sun don’t shine”.

Subungual melanoma (skin cancer under the nail) is a rare form that occurs under a nail and can affect the hands or the feet. It’s more common in african americans and in other people with darker skin pigment. The first indication of a subungual melanoma is usually a brown or black discoloration that’s often mistaken for a bruise (hematoma).  Long standing streaking is more likely not to be cancer, but, you should always get it checked out by a podiatrist or dermatologist.  My colleagues have reported to me cases where evaluation was delayed by the patient and by the time a diagnosis was made it was too late and the patient died from the spread of the cancer.  If caught early, recover rates are quite high.  A biopsy is the first line of treatment with the nail being removed or softened to allow for a segment of the skin to be removed and sent to a pathologist.


Nail fungus is a tough disease to treat successfully.  The older we get, the more likely we are to develop a toenail fungal infection.  The reason for this is unclear, but some studies have suggested that certain immune system deficiencies may set you up for an infection.  A very clear trend is that the older the patient, the more likely they are to contract this disease.  The likely reason for this trend is the wide spread exposure we have to the spores the fungus drops like seeds all around our environment.


The most succesful treatment options include oral antifungal pills.  Lamisil is the most common and the most effective, with a 50-60% success rate.  It is taken once daily for 3 months.  Concerns of liver damage from this pill have lessened considerably over the last few years with recent recommendations saying that liver tests only have to be done prior to taking the drug and not after, since a healthy liver is very unlikely to be damaged during its’ use.  The nail does take upwards of a year to grow out, but the pill seems to persist within the tissues around the nail creating lasting effects.

Other treatment options include topical drugs such as Penlac that is applied daily for about a year.  My only issue with this one is ease of use.  It does require you to remove the film that builds up with a toenail polish remover at least once a week.  Another option is Formula 3 that is oil based and never needs to be removed (sold only in a Dr’s office).  Formula 3 is usually only available through a doctors office such as ours.  None of these have reliable shown to be more than 30-40% effective.

For very thick nails, a power debrider sometimes is necessary along with nail nippers.

You may have also heard of Laser nail treatment options.  Please see this link for a more in-depth discussion on that aspect.  In short, lasers only appear to work on slight cases of fungal infection.

If you google “nail fungus treatment” you’ll find an endless list of options.  This is always a bad sign in medicine, because if a silver bullet existed with few side effects we wouldn’t be searching madly for the cure.

In conclusion, if a patient is truly concerned about their fungal infection and they have a healthy liver, I’ll first help reduce the nail bulk in the office and then place them on the oral pill Lamisil and the topical medication Formula 3 to increase our chances of success.  We will take a simple liver blood test prior to starting Lamisil to verify the liver is functioning at a high enough level for safety.

Normally, this disease is not a threat to your overall health. There are a few exceptions including the fungus in the nail can be a source of fungal infection of the skin (athletes foot).  If you have little sensation in you feet like with some diabetics or back injury patients, the nail can become thick and rub in a shoe causing a wound under the nail that can become infected etc.  For most people, nail fungus is purely a cosmetic concern.

I could go on and on about the different disease states that can affect the nail, in short, if it concerns you have it checked out sooner than later by a podiatrist or a dermatologist.

As always, I welcome any questions or comments you may have.

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists
Posted in Toenail Topics | Tagged , , | 3 Comments

Toning Shoes

Five Essential Steps to Choosing Toning Footwear

American Podiatric Medical Association Offers Toning Shoe Tips and Foot-Friendly Products

Bethesda, MD – Shoes that feature “rocker bottoms” and “pods” have become the latest footwear craze—a new way to get in shape simply by walking or running. Toning footwear, which claims to promote muscle toning using micro-instability, can be found in a variety of brands and designs. While many may be ready to lace up the first pair they find, the American Podiatric Medical Association (APMA) reminds consumers to be mindful of the footwear products they purchase and to wear them safely.

“It’s important for people to realize that so-called ‘toning’ or ‘fitness’ footwear is not a cure-all that will tone the entire body,” said APMA President Dr. Kathleen Stone. “Toning shoes should be utilized similar to any other piece of athletic training equipment. This type of footwear should be viewed as an addition to an exercise program, to strengthen and tone certain targeted muscle groups.”
Certain types of toning footwear, such as Reebok’s EasyTone Reeinspire (above), have been given the APMA’s Seal of Acceptance.

