Can Shoes Be “Tiny Coffins”. Yes, they can.

(Please read comment section below. Author Chris McDougall has posted an informative comment and added to the quotes seen in Born To Run.  I’ll extract from the quotes, but be sure to read the comment. (If it says “comments closed”, which the blog does automatically at a set time interval, please click on the blog title which will open this entry in full, with the comments visible.) The thrust of this blog entry will remain the same. For me the deadly shoes I’m speaking of point to the neuropathic foot which was a large part of Paul Brand’s professional life work. )

Paul Brand, M.D. (1914 – 2003) was quoted by Chris McDougall in Born To Run as essentially saying that if everyone stopped wearing shoes, his office would be less busy and most foot problems would disappear in a generation.

Paul Brand 2002

While many may think Paul Brand had an ordinary waiting room, he did not. Brand did not specialize in treating the usual foot problems. He was a brilliant innovator on the special problem of diseases which cause loss of pain sensation via neuropathy.  He worked for many years at the National Hansen’s Disease Center at Carville in Louisiana. He specialized in  the orthopedic treatment of Hansen’s Disease (leprosy). Among other innovations, his work led to contact casting to help heal ulcers in feet with neuropathy, such as diabetics and those with Hansen’s Disease.  He contributed a good deal to knowledge about the significance of neuropathy in the creation of ulcers and to the care of insensitive feet. (Brand also worked extensively on hands with problems related to neuorpathy and insensitivity.) These neuopathies also affected strength rations of opposing muscle groups which often led to significant foot problems including hammer toes and bunions. Insensitivity combined with altered biomechanics, physical deformity, create special problems in walking and wearing shoes, particularly ones that are not fit well and do not serve to balance areas that are overloaded by pressure (pressure points on toes, hallux valgus, or on the plantar surface (metatarsal area or any other part of the bottom of the foot).

Brand worked with patients whose shoes often did create significant and even life threatening problems. Lacking sensation, because of neuropathy, they couldn’t feel the blisters, ulcerations, and infections developing. Another one of his sayings was “Pain is god’s greatest gift”. A shocking statement, but he said that because those lacking normal sensation did terrible damage to themselves.

As tiny coffins in this case, the shoes which caused the problem could lead to an amputation of a foot or leg in a diabetic which would lead to a second amputation more than 50% of the time within 2 years. Amputation in diabetics also is known to have a high mortality rate over 5 years (up to 74%, note that bypass operations may help). Slow healing ulcers have a death from all causes mortality of up to 50% within 5 years. This is worse than many forms of cancer.

Chris McDougall has provided some direct quotes, ( I believe from one of Brand’s biographical works – which will is now added to my reading list.) I’ll add some of those here. For the remainder, please be sure to read the comment section.

“A high proportion of the world’s population walks barefoot most of the time, and the average person who walks barefoot has much healthier feet than the average person who wears shoes.”, said Dr. Brand. Speaking of his own personal experience he said that “The barefoot walker receives a continuous stream of information about the ground and about his own relationship to it, while a shod foot sleeps inside an unchanging environment. Sensations that are not used or listened to become decayed and atrophy. There is a sense of aliveness and joy which I experience walking barefoot that I never get in shoes.”

Chris reports that Dr. Brand said this of normal people in normal shoes. And adds that Dr. Brand was a proponent of barefoot walking and sports. We will accept that as Dr. Brand’s opinion and statement and warn people who do suffer from pain insensitivity to not take this as advice directed at them. They are usually given special advice to not go barefoot, and in many cases to have carefully designed shoes, often custom, with special insoles or diabetic orthotics designed to decrease pressure, and to lessen excessive pressures over areas at risk. In spite of this care problems may still develop and this is only a cursory and incomplete look at these problems and their causes.  Patients with pain insensitivity must perform a self-inspection daily.

I was lucky to meet Dr. Brand in 2002 at the American Podiatric Medical Association meeting in Seattle, Washington. Dr. Brand opened a special section on insensitive feet which included presentations by his former prodigies on their current work. While I spend more time working with athletes, all knowledge is helpful, and Dr. Brand was a true icon.

While I scoffed the other day at  the quote in the New York Times about shoes as tiny coffins that halted evolution, in cases like these they truly are tiny coffins. They could cause your loss of limb and ultimately put you at a much higher than normal risk of death. Seeing the New York Times quote calling them “tiny coffins” did immediately make me think of the neuropathic foot. We’ve previously discussed the cost of amputation. We also see that diabetic ulcers and amputation are also deadly problems.

Preventative care, helpful? Yes, of course.  Make sure it gets properly included in any health care reform. Medicare ( a government run system) includes special shoes, non-custom inserts, yearly foot checks, and some  insurance carriers include this also. Some policies cover custom orthotics for diabetics, but not for runners. The policies and medicare aren’t quite up to speed but they are improving. Make sure that encouraging healthy life habits and preventative care is incorporated in some fashion and included as a core feature in future health policy to assist in decreasing the overall cost of care and in particular the cost of chronic illness. If you are diabetic, get your feet checked regularly, check them yourself, and learn how to both check and care for them. Exercise as recommended by your physician, and make sure you eat correctly, and monitor and control your blood sugar appropriately. Follow advice from your podiatrist on what foot wear  and socks are best for you.

For the runners, I expect you should shortly find here some blogs on what bad can come to you from your shoe, and what steps to take.

References:

Diabetic foot ulcers: prevention, diagnosis and classification.
Armstrong DG, Lavery LA. Am Fam Physician. 1998 Mar 15;57(6):1325-32, 1337-8.

Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial. D. G. Armstrong, L. A. Lavery, S. Wu, and A. J.M. Boulton. Diabetes Care, March 1, 2005; 28(3): 551 – 554.

Revisiting the Total Contact Cast. Maximizing off-loading by wound isolation. Petre, M, Tokar, P, et. al. Diabetes Care  April 2005   vol. 28  no. 4  929-930

The total contact cast. A therapy for plantar ulceration on insensitive feet
WC Coleman, PW Brand, and JA Birke. J Am Podiatr Med Assoc, Vol. 74, Issue 11, 548-552, November 1, 1984

Mortality rates and diabetic foot ulcers. Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. J Am Podiatr Med Assoc. 2008 Nov-Dec;98(6):489-93.

What is the most effective way to reduce incidence of amputation in the diabetic foot? Apelqvist J, Larsson J. Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S75-83.

Diabetes Res Clin Pract. 1997 Jul;37(1):41-7. Mortality following lower extremity amputation in minorities with diabetes mellitus. Lavery LA, van Houtum WH, Armstrong DG, Harkless LB, Ashry HR, Walker SC.

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Moulik PK, Mtonga R, Gill GV. Diabetes Care. 2003 Feb;26(2):491-4.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Faglia E, Favales F, Morabito A. Diabetes Care. 2001 Jan;24(1):78-83.