San Francisco Podiatry Video

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Thursday, April 13, 2017

Will Custom Orthotics Help? How much do custom orthotics cost?

Here is a question from someone considering custom orthotics:


Hi there,
I have high arches and have not been able to find an arch support that works well for me. I don't experience pain but rather weakness/numbness or just the sensation that something is "off".
Hoping to get an evaluation and possibly orthotics.
Wondering, what is your rate for a clinic appointment in San Francisco and general cost for orthotics.
Many thanks,
ML

Hello ML,

Thank you for your inquiry!  I am sorry to hear that you have been having so much trouble finding arch supports that have worked for you, but I will be happy to help.

In many cases, numbness and weakness may be attributable to issues that may not even respond to over-the-counter shoe inserts or custom orthotic therapy. Of course, we would determine that during your evaluation.

I can assure you that I will not make custom orthotics for you unless I am certain I will help. We offer a money back guarantee on custom orthotics and in more than 10 years I've only had one pair returned. Just so happens that the pair was returned from a teenage girl who refused were anything other than flip-flops. 

The guarantee is as follows: you can use the custom orthotics for one full year. If after one year, you don't believe the orthotics have been helpful in alleviating your discomfort, helping you maintain an increased activity level, helping you run faster, or you are unhappy with the custom orthotics for any reason whatsoever you may return them for a full refund of the orthotic fee. The only condition or "fine print" is that you must return them to me within 370 days of delivery. That way you have a full year to try them out.

I do house calls so I will come see you and will cast you for custom orthotics at home during the initial evaluation, if custom orthotics seem appropriate. Seeing you at home can help facilitate evaluation because we can look at all of your shoes to help determine whether or not any of the shoes you are currently wearing may be contributing to the problem.

The rates are as follows: 

New patient evaluation: $500. The appointment is usually about 1 hour to 90 minutes. No additional fees if they you have lots of questions and the appointment runs longer.

Custom orthotics: $487. This includes the a Biomechanical exam, plaster casting to create molds of your feet for the custom orthotics, and the actual production of the custom orthotics.

I will return to your home one week after the casting to deliver the custom orthotics, fit them to your shoes, and discuss the process of break-in. There is no additional charge for the second house call appointment when I deliver the custom orthotics. The cost of the follow-up is included in the orthotic fee.

Please let me know what works best with your schedule so we can find a time that doesn't disrupt your work schedule. 

I look forward to meeting you. 

Sincerely, 
Dr. Christopher Segler
Doc On The Run



Monday, February 2, 2015

Can I Run with Plantar Fasciitis?

Dear MyRunningDoc,

I am a runner who has been suffering with plantar fasciitis for several months. I tried couple of different things myself to get the heel pain to go away but it still continue to bother me. When I went to see my doctor, she told me that I had to stop running.

Can I run with plantar fasciitis? Will my heel pain get worse if I keep running? Or can I run with plantar fasciitis and still heal.

John H. 
San Jose, CA




Hello John,

Heel pain can be frustrating when you are a runner. It isn't that the heel pain is so debilitating that it stops you from running, but that you are often distracted by it, and concern that the problem will get significantly worse or translate into other overuse injuries.

Plantar fasciitis of course is the most common form of heel pain. But it isn't the only type of heel pain that happens in runners. The short answer is that if it is only plantar fasciitis, you can probably keep running without the problem getting worse. It is also possible to continue running and still heal your heel pain.

This all assumes that you have been correctly diagnosed, and have not been mis-diagnosed. If your doctor mistakenly diagnoses you with plantar fasciitis, when in fact have a calcaneal stress fracture (crack in the heel bone), or a partial rupture of the plantar fascia (a small tear in the plantar fascia), you will have to stop running for some period of time, depending upon the severity of the condition.