In general, toning footwear is designed to increase the use of certain muscle groups that may not be challenged in typical running or walking shoes. This increased use of specific muscles may result in increased muscle tone over time, similar to the benefits of walking barefoot in sand. However, proper safety should always be considered. Excessive exercise in toning footwear, including walking for extended periods of time without building up a break-in period, could lead to overuse injuries including sprains, Achilles tendinitis, and shin splints.

The APMA highly recommends that consumers educate themselves about each specific toning product and what it has been designed for to help avoid injury. Individuals with tight posterior calf muscles or Achilles tendons may not be able to tolerate toning shoes, as they put increased strain on these body parts.

Additionally, keep in mind the following when considering toning shoes as part of your exercise routine:

  • Ease into wear. Toning footwear often has a break-in period in order to be worn safely and effectively. All types of toning shoes should first be worn for short periods of time, until the body adjusts to the new style of walking. Those with pre-existing balance or stability problems may want to avoid wearing toning footwear.
  • Look for the APMA Seal. Several toning footwear products, such as Reebok’s EasyTone and those made by Grasshoppers, Avia, and Ryka, have been evaluated by the APMA and found to be foot-friendly. These products have been granted the APMA’s Seal of Acceptance.
  • Find the right design for you. There are numerous types and brands of toning footwear currently on the market, including designs created specifically for running or walking only. Since there are differences in how toning shoes are constructed, find a toning shoe that fits the foot comfortably and that does not cause your natural gait to feel too unstable. Read product packaging and description for the manufacturers recommended use.
  • Remember to stretch. As with any form of exercise, spend several minutes stretching before and after participating in any type of physical activity—especially when preparing to wear toning footwear.
  • Be wary of claims. APMA has evaluated certain toning products and confirmed that they are beneficial to foot health and of significant value when used in a consistently applied program of daily foot care and regular professional treatment.

A full listing of toning footwear with the APMA’s Seal of Acceptance can be found at

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists
Posted in Rocker Bottom Shoes | Tagged , , | Leave a comment

Diabetic Wounds and The Importance of Podiatric Care


Authors: Teresa B. Gibson, PhD; Vickie R. Driver, MS, DPM, FACFAS; James Wrobel, DPM, MS; James R. Christina, DPM; Erin Bagalman, MSW; Roy DeFrancis, DPM; Matthew G. Garoufalis, DPM; Ginger S. Carls, PhD; Sara S. Wang, PhD

Summary by Dr Dan Preece:



  • Type of Study: retrospective
  • Size of the study: 32,000 patients.  20,330 medicare eligible >65 yo, and 11,766 non medicare eligible patients <65 yo.
  • Question of the Study: Does having a Podiatrist on the Diabetic Patient’s health care team decrease the rate of major amputations and hospitalizations due to diabetic foot complications?
  • Materials and methods:  

–  Adult patients (>18 years old) with diabetes and a diagnosis of foot ulcer were found in the Thomson Reuters MarketScan® Research Databases, from 2005–2008.

–  Patients with a previous history of foot ulcer or amputation within 12 months of first being diagnosed with an ulcer were excluded.

–  Patients were noted to either have had one or more visit with a Podiatrist in the 12 months prior to ulceration or not.

–  Patients were matched by age, health insurance type, health problems etc.  The only difference between the two groups was that of receiving a podiatrist’s care or not.


  • Major Points:

– Among non-Medicare patients with foot ulcer, those seen previously by a podiatrist had a 15% lower risk of amputation and a 17% lower risk of hospitalization compared with patients not seen previously by a podiatrist (P < 0.05). The difference in risk of major amputation was not statistically significant between patients receiving care from podiatrists and those who did not (P >0.05).

– Among Medicare-eligible patients with foot ulcer, those seen previously by a podiatrist had an 18% lower risk of amputation, a 23% lower risk of major amputation, and a 9% lower risk of  hospitalization compared with patients not seen previously by a podiatrist (all P < 0.05).


