MILITARY MEDICINE, 173, 4:359, 2008

A Survey of Deployed Foot Problems in a Desert Environment

Col John S. Cramer, USAF MC SFS*; 1st Lt Kelly Forrest, NC NYANG†

ABSTRACT A casual comment made regarding the amount of “mole skin” being dispensed to airmen to handle
blisters, pressure points, and foot pain led to the development of an impromptu voluntary survey in an attempt to
quantify the number of personnel with foot care concerns and the spectrum of those problems. With only a small number
of sick call visits related to foot and ankle problems, the amount of mole skin being dispensed was surprising. This

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survey represents the results of a comprehensive evaluation of a base population involved in support of the first 2 months
of Operation Iraqi Freedom.

INTRODUCTION National Guard member deployed to a base in Southwest

During a conversation with medical technicians at an austere
desert base in 2002, a casual comment was made regarding
the amount of “mole skin” that was being dispensed to airmen
to handle blisters, pressure points, and foot pain. Fifteen
square feet was being used on a monthly basis for a base
population of approximately 1,500 personnel. The amount of
mole skin being dispensed came as a shock as only a small
number of sick call visits were related to foot and ankle
problems. As a result, an impromptu voluntary survey was
conducted in an attempt to quantify the number of personnel
with foot care concerns and the spectrum of those problems
(Table I, columns 1 and 2). A foot care brief was developed
for the base to deal proactively with these concerns. In
addition, a comprehensive literature search on the problem
was done to support recommendations, which resulted in a
very limited number of relevant articles.
Personnel with blisters have been found to be at a higher
risk for subsequent injury, which could potentially interfere
with mission execution.1 Therefore, it seemed reasonable to
attempt to quantify the nature and extent of foot problems
during a future deployment in 2003 to an austere desert
environment. This survey represents the results of a compre-
hensive evaluation of a base population involved in support
of the first 2 months of Operation Iraqi Freedom (Table I,
columns 3 and 4).
METHODS/DATA ANALYSIS
The method of data collection was a survey filled out by
every active duty Air Force, Air Force Reserve, and Air
*48th AMDS/SGPF, RAF Lakenheath, Brandon, Suffolk, U.K., IP 27
9PN.
†107th ARW, Medical Group, 9905 Blewett Avenue, Niagara Falls, NY
14304-6003.
The opinions and assertions expressed herein are the private views of the
authors and are not to be construed as official or reflecting the views of the
New York Air National Guard, U.S. Air Force, or the Department of
Defense.
This manuscript was received for review in February 2007. The revised
manuscript was accepted for publication in July 2007.
Reprint & Copyright © by Association of Military Surgeons of U.S.,
2008.
Asia during the time period of March to May 2003. Although
all members deployed to the base were required to fill out the
survey, consent was not required since all data were collected
anonymously. A total of 341 surveys were analyzed. The
survey captured information regarding foot problems before
deployment (yes or no), advance issue of desert boots (ⱕ2
weeks, ⬎2 weeks), whether break-in time was adequate (yes
or no), foot concerns since arrival (yes or no), the use of
steel-toe boots (yes or no), the longest time spent in boots
(ⱕ12 hours, ⬎12hours), whether socks were swapped out
(yes or no), and whether adequate foot care information had
been provided to the member (yes or no). The categories
under “foot concerns since arrival” included the following:
foot pain/aching, toe pain/aching, corns, bunions, blisters,
calf pain/aching, skin cracking, calluses, itching/burning, and
ingrown nails.
Overall incidence rates were calculated. Relative risks,
with 95% confidence intervals were used to examine the
relationship between foot concerns since arrival in-theater
and factors that may have influenced them. Logistic regres-
sion (backward selection) was used to determine important
statistical associations. Statistical analysis was performed us-
ing SAS statistical software (version 9.1.3; SAS Institute,
Cary, North Carolina).
RESULTS
Included in this analysis were surveys completed by the base
population of 341. Eighty-four members reported foot con-
cerns since their arrival in-theater, for an incidence rate of
24.63 foot concerns per 100 members. Forty-four percent of
those who reported concerns reported more than one foot
problem. Blisters were the most common reported problem in
this group, accounting for 44% of foot concerns since arrival
in theater (Table I, columns 1 and 2). This represented 10.9%
of the base population.
There were three factors that showed a positive correlation
for those members who indicated they had foot concerns
since their arrival in-theater. These were: previous problems
(relative risk, 2.64; 95% confidence interval, 1.66 – 4.17),
⬎12 hours in their boots (relative risk, 1.26; 95% confidence