It is important to note that stopping running alone will not cure any of the above mentioned causes of heel pain. conditions. Many runners can self-diagnose their heel pain without ever seeing a doctor. But if you have any doubt about the accuracy of your diagnosis, or specifics about how to continue running while you have plantar fasciitis, you should seek a second opinion from a sports medicine podiatrist who specializes in the treatment of runners.

Dr. Christopher Segler is a 14-time ironman triathlon finisher and sports medicine podiatrist who specializes in the rapid treatment of running injuries. He performs remote consultations via Skype for runners and triathletes overseas who do not have access to Western medical doctors and running experts. You can learn more about running with heel pain at DocOnTheRun.com or learn more about plantar fasciitis at AnkleCenter.com



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Saturday, January 31, 2015

Can I run a marathon with a metatarsal stress fracture?

Hello Running Doc,

I have been training for my first marathon for the last four months. I have been following an online training plan and my mileage has been increasing steadily. After overcoming all of the initial soreness with the periods of increased distance, I have been doing well. Until recently…

I started having this aching pain in the ball of my foot. At first it was only when I was running. I iced it and kept training. Eventually I started having aching pain and throbbing on the top of my foot as well. I went to see my primary care doctor and I was told that I have a metatarsal stress fracture. My doctor told me I had to stop running for 6 weeks and skip the marathon.

Is it possible for me to still run the marathon, even though I have a metatarsal stress fracture?

Thanks for any advice!
Erin M.
Oakland, CA



Metatarsal stress fractures are one of the most common causes of pain in the ball of the foot in runners. It is also one of the most common reasons that a marathon runner is forced to stop training and skip a race like a marathon.

The short answer is, yes, you could probably still run the marathon. However, that depends on several factors.

The doctor’s job is not to tell whether or not you can run. The actual job of the of a sports medicine podiatrist is to explain all the risks and benefits of a given course of action. It is then of course up to you to decide what is best for you given your circumstances.

Metatarsal stress fractures come in a full range of trouble. In the very early stages it is actually a stress response, that is affecting the metatarsal bone and causing the pain. In many cases of the stress response the metatarsal calms down and heals quickly. If you did not remove the stress that is being applied to the metatarsal (i.e. training) then the metatarsal stress response can get worse and a tiny little crack forms and the bone. This is a metatarsal stress fracture.

If you have a metatarsal stress fracture and you continue to ramp up your training it is possible that the tiny little crack can form a complete break in the bone. This is when the real trouble begins.

The first thing for you determine is whether or not you actually have a true metatarsal stress fracture or just a metatarsal stress response. If it is only a metatarsal stress response, you could substitute running for some other activities that apply less stressed to the metatarsal, maintain your fitness and then resume your training in time to run the marathon.

But if you have a true metatarsal stress fracture and you're not careful about which activities you choose, it is possible that the metatarsal stress fracture could turn into a completely broken bone that requires surgery for repair.

It is indeed possible that you could continue to train, with the appropriate direction, and then run your race. However, it is a dangerous game to play if you're not certain about the exact condition that is causing the pain in the ball of your foot.

You must work with a sports medicine podiatrist who specializes in the treatment of runners to guide you through the alternative activities so you can maintain your running fitness while decreasing the risk of making the stress fracture worse.


Dr. Christopher Segler is a runner,  sports medicine podiatrist and 14-time Ironman triathlon finisher. His practice focuses on the rapid treatment of running injuries, and a rapid return to running for his patients in the San Francisco, Oakland, and San Jose. He also does remote consultations via Skype for runners and triathletes overseas. If you have a question about metatarsal stress fracture that it is affecting your ability to run, you can reach him directly at 415–308-0833. You can also learn more about metatarsal stress fracture surgery for runners at DocOnTheRun.com and learn more about metatarsal stress fractures at AnkleCenter.com 


All content copyright 2015, Dr. Christopher Segler, Doc On The Run.

Thursday, January 29, 2015

Should a Runner Have Morton's Neuroma Surgery?

Hello Running Doc!