Critiques : This was a good study overall.  One critique is that patients that were included had employer sponsored insurance, therefore results may not apply to all population groups (ie poverty level groups).

(Clicke Here For Article Source)


I love this article for the simple reason that it answers the questions, “Why see a Podiatrist?”, and “What is so unique about a Podiatrist?”.   The short answer is that we know the foot and ankle better than the rest of the medical profession.  We truly understand the foot and its’ many unique characteristics, the challenge with taming the interface between the foot and the earth and how to heal the foot when it becomes damaged.  It’s nice to see some hard data that demonstrates the uniqueness of our education and the value we bring to the medical field as the only true foot and ankle specialists.

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists


Posted in Diabetic Wounds | Tagged , , | Leave a comment

Podiatric Preventative Care


Results Published in Journal of the American Podiatric Medical Association Bethesda, MD
  • If every American at risk for developing a diabetic foot ulcer visited a podiatrist once before complications set in, the US health-care system could save $3.5 billion in one year. Closing this gap in podiatric care would reduce health-care waste on preventable conditions, which reportedly starts at $25 billion, by 14 percent.
  • This estimation is a projection based on findings from a Thomson Reuters study published in the March/April 2011 issue of the Journal of the American Podiatric Medical Association (JAPMA).
  • The study’s numbers were based upon the American population that has either commercial insurance (116 million) or Medicare (46 million) in the Thomson Reuters MarketScan Research Database. Sponsored by APMA and independently conducted by Thomson Reuters, the study measured the health-care records of nearly 500,000 patients with commercial insurance and/or Medicare.
  • “The study’s findings are astounding. If just one individual at risk for a foot ulcer sees a podiatrist once before a foot ulcer becomes apparent, they will have singlehandedly saved our country nearly $20,000 over three years,” said Kathleen Stone, DPM, president of APMA. “This data does not even include the 47 million uninsured Americans or the 58 million currently on Medicaid, who have a higher incidence of diabetes and complications. The bottom line is that seeing a podiatrist saves limbs and lives, and equates to billions of needed dollars saved for America’s health-care system.”
  • After comparing health and risk factors for those who had seen a podiatrist for care to those who did not, the commercial insurance group saved $19,686 per patient over a three year time period. The Medicare group saved $4,271 per patient over the same three years. Conservatively projected, these per-patient numbers support an estimated $10.5 billion in savings over three years ($3.5 billion a year).
  • Including today’s podiatrist in the diabetes management team is a vital step to preventing ulcers and amputation. Recent Centers for Disease Control and Prevention statistics show that in 2006, more than 65,000 lower limb amputations were performed in the US due to diabetes-related complications.
  • Diabetes currently affects nearly 26 million people in the US, seven million of whom are undiagnosed.

For additional information on the study and a link to the March/April JAPMA article, visit

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists
Posted in Podiatry Preventative Care | Tagged , , | Leave a comment

Barefoot Running and Vibram Five Fingers

After multiple patients and fellow physicians asked me my opinion as a foot and ankle specialist on the recent barefoot running craze, I finally borrowed the book Born To Run by Christopher McDougall to see what all the fuss was about.  I sat down with pen and paper to prove this silliness wrong.  A few days later I emerged a partial believer in the idea.  Although barefoot running techniques and training have been around for ages, this book has launched a new wave of enthusiasm for barefoot running and maybe for good reason, then again…

Most of the research below was mentioned in McDougall’s book:

Runners wearing top-of-the-line trainers are 123 per cent more likely to get injured than runners in inexpensive ones. This was discovered as far back as 1989, according to a study led by Dr Bernard Marti, the leading preventative-medicine specialist at Switzerland’s University of Bern.

Dr Marti’s research team analyzed 4,358 runners in the Bern Grand Prix, a 9.6-mile road race. All the runners filled out an extensive questionnaire that detailed their training habits and footwear for the previous year; as it turned out, 45 per cent had been hurt during that time. But what surprised Dr Marti was the fact that the most common variable among the casualties wasn’t training surface, running speed, weekly mileage or ‘competitive training motivation’.  It wasn’t even body weight or a history of previous injury.