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 Clinical Report

TABLE I. Foot Care Survey TABLE II. Association between Foot Concerns Since Arrival
In-Theater and Other Factors
Impromptu 405th
EMDG, June 19, Formal 487th EMDG, 95% Confidence
2002 May 20, 2003 Factor Relative Risk Intervals pa
Column 1 Column 2 Column 3 Column 4 Previous problems 2.64 1.66–4.17 0.001
Foot Care Survey (n) (%) (n) (%) Time in boots ⬎12 1.26 1.13–1.41 0.001
Foot problems hours
before Advance issue of boots 1.71 1.14–2.57 0.008
deployment ⱕ2 weeks
Yes 17 11.49 15 4.40 Adequate boot break in 0.72 0.49–1.00 NS

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No 131 88.51 326 95.60 time
Advance issue of Steel-toe boots 1.3 0.86–1.97 NS
desert boots Swapping out socks 1.34 0.88–2.05 NS
ⱕ2 weeks 97 66.90 181 54.35 Adequate foot care 0.85 0.35–2.06 NS
⬎ 2 weeks 48 33.10 152 45.65 information
Time to break in a
A significant p value is defined as ⬍0.05. NS, nonsignificant.
boots
Yes 65 44.83 127 37.35
No 80 55.17 213 62.65
Foot concerns 87 58.39 84 24.63 population reported they had foot concerns during the de-
since arrival
ployment. The implication of foot disorders relates to the
Foot pain/aching 32 36.78 25 29.76
Toe pain/aching 32 36.78 15 17.86 potential for degraded performance of members and subse-
Corns 7 8.05 3 3.57 quent risk to mission execution. The deployed personnel in
Bunions 4 4.60 3 3.57 this survey showed a rate of blister formation of 5.43 per 100
Blisters 56 64.37 37 44.05
member months during this deployment as compared to only
Calf pain/aching 6 6.90 8 9.52
Skin cracking 22 25.29 17 20.24 2.05 per 100 recruit months in the Marine initial physical
Calluses 23 26.44 13 15.48 training study.1
Itching/burning 14 16.09 17 20.24 One study attempted to evaluate the impact of using anti-
Ingrown nails 3 3.45 4 4.76
perspirants, in the form of 20% aluminum zirconium tetra-
Longest time in
boots chloridyrox glycine in an emollient base, on blister formation.
ⱕ12 hours 20 13.16 76 22.35 Their simulation involved marching at 3.1 mph (1.39 m/s) for
⬎12 hours 122 84.72 269 79.12 200 minutes with a 46-lb pack (21 kg) at a temperature of
Swap out socks
84°F (28°C) and 25% relative humidity.2 They found no
through shift
Yes 11 7.38 65 19.17 difference in sweat accumulation, hot spots, and blisters (size
No 138 92.62 274 80.83 or number). Concerns with the lack of response in this study
Number of 149 341 relate to: the limited duration in the boots (⬎12 hours in the
respondents
field in our survey), the heat stress (40°C in the field in our
deployment), and the specific antiperspirant in combination
with an emollient (6 –20% aluminum chloride hexahydrate is
interval, 1.13–1.41), and 2 weeks or less of advance issue of the current topical standard of care).2,3 There were no com-
their boots (relative risk, 1.71; 95% confidence interval, parative studies available for 15% aluminum chloride aque-
1.14 –2.57) (Table II). Although not statistically significant, ous solution (Maxim, over-the-counter; Conrad Healthcare,
there was an association between foot concerns since arrival Inc. Available at http://www.stopsweat.com) or 20% alumi-
in-theater and adequate break-in time, steel-toe boots, swap- num chloride hexahydrate (Drysol by prescription), but they
ping out socks, and adequate care instructions. remain the primary recommendation for the topical treatment
of plantar hyperhidrosis.4 Tinea pedis can be a considerable
DISCUSSION additional risk through skin maceration secondary to the
Previous studies have clearly demonstrated the significance occlusive effect of the boot, heat, and perspiration. Although
of foot morbidity in military populations. Blisters are an topical antifungals remain a mainstay of treatment, it is
important source of morbidity and were associated with a important not to forget the benefit of a 1:40 Burow’s solution
50% increase in the subsequent risk for other lower extremity soak and the therapeutic utility and convenience of an appli-
injury in a prospective study of Marine recruits during initial cation of 1:10,000 potassium permanganate.5
physical training.1 While in our survey only 3% of sick call Although nothing could be found in the literature on the
visits involved blisters, 11% of those involved in the survey role of “mole skin,” there is no question that it can be used to
reported experiencing blisters. In addition, while only 12% of effectively reduce pressure points and friction as well as
sick call visits were related to foot concerns, 25% of the base protect boney prominences.