I am a life-long time runner who has done many marathons. About a year and a half ago I started developing tingling and pain in the ball of my foot about. The pain gradually got worse. I saw a podiatrist and learned that I had a Morton’s neuroma.  I was given some neuroma pads to try to take the pressure off it, but it still continued to bother me after I would run. Eventually I went to the doctor again and I was told that I would have to stop running.

I really don't want to stop running. For this reason I went and got a second opinion from an orthopedic surgeon. He recommended that I have surgery on my foot to remove the Morton's neuroma. I'm still not sure if this is the right approach because I am concerned that surgery can alter my foot in someway that might change my running biomechanics. Is that something I should really be concerned about?

Thanks!
Henry B.
San Jose, CA


A painful Morton's neuroma certainly can disrupt your ability to run. The swollen nerve on the bottom of the foot can cause tingling and burning pain. But in addition this pain can get worse. In the initial stages of the development of then neuroma, many patients will say that they have tingling foot pain that is intermittent and only happens following long runs.

But over time, the continual irritation of the neuroma makes the nerve swell and the pain becomes more frequent. The nerve endings in the painful neuroma become over active. Then you start to have pain when you're simply sitting in a chair, driving your car, or even while relaxing reading a book.

Surgery can be an effective treatment for a Morton's neuroma that is keeping a runner from running. Basically the nerve is removed and you get numbness in the area where you previously had pain. That is the biggest concern is explained by surgeons before you have surgery.

But there are other risks to surgery. The one that is particularly relevant to your concerns is that in order to remove the neuroma the most common surgical approach involves cutting of the intermetatarsal ligament that stabilizes the forefoot. This ligament is not sewn back together once the nerve has been removed.

Because you have essentially removed a ligament in the ball of the foot, you can have a small amount of foot instability that was not present prior to surgery. This is not a “surgical complication” but is just a consequence of the surgery as it is normally performed. The only other alternative is to place a surgical incision on the bottom of the foot. However a painful surgical scar on the bottom of the foot can be even more disruptive to your capacity to run than the Morton’s neuroma.

If you are really considering having surgery in order to surgically remove the Morton’s neuroma, you have to make sure that you discuss your running activity in great detail with your sports medicine surgeon. You have to make sure that your surgeon understands how much you run, which surfaces you prefer to run on and, for what distances. As long as you understand the biomechanical implications of the surgery and you and your surgeon agree that it is the best option for you, it may be appropriate to proceed with surgery to remove the neuroma. If you're not convinced that neuroma surgery is right for you then you should try all of the other alternatives to surgery to make sure that you have tried the less invasive options that can better preserve your ability to run.

Dr. Christopher Segler is a sports medicine surgeon and runner. He is 14-time Ironman triathlon finisher. His practice focuses on the rapid treatment of running injuries, and a rapid return to running for his patients in the San Francisco Bay Area.  If you have a question about a painful neuroma that it is affecting your ability to run, you can reach him directly at 415–308-0833. You can also learn more about Morton’s neuroma at AnkleCenter.com and alternatives to neuroma surgery at DocOnTheRun.com 

Friday, July 25, 2014

What is a Real Runner?




A couple of days ago I had an interesting conversation with a woman. We were talking about exercise, not just for fitness sake, but for enjoyment. About fitness as a lifestyle worth living. I asked her how much she runs, and she explained that she “only runs a few miles several days per week.”

“You seem like a real runner,” she said.

I remember feeling an involuntary wrinkle in my brow and being taken aback for a moment. 

Because even though I started running as a kid and I still run a lot today, I don't actually didn’t think I ever perceived myself to be “a real runner.” 

When I think of a real runner I picture Karen Gaucher, Ryan Hall, Deena Castor and Meb Keflezighi. I tend to conjure mental images of people who have dedicated their lives to running in ways that I never could. In someway, I think I had classified a real runner as somebody who could consistently run 100 miles per week during their training periods or win races.