It was the price of the shoe. Runners in shoes that cost more than $95 were more than twice as likely to get hurt as runners in shoes that cost less than $40.

Follow-up studies found similar results, like the 1991 report in Medicine & Science In Sports & Exercise that found that ‘wearers of expensive running shoes that are promoted as having additional features that protect (eg, more cushioning, ‘pronation correction’) are injured significantly more frequently than runners wearing inexpensive shoes.’

Stanford running coach Vin Lananna has been quoted as saying, ‘I once ordered high-end shoes for the team and within two weeks we had more plantar fasciitis and Achilles problems than I’d ever seen.  So I sent them back. Ever since then, I’ve always ordered low-end shoes. It’s not because I’m cheap. It’s because I’m in the business of making athletes run fast and stay healthy.’

Studies have shown that the cheaper and simpler the shoe, the fewer injuries the runner will sustain.

The new Nike Free is a minimalist shoe, approximating the Vibram 5 Finger Shoe.  Interesting that Nike is now back pedaling and removing all the gizmos after years of  “technology” laden running gear.  None of which have been shown to increase performance or decrease injury rates.

Squadrone et all conducted a small study comparing neutral running shoes, Vibram 5 Finger shoes and barefoot running.

Compared to the standard shod condition when running barefoot, the athletes landed in more plantarflexion at the ankle. This caused reduced impact forces and changes in stride kinematics. In particular, significantly shorter stride length and contact times and higher stride frequency were observed (P<0.05). Compared to standard shod condition, V.O(2) and peak impact forces were significantly lower with Fivefingers (P<0.05) and much closer to barefoot running. Lower limb kinematics with Fivefingers was similar to barefoot running with a foot position which was significantly more plantarflexed than in control shoe (P<0.05).

The data of this study support the assumption that changes in the foot-ground interface led to changes in running pattern in a group of experienced barefoot runners. The Fivefinger model seems to be effective in imitating the barefoot conditions while providing a small amount of protection.

(R Squadrone; C Gallozzi.  Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners.  Journal of Sports Medicine and Physical Fitness; Mar 2009; 49, 1.)

Other studies have showed that minimalist shoes wearers have increased muscle strength and tone in the foot compared to normal running shoe wearers.  Anecdotal evidence around the country is mounting with increasing reports of stress fractures due to patients wearing Vibram 5 Finger Shoes and beginning new training programs.  Personally, over the last year I have treated many injuries resulting from minimalistic shoegear and inappropriate training method combinations.

How about a shoe’s shape?

This interesting study was conducted on Marine Corps Recruits.   After foot examinations, Marine Corps recruits (408 men, 314 women) were provided motion control, stability, or cushioned shoes for plantar shapes indicative of low, medium, or high arches, respectively.  A control group (432 men, 257 women) received a stability/neutral shoe regardless of plantar shape. Injuries during the 12 weeks of training were determined from outpatient visits obtained from the Defense Medical Surveillance System. Other known injury risk factors (eg, fitness, smoking, prior physical activity) were obtained.   This comparison showed little difference in injury risk between either group.   Men (hazard ratio [E/C] = 1.01; 95% confidence interval, 0.82-1.24), women (hazard ratio [E/C] = 0.88; 95% confidence interval, 0.70-1.10).

This prospective study demonstrated that assigning shoes based on the shape of the plantar foot surface had little influence on injuries even after considering other injury risk factors.

(image source)

FYI: The military has recently announced a new policy stating that “Vibram 5 Finger type shoes” are not approved shoe gear.

Splinting and Bracing:
Anecdotally, Vibram Five Fingers type shoes can be used as a unique type of splint for hammertoes and bunions. This may be a  preferred method for kids and some adults  compared to traditional splinting and taping.  The cost however is many times more compared to cheap bracing/strapping/taping.

