That bony lump at the back of your heel
This post stems from an email I received. It covers the following topics:
- Haglunds deformity (pump bump) and heel blisters
- ENGO Patches vs ArmaSkin socks
- Golf and walking
- Taking a systematic approach to combatting blisters
I live in the UK and am a frequent golfer - playing in a range of climatic conditions and in different countries ranging from cold Scotland to warm South Africa, Florida and Turkey.
My preference is always to walk when playing golf. On average I play 18 holes of golf (roughly 4 to 6 miles) at least 3 times a week. Sometimes I have to carry my golf bag which weighs about 12 kilos. I play mainly hilly grass courses which are normally soft underfoot.
I have a Haglund on each of my heels which are not sufficiently serious enough or large enough to warrant any surgical intervention. However I do suffer from blisters and deroofing around the area of the Haglund on each heel.
The incidence level varies and is not confined to playing golf. Walking just in town, trail walking and the wearing of new shoes even for short distances can cause both blistering and deroofing. The use of Compeed dressings and similar products have proved ineffective - with the dressing soon becoming detached and the adhesive then causing a sticky mess on the sock material. I have used merino wool walking socks, double layer socks including 'Hilly' running socks with a polypropylene inner all to limited effect. I have also resorted to using some Hypafix Dressing fixing tape - which has had some good results if used with double layer socks.
Having applied most of your advice contained in your Blister Guide to varying degrees, my question in a nutshell is "which primary method of blister prevention would be more effective between ENGO patches and Armaskin socks?" It appears to me as a lay person that they work in totally different ways to combat the same issue.
Any advice would be most gratefully received.
You're spot on. The Armaskin socks and the ENGO Patches do work in totally different ways to combat the same issue - managing friction.
Basically, in combatting blisters and abrasions you can do things like:
- Changing the structural characteristics of your skin – That means adapting it to the loads it encounters, with training in your sport and building a little bit of callus over the lump. These things you will have already exhausted
- Reduce the repetitions – That means don't walk or play golf so much … not a great option!
- Reduce movement of the heel bone - Tight calf muscles would be relevant to blisters at the back of the heel, so calf stretches may help if you are tight.
- Reduce the coefficient of friction - which means pressure and friction. Let's me expand on this fourth point ...
With a Haglunds deformity, pressure is an issue because of the lump. But like all foot blisters, we can only do so much to reduce pressure - you still have to walk on your feet and wear shoes. So there is always going to be high-ish contact pressure from your shoe all around your foot. In reducing pressure at the back of your heel, all you can do is make sure the area is padded (no doubt you've done all you can here) or wear shoes with no back in them (not a solution for golf). Oh, or of course you can change the anatomy at the back of the heel to take away that bony lump (surgery). But remember, people still get blisters at the back of their heel even without Haglunds, so it may not be a 100% solution.
That takes us to friction. When we walk, our foot bones don't stay exactly still in the shoe. There will be a movement differential between the bones of the foot and the shoe itself. Shoes and socks are made of high friction materials in an attempt to keep the foot still - which is good because your foot needs traction in the shoe for the mechanical efficiencies of gait. So the shoe grips the sock, and the sock grips the skin to provide this necessary traction. But that doesn't stop the bones moving within the foot. And so this is where the movement differential occurs - we call it shear which is the stretching under the skin.
Most people go fine with a lot of shear within their skin and don't get blisters. But for some of us, that internal movement differential and resultant shear happens to excess, or at least to a level above the threshold of our skin, which is very individual, and we get blisters.
So, if we need to reduce the degree of shear distortions within our skin, and all of the above methods have failed [skin characteristics, repetitions, bone movement and pressure], we need to manage friction - so that rather than the movement differential happening within our foot, it happens external to our foot. That means, we need to encourage rubbing either:
- Between the skin and sock - this is what lubricants do, but they have some significant downsides. Basically, they really do cut friction levels for a while, but after a time as it disperses into the sock, friction levels rise such that the rubbing that happens is abrasive. So the mechanics are there for blister development again, which will probably deroof. And if you don't get a blister, you will probably get an abrasion - slightly different skin injuries that end up looking the same and feeling equally painful.
- Between two sock layers - this is double socks. Of them all, I think Armaskin does it best. Unlike other double-socks, these socks artificially increase the friction level between the skin and the sock, so that no matter how long you wear them, there is absolutely no movement [rubbing] against your skin. And in turn, the slippery outer of the Armaskin sock means that you can pretty much guarantee friction will be lowest between the two sock layers and this is where the movement differential will occur. This saves your skin from both abrasion and blisters.
- Between the shoe and sock - this is what ENGO Patches do. The way they manage friction is they drastically reduce the friction level between the shoe and the sock to ensure this is where the movement differential [rubbing] will happen - and so you don't get blisters. And because the friction level between the skin and sock is higher, it means the sock stays stuck to the skin and protects it from abrasion injury.
And now to answer your question Bruce. I have a bias towards the ENGO Patches which you must take into account, but I try to be as objective as possible. I think ArmaSkin socks and ENGO Patches probably work similarly well. I have a pair of the Armaskin socks myself and I've seen and heard some good feedback about them. But I don't know a lot about the technical side of the socks. And to my knowledge, no research has been done with them. So my comparisons can't be based on research evidence.
I think the strategy you find that suits you best will be in the other pros and cons of each product.
- With ENGO, it will be things like they last a long time, once they're in your shoe you can virtually forget about them, you can wear them in any type of shoe and they are hidden in the shoe - but if they get waterlogged them might come unstuck and you do have to be a little cautious when you push your foot into your shoe.
- With ArmaSkin socks, it will be things like you can take them off and on as you need them - but they are a bit trickier than normal socks to get on and some people don't like the way they feel on the skin (I expected this to be an issue for me but it wasn't).
The only difference that might be significant is the fact that ArmaSkin socks reduce friction all over and so traction might be an issue (I noticed this more in the initial stages of wearing them). Whereas ENGO reduces friction in a targeted way, maintaining good friction everywhere else to maintain traction for the foot in the shoe.
This has turned out to be a much longer email than I intended Bruce. I hope it helps explain all of your options. If there's anything you'd like me to clarify, please just let me know.
Written by Rebecca Rushton
Rebecca is an Australian podiatrist with over 20 years experience. She has spent a lifetime dealing with her own blister prone feet in her sporting and everyday life. Rebecca specialises in helping athletes and sports medicine professionals figure out how to manage foot blisters with ease. And for kicks, she enjoys providing blister care at multiday ultramarathon events.
Rebecca is the founder of Blister Prevention and author of "The Blister Prone Athlete's Guide To Preventing Foot Blisters".