A real runner, I had always thought, never loses that focus on the future. Keeps her eye on the goal. She visualizes achieving her aim. Always thinks about finishing, and how it will feel.

But as I thought about that, I started to think about my friends who I think of as “real runners.” And I immediately came up with several that don't run outrageous distances. None of them run for paychecks. All of them truly love running.

John Hunt, Anjulee Johnson, Phủỏng Mai N, Sarah Graham, Mimi Jacobson-Kwok, Brynn Ewen, Laura Duplantis. These are my friends, normal people, and they are all “real runners.” In one way or another each one of them has impressed me. I have seen pictures of their runs and have been inspired. The way they have described a specific run, the way they felt, what they get from running has made me smile. 

What I realized is that their stories, their reasons for running and how their descriptions of running touches me is always about being in the moment.

It's about rows of palm trees on the Stanford campus. The smell of running through the redwoods. The beauty of oaks and pine trees passing overhead. It is about sunshine and fog and feeling alive. It's about being grateful to be fit, and able to run. It is about enjoying movement in a beautiful place, right now.

Its not about pace or distance. Its not about how many finisher medals hang on the wall. Its not about being a Kenyan. And its certainly not about how the next marathon finish will feel, tomorrow, next month or next year.

Its about gratitude. An instagram pic of a beautiful setting or a genuine smile in the middle of a long run. Its about now. The way it feels to run 47 blocks in Oakland, one way, today.

And then she asked me what my last run was like.

I didn’t think about how the run fit into my Ironman training plan. I didn’t think about the pace I kept. I described the feeling of warm sun on my shoulders, strength in my legs, 7 deer quietly feeding on the side of the trail, the amazing blue of Crystal Springs set a against a sea of green trees hugged gently by a thin blanket of clouds under a clear blue sky. I though about how that run made me feel so alive, in that moment. 

And I thought, “maybe I am a real runner.”  



Dr. Christopher Segler is a 12-time Ironman Triathlon Finisher, but more importably he is a real runner.  His podiatric sports medicine practice caters to athletes who think that there has to be way to stay fit, keep training, yet still heal an injury. He often lectures at medical conferences on the treatment of complicated running injuries, running biomechanics, and subtle fracture patterns of the foot and ankle. If you have a question about a running injury you can call him directly at 415-308-0833.  You can also learn more about running injuries at www.AnkleCenter.com and www.DocOnTheRun.com


Thursday, January 16, 2014

Can I play basketball with these blisters?

Question:
Hi MyRunningDoc!

I have a basketball game tomorrow. Can I play basketball with these blisters without causing any problems?   What can put on it while I play?

Thanks!
JM


Answer:
Blisters under the ball of the foot can be painful. In the images above you can see that JM has developed some large blister that cover the entire big toe joint area. The blister may have started draining, or maybe he simply decided to pop and de-roof (meaning cut the blistered skin off) the blister in order to relieve the pressure. With large blisters, it is often necessary to drain blisters ton keep them from getting bigger. Yet doing so can make them more painful and take longer to heal.

In this case the raw pinkish area is going to be painful when running. Suddenly stopping or changing direction will also put a lot of stress on the blistered area and aggravate the raw skin under the big toe joint.

When you run, about 50% of you body weight is transmitted through this area. There are really only two ways to decrease the pressure to the ball of the foot at the big toe joint.

1. Decrease your activity (as in no basketball, walk less, etc.).
2. Move the pressure somewhere else. 

It is a simply rule of physics: you cannot remove pressure, but you can transfer it. It is possible to create a pad that moves the pressure from the big toe joint to the rest of the ball of the foot. By moving much of the pressure and irritation to the little toe joints, it may possible to play with less discomfort.


 
You can purchase pads at any drugstore that are designed for the ball of the foot. The idea is to hold the pad on the foot and identify the painful area. Clear pads obviously make this easier.

 The painful area is outlined on the pad.

The outlined area over the blister is cut away.