The Answer:

So what is the answer?  I would definitely recommend at this point that runners wear a protective covering on their feet at all times.  I don’t care how strong and thick your skin becomes, it will never keep a needle, nail, glass shard or thorn out with your full weight slamming down on it.  If you do elect to go with the minimalist Vibram 5 Finger shoe or any of the knock off versions, you will be best served by training with an experienced “barefoot” runner or trainer.  Many podiatrists around the country and our own office are reporting increased rates of stress fractures and puncture type wounds from patients who either didn’t wear any foot protection, or started an aggressive running program without any thought to changing their running technique.  If you continue to run as you did in the expensive Nikes you bought last year when you switch to Vibram’s you are likely to injure yourself.  I have seen a lot of injuries recently due to minimalist running techniques and/or shoegear.  Caution is advised.

Be safe, be smart and do your research before getting too crazy out there.  One thing has absolutely been born out through the vast majority of scientific literature, that is the value of exercise in treating almost every chronic condition plaguing America today; Diabetes, high blood pressure, high cholesterol, vascular disease, etc.  Under the care of a physician or experienced physical therapist, exercise and weight loss can reverse many of these diseases.

If you include running into your overall health plan, please do it wisely.

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists


Posted in Barefoot Running / Vibram 5 Finger | Tagged | 4 Comments

Rocker Bottom Shoes

All About Rocker Sole Shoes
By Cam White, CFts







Rocker sole shoes have become the latest trend in active walking, comfort footwear. Almost every manufacturer of comfort shoes is entering the marketplace with a rocker sole shoe. With so many options to choose from, and millions spent in advertising these brands, there will no doubt be some confusion about which brand to buy. The purpose of this discussion is to provide a better understanding of the rocker sole footwear category.

Rocker sole shoes have long been known for their therapeutic benefits. They can protect the heels and the balls of the feet from repetitive impact with concrete and hard surfaces. They can be helpful for those suffering from heel and arch pain. They can also be helpful for those suffering from arthritis in the big-toe-joint (hallux rigidus).They promote good posture and can improve circulation. Rocker soles tend to engage core muscles and can improve proprioception. But rocker sole shoes are not for everyone. If you have problems with vertigo or dizziness, for example, a rocker sole shoe may not be appropriate.

There are 2 Subcategories of Rocker Sole Shoes: Unstable and Stable

Unstable rocker shoes are designed to induce instability in all planes of motion. The idea is that if you walk in an unstable shoe, your body is forced to adapt, thus simulating the effect of walking on soft, uneven terrain. Your core muscles are strengthened as your body adapts to the instability of the shoe. Unstable shoes use soft EVA memory foam or pods to create instability. MBT pioneered this concept, but brands like Skechers, Reebok, Joya and Z7 now have offerings in the unstable subcategory. If you have good control over your lower extremities – an unstable shoe may be right for you.

Stable rocker shoes rock straight ahead, but offer much better medial/lateral stability. These shoes are better suited for people that want to enjoy the exercise & postural benefits of a rocker-sole shoe, but need stability and support as well. People that over-pronate or have unstable feet tend to feel much better in a stable rocker-sole shoe. I encourage the use of custom or over-the-counter orthotics in stable rocker-sole shoes to achieve the greatest amount of stability and control. Brands like RYN, Finn Comfort “Finnamic”, Mephisto Sano and Cogent all are good examples of stable rocker shoes. Z-CoiL shoes actually function as a stable “double-rocker” shoe. As the coil compresses, it returns energy across a firm orthotic into a forefoot rocker.

Within these 2 subcategories, the degree of the rocker will determine the amount of muscle activation. In the unstable subcategory, the MBT Sport and Chapa models probably provide the greatest muscle activation. The RYN shoes provide the most aggressive rocker in the stable rocker shoe subcategory. People that buy “active walking” shoes to get the most out of their walk will probably favor MBT and RYN. The key decision will be whether they prefer an unstable or stable shoe. Here’s a breakdown of unstable and stable rocker sole shoes:

UnstableMBT (shown)
Skechers Shape Up
Reebok Easy Tone

RYN (shown)
Chung Shi
Mephisto Sano
Finn Comfort “Finnamic”

Guidelines for Buying Rocker Sole Shoes

1.     If possible, go to a store and get personally fitted for your shoes. Rocker sole shoes should fit securely and move with your feet, without heel slipping. A trained sales associate should measure your feet and observe how you are walking in the shoes. Visiting a store also provides you with an opportunity to try on various brands and styles to find the shoe that works the best for you.