360 MILITARY MEDICINE, Vol. 173, April 2008

 Clinical Report
TABLE III. General Principles for Deployed Foot Care
Principles for Deployed Foot Care
Make sure you have a good fitting pair of shoes or boots
Make sure you have a second pair
Make sure they are broken in
Try to have a different heel height between them
Be sure there is a good arch support: if not purchase an insert
Look for a boot with a well-cushioned sole and heel strike area
Use socks that breathe: preferably cotton or newer “wicking”
materials
Get out of your shoes/boots as often and as much as possible
Keep your feet as cool, clean, and dry as possible
If necessary, swap out socks during a shift
Wash your feet well and pay attention between the toes
If spending long hours in a hot environment, use athlete’s foot
powder in anticipation of problems
Lace boots up tightly enough to avoid movement within the boot
Avoid friction and pressure points: consider use of “mole skin”
If necessary, use a second pair of socks, “mole skin,” band-aids, or
corn pads, etc. to relieve friction and pressure points
A good soak with one-half of a cup of Epsom salts to 1 quart of
hot water is therapeutic for sore aching feet
Avoid dry, cracked skin with the regular application of a
moisturizing lotion
If you suspect you have a problem or it is getting away from you,
be sure to get to sick call and have the issue properly dealt with
early
LIMITATIONS
This survey had several limitations reflecting the lack of
information on the age, sex, race, and body mass index of the
personnel surveyed. There have been concerns that foot pain
can be correlated to body mass index.6 It has also been
suggested that women’s higher arch put them at higher risk of
problems in traditional combat boots, while older populations
will experience a greater incidence of static foot deformities
(hallux valgus, hallux rigidus, bunions) predisposing them to
secondary foot problems.7 Lastly, there was no control pop-
ulation surveyed concurrently at a home base, so it remains
unclear as to the exact burden on personnel’s feet from a
deployed desert environment alone.
MILITARY MEDICINE, Vol. 173, April 2008
CONCLUSIONS
Based on our analysis, anyone with a previous history of foot
problems represents the greatest risk while deployed. Ad-
dressing this aggressively before deployment could reduce
the risk of problems while deployed. General principles for
deployed foot care could be provided to troops before de-
ployment and again during their in-processing brief. An ex-
ample is provided in Table III. Issuing boots to allow suffi-
cient time to break them in properly (⬎2 weeks) as well as
ensuring that they are worn and broken in before deployment
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should reduce subsequent problems. Predeployment recom-
mendations to bring alternate footwear to swap out after duty
hours and reinforcement in-theater could help to limit issues
associated with total time in boots. It goes without saying that
properly sized boots with adequate arch support are a neces-
sary key to the success of any of the other recommendations.
Should the built-in insoles have insufficient support, encour-
age the purchase of alternate arch supports off the shelf or as
custom orthotics.7 Lastly, since blisters were reported in
10.9% of the base population (44% of those who reported
foot problems), be prepared to provide an adequate supply of
“mole skin” and ensure a liberal distribution policy.
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3. Merck Manual: Hyperhidrosis 2006. Available at http://www.merck.com/
mmpe/sec10/ch118/ch118c.html; accessed December 13, 2006.
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