The pad now can put more pressure on healthy skin under the ball of the foot. The pad may stay in place well with a sock on. If not it can be taped in place to secure it. If properly placed, there will be less pressure on the blistered area. 



Even if properly offloaded, there is a risk that continuing to play will further erode the skin and cause more discomfort. In the end, if continuing to play on a de-roofed blister, it will take longer to heal. The increased mechanical irritation of running increases the chance of the blistered area becoming infected.

With any de-roofed blister (or other open wound) it is always best to seek an evaluation from your own physician before attempting treatment. You should speak with a sports medicine podiatrist to make sure that the blisters heal properly. You also need to identify the cause so that it doesn't happen again.

Dr. Christopher Segler, DPM is a podiatrist, Board Certified, American Board of Podiatric Medicine. He is also a 12-time Ironman Triathlon finisher. His sports medicine practice caters to athletes He sees patients in person in San Francisco, Houston, and Hawaii. He also offers remote consultations via webcam to athletes living abroad. If you have a sports injury question and are trying to figure out how to keep running, you can reach him directly at 415-308-0833. You can also learn more about blister causes and treatment at AnkleCenter.com and DocOnTheRun.com



 

Sunday, October 20, 2013

Ironman Lake Tahoe Race Report



Wednesday September 18, 2013

Driving through the mountains on I-80 I heard myself say, “If this wasn’t number 12, there is no way I would be doing this.”

Sitting in my truck with my P3 nestled comfortably in back I was on the way to Lake Tahoe and talking to my friend Henry on the phone. I was trying to explain what I was about to do. And I was having a hard time buying my own reasoning.

Today I was driving from San Francisco to Lake Tahoe simply to drop my bike and gear bag with Megan Lewis and SAG Monkey extraordinaire Nick.  I was then going to drive to Reno where I would spend one night in a casino hotel, only so I could get a little sleep before I had to wake up the next morning to see if I could make it to the very front of the line at athlete registration. Next I would fly to Las Vegas where I would be giving a lecture at a medical conference that afternoon. I would lecture again the next day before flying back and hopefully make it back from Reno to Squaw in time for the dinner and athlete meeting. Then of course, I would do Ironman Lake Tahoe.

Less than a week before I had unpacked my bike.  It had been in the case since I flew back from Ironman Texas in May.  Last week I assembled it and took it to Tam Bikes in order to get new cables and a new chain installed. I hadn’t even had a chance for a test ride yet.

Work and daddy-duties had been so busy that I had only done about 8 bike rides, 5 swims in the pool and 4 runs (of about 3 miles each) in the past 4 months. Pretty hard to argue that I might be ready for what was about to happen.

But as I was explaining to Henry, if I could just finish before midnight, that would be 12 Ironmans and I might finally get a “Legacy Slot” and a chance to stand on the starting line of the Ironman World championships in Kona. 

Seems like that might be worth any dose of suffering.


Thursday September 19, 2013

I woke up at 4:58 AM, 2 min. before my alarm clock was scheduled to sound.  I hobbled out of bed, put on some clothes and went down the casino elevator to find some coffee and breakfast. When I got back to the room I returned some patient e-mails and packed my suitcase. I stopped by the lobby just long enough to drop my key card in the express checkout box and choke on some casino smoke.

And away I went, back to Lake Tahoe.

Less than an hour after packing in the hotel I was in the Squaw Valley parking lot looking for athlete registration. They were still setting up tables and chairs. Goal #1 was accomplished; I was first in line for athlete registration.

This was important as registration was not scheduled to open until 9 AM. My flight from Reno to Las Vegas was at 11 AM. And Reno is about 45-50 minutes from Tahoe.

At 9 AM sharp I was handed a form which I quickly filled out and signed. I made my way through athlete registration, got my timing chip, picked up my transition bags and then ran through the expo tent the buy a visor for my brother-in-law Todd who is currently training for his first Ironman.