2.     Break the shoes in gradually. If you have never worn rocker sole shoes before, there’s a very good chance that you will feel some muscles that you haven’t felt in quite some time. Listen to your body. If you feel like you’re over-doing it, you probably are.

3.     Beware the hype. If you think that just lacing up a pair of shoes will magically burn fat, you’re fooling yourself. Start moving, and pay attention to your form as you walk. You will feel the muscles getting worked harder, especially when you walk uphill. The more you move, the more calories you burn. In my experience, RYN shoes are the ultimate shoe for elliptical trainers. The rocker adapts to the pitch of the pedals, and there is absolutely no stress on my knees when I work out on the elliptical trainer.

4.     You get what you pay for. If the price looks too good to be true, you are probably buying a poorly made shoe or a counterfeit. Only buy from reputable, authorized dealers and allow yourself to be fitted in person, if possible. Brands like RYN, Z-CoiL and Finn Comfort cost more than cheaper shoes, but they will last for years, instead of being replaced after a few months.

5.     Do your homework. A good way to check out shoes is to read online reviews for each brand. Please bear in mind that some of the “online reviews” are probably sales people posing as “thrilled” or “angry” customers.

Posted in Rocker Bottom Shoes | 1 Comment

Laser Treatment for Nail Fungus

Dr’s Huppin and Hale ( have provided this great summary regarding the new toenail fungus laser treatment.  I have updated the article where appropriate:

Current Recommendations: Laser’s should only be used for slight cases of fungal nail infections unless adverse effects from Lamisil (ie pt has a compromised liver or wants to avoid any possibility of liver complication) in which case lasers are a safe option albeit less effective.

Below we provide information on laser treatments. We’ll start with a review of current research on oral medications so that we can compare laser treatment to the oral medications which are regarded as the most current effective treatment option.

What Do Studies Show About the Effectiveness of Oral Medication for Fungal Nails?


  1. Mycological cure (100% resolution of fungus from nail sample):defined as patient’s nail sample does not show fungus under a microscope and does not grow fungus in a laboratory medium. Mycological cure does not evaluate visual appearance of nail.
  2. Effective treatment – defined as mycological cure and >5mm of unaffected nail growth (thus clinically still signs of fungus)
  3. Mycological cure plus clinical cure (no laboratory or visual signs of nail fungus)

The oral pill Lamisil demonstrated the following in studies:

  1. 70% Mycological cure (no laboratory signs of fungus).
  2. 59% Effective Treatment 48 weeks after a 3 month treatment of oral antifungal (no laboratory signs of fungus and >5mm of unaffected nail growth).
  3. 38% Mycological cure plus Clinical cure (no laboratory or visual signs of nail fungus).

There are four companies developing lasers for treatment of toenail fungus. PinPointe FootLaser, Noveon laser, CoolBreeze Laser and GenesisPlus Laser.

I. PinPointe FootLaser:

How does Pinpointe laser study assess results of fungal toenail treatment?

  1. Nail Bed Clearing – visual improvement of nails measured by analyzing high resolution photographs. They do NOT mention Mycological cure (no laboratory signs of nail fungus). They only mention visual improvement and not laboratory signs of improvement. They also do not state what percent or size of nail improvement defines “nail bed clearing”.

On October 15th, 2010 the PinPointe™ FootLaser™ received FDA clearance as an indication “for use for the temporary increase of clear nail in patients with onychomycosis“. According to the government web site nail bed clearing is “measured from high resolution photographs”. Also, they excluded patients with end of nail thickness greater than 2 mm of either great toe. PinPointe Laser did not publish their FDA clinical study results on the government web site but their web site states ““PinPointe submitted clinical evidence to FDA demonstrating that after a single treatment, between 68 percent and 81 percent of patients experienced increased clear nail at six and 12 months and  81 percent of all patients had sustained improvement at 12 months”. Again they do not state what percentage of nail improvement defines “clear nail” and we are not sure why the FDA letter states “temporary increase of clear nail”.

II. Nomir Medical Technologies Noveon laser: Nomir, according to the government clinical study web site is “currently recruiting participants” for their government study. Nomir has some positive early results in well run studies. Nomir, however, is waiting for FDA approval before bringing their Noveon laser to market. This is an ethical approach and we applaud them for it. So far we find Nomir to be the company with the best evidence for use of their laser; however, their laser is not yet on the market.  As of early 2011, there are some rumors that Noveon has run into financial trouble. We will keep an eye on this and send an update when more information is available. A study on the use of the Noveon laser in the treatment of onychomycosis was published in JAPMA, June 2010. Results showed the following results 180 days after laser tx: 65% with at least 3 mm of clear growth, 48% with negative laboratory/microscopic findings (PAS), 39% with negative culture and at least 3 mm of cleared nail growth.

III. Cutera (GenesisPlus Laser).  

• Summary of results 16 weeks post final
treatment of the 37 nails treated:
• 30 nails (81%) showed either “complete clearance” or
“moderate to significant” clearance
• 19 nails (51%) showed “complete clearance” with 100%
testing negative for fungi
• 6 nails (16%) that showed no improvement had a turbidity
of 10 at baseline

IV. CoolTouch (CoolBreeze Laser) has started marketing their lasers for treatment of toenail fungus.  This company seems to have had lasers available for treatment of other problems and have decided to jump on the bandwagon and start marketing them for treatment of fungal nails.   No good studies available, FDA approval pending.

How do these lasers differ from each other?

Each of these lasers work on a different wavelength of light and different wavelengths have different effect on fungus and on human tissue. This means that any studies that are done must be done with the specific light wavelength to determine if a particular laser is effective at killing fungus and safe to use on humans. That is why the format of the studies is so important. A result from a study on one laser has absolutely no relationship to other lasers.

Our Current Recommendations on Lasers for Treatment of Fungal Nails

The FDA does not feel there is any valid evidence that these lasers work to cure nail fungus.   If your great toe nail thickness at the tip is less than 2mm and you would like to have a chance at temporary increase of clear nail you could try the PinPointe Laser or Genesis but you must weigh the cash price verses the FDA statement temporary increase of clear nail. Also, clear nail seems to mean just some visual improvement not a  perfect looking nail. The thicker your nail the higher chance of failure.

Our opinion is that you should avoid the Nomir Medical Technologies Noveon laser, CoolBreeze laser by CoolTouch until they obtain FDA clearance.  We welcome input from these companies if they can provide evidence based studies showing the effectiveness of their lasers. We are more hopeful that the Noveon laser will be able to provide effective treatment.

Dr’s Hale and Huppin DPM (


Summary (Dr. Preece):

On a personal anecdotal level, I have had the experience of performing and observing different laser nail treatments on hundreds of patients while working as a resident in the office of different podiatrists in Utah.  Other than very mild pain, few patients have reported any side effect from the laser treatments.  Outcomes mirrored the above literature review with results less reliable than Lamisil pills but with fewer side effects by far.  Only patients with mild cases of proven fungal infections had reliable outcomes but some difficult cases are seen with great success.  Very thick nails often appear to be resistant to this treatment likely because of the thickness of the nail and the inability of the laser to penetrate to the needed depth.  Also, thickened nails can often be the result of microtrauma combined with fungal infection meaning that even if the fungus is eliminated, the nail may still appear thickened because of scaring of the matrix.   I would only recommend the laser option for very mild fungal infections at this time if you are looking for reliable results.  However, if you health precludes any medication that is processed through the liver and you have the money, then laser treatment can be a viable option.

The most effective, scientifically proven treatment option at this time is a three month course of Lamisil combined with long term use of topical antifungal medication (ie Formula 3 or Penlac).

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists


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What is a Podiatrist anyway?

The APMA (American Podiatric Medical Association) recently released the following regarding Podiatry Profession:

The Profession

• Doctors of podiatric medicine are podiatric physicians and surgeons, also known as podiatrists,
qualified by their education, training and experience to diagnose and treat conditions affecting the foot, ankle and related structures of the leg.

• Doctors of podiatric medicine receive medical education and training comparable to medical
doctors, including four years of undergraduate education, four years of graduate education at
one of eight accredited podiatric medical colleges and three years of residency training.

• Doctors of podiatric medicine are uniquely qualified among medical professionals to treat the
foot and ankle based on their education, training and experience.

• Podiatry is to the foot and ankle what ophthalmology is to the eye, cardiology is to the heart or
otolaryngology is to the ear, nose, and throat.

• By virtue of their education, training and experience, doctors of podiatric medicine can:
o Perform comprehensive medical history and physical examinations
o Prescribe drugs and order and perform physical therapy
o Perform basic and complex reconstructive surgery
o Repair fractures and treat sports-related injuries
o Prescribe and fit orthotics, insoles, and custom-made shoes
o Perform and interpret X-rays and other imaging studies

•Doctors of podiatric medicine are authorized to practice podiatric medicine by state statute and are regulated and licensed to practice podiatric medicine in all 50 states and the District of Columbia.

• Forty states have podiatric licensing boards. In the remaining 10 states, podiatric medicine is regulated by medical licensing boards.

• Podiatrists are defined as physicians by the federal government and in most states. In the few
states that do not use the term “physician” in the definition, podiatrists are licensed to diagnose
and treat the foot, ankle and lower extremity.

Podiatric Medical Education

• Doctors of podiatric medicine receive basic and clinical science education and training comparable to that of medical doctors:
o Four years of undergraduate education focusing on life sciences
o Four years of graduate study in one of the eight accredited podiatric medical colleges
o Three years of postgraduate residency training

• The education, training, and experience podiatrists receive in the care and treatment of the lower extremity is more sophisticated and specialized than that of broadly trained medical sub-specialists.

Podiatric Residency Training

During residency, podiatrists receive advanced training in podiatric medicine and surgery and serve clinical rotations in anesthesiology, internal medicine, pathology, radiology, emergency medicine, and general surgery, as well as elective rotations. Podiatric residency programs are three years in length and are provided in a hospital setting. During residency training, podiatric residents have substantial involvement in more than 1,000 foot and ankle surgical procedures performed on more than 600 patients. The surgical case load related to the lower extremity and the intensity of surgical involvement afforded podiatric residents far exceed those provided to orthopedic residents in four to six years of broadly-based residency training programs. The education, training, and experience podiatrists receive in the care and treatment of the lower extremity is more sophisticated and specialized than that of broadly-trained orthopedists.

Council on Podiatric Medical Education

The Council on Podiatric Medical Education (Council) is recognized by the Council for Higher Education
Accreditation and the US Secretary of Education as the accrediting agency for first professional degree programs in podiatric medicine. For 90 years, the Council has served to evaluate and promote the quality of doctoral education, postdoctoral education, board certification and continuing education for doctors of podiatric medicine. Compliance with standards and requirements set by the Council ensures a degree of uniformity upon which residency programs, certifying boards, state licensing agencies, and other credentialing entities can rely.

As of 2008, the Council accredited eight colleges of podiatric medicine. To achieve accreditation, colleges of podiatric medicine must provide classroom curricula and clinical education experiences that enable podiatric medical students to achieve specific competencies set forth by the Council. As of 2008 the Council approved 240 healthcare institutions as sponsors of podiatric medical residencies. To receive approval, residencies in podiatric medicine and surgery must meet the standards and requirements established by the Council. As of 2008, the Council recognized two certifying boards: the American Board of Podiatric Surgery (ABPS) and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM).

National Board of Podiatric Medical Examiners

The National Board of Podiatric Medical Examiners (NBPME) is the national testing agency for podiatric
medicine. NBPME examinations are designed to measure the knowledge necessary to perform
at the level of minimum competence as a newly licensed podiatric medical practitioner. Passing the NBPME examination has been accepted by most state licensing entities as a requirement for obtaining a license to practice podiatric medicine in a given jurisdiction.

Board Certification

Certification in podiatric surgery or podiatric orthopedics and primary podiatric medicine attests to the achievement of individual podiatrists in possessing higher levels of knowledge and skills beyond those needed for minimal entrance into the profession. Over 5,000 hospitals and third party payers annually verify the credentials of ABPS board certified and qualified podiatric surgeons.

Dan Preece, DPM


Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
     Foot & Ankle Specialists
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