I then ran back to my truck and pointed it at the Reno airport. As I was driving I got a text message that my flight had been delayed by 5 hours. Not good. This meant that I would miss my first lecture.  Luckily I was able to call the airline and reschedule for an earlier flight. I would still be in good shape.


A few hours later I landed in Las Vegas and went to the Wynn hotel and casino to check in. Once I got to the room I showered and changed into my suit.  I checked in with the International Foot and Ankle Foundation conference administrators and rechecked my talk to make sure everything was in order.

A couple of hours later I was at the podium lecturing on tarsometatarsal fracture dislocation patterns and how not to miss them. I sat through the closing lectures and 9 PM headed back up to my room to get some sleep.


Friday September 20, 2013

I woke up at 4 AM so that I could review the slides for my next talk.  After a quick review I went down to the exhibit hall floor so that I could spend some time in the DG Instruments booth.  DG instruments currently licenses and markets the surgical instrument which I invented. So I try to spend some time in the booth to see if any surgeons have questions about the instrument, or its use in surgery.

Later that morning I gave a lecture on lateral process fractures of the ankle. I was able to attend a few more lectures before had to fly back to Reno. Unfortunately on my way to the airport I received a message that my flight was delayed.  Switching flights wasn’t going to help.

At about 9 PM I was picking up my bike and gear bag from Nick. Because Nick is the official Ironman Lake Tahoe SAG Monkey, I said, “I appreciate your help, but certainly hope I don’t see you on Sunday!” 

At about 10 PM I was knocking on the door of the awesome ski cabin arranged by Andrew Muff. I met Dana and Christine who were super nice.  But I was in bed before I met anybody else. 

Saturday September 21, 2013

Shortly after I got up, the rest of the housemates started to trickle through the kitchen. We all had coffee before heading out for breakfast.

At that point, since I had just assembled the bike and had new cables installed, I was still hoping to get to take the bike out for a short test ride. But now it was raining. I was already worried about the cold, so I wasn’t willing to soak my cycling shoes (or anything else) just to verify that the guys at Tam Bikes did a great job. I chose to trust instead.

After breakfast, I went to pick up some last minute supplies and see if I could find some additional layers. Dana and I found a ski shop that had some consignment gear. I found a used medium weight cycling top for $20 that fit just right. I also found some glove liners for $12.  Perfect! $32 worth of insurance to insulate me from the predicted chill.

Back at the cabin I packed my bags and prepped for the gear drop off.  All of this was fast and simple as I have detailed race-day packing lists. I even have pre-packed zip-locks with the proper contents for each of the special needs bags. By packing them in advance, I think (and worry) way less than I used to. 

FYI: I will post my soon-to-be-no-longer-top-secret Ironman Packing List and Tips. (Feel free to swipe and deploy.)  Such a list will significantly decrease your day-before anxiety.

Because it was raining and I had packed all of my cold weather clothes in my transition bags, I was on my way to transition donning a trash bag as outerwear. But better to freeze today, instead of tomorrow. 

Because it was raining today and predicted to be freezing overnight, I had trash bags covering my handlebars and seat. Certainly didn’t want to start the day on a wet saddle or gripping frozen handlebars. 

As I racked my bike I noticed the guy next to me had no bags to cover anything. So I offered, “Hey would you like a couple of bags to cover your seat and bars?”

“Sure! Just one,” he said.

“Why just one.” I asked.

“I just need to cover my drive train to make sure it won’t still be frozen on the first descent.”

That was a thought I really didn’t need to hear.

I wandered off to find Andrew who had finished racking his bike and dropping his swim-to-bike T1 bag. We headed to Squaw to drop our T2 bags and meet the rest of the group from the cabin. I made an emergency sweatshirt purchase at the expo, realizing I that I had nothing warm (other than a wetsuit) to wear to the start.

By the time we got done at Squaw I was completely soaked and freezing cold. I was having a hard time imagining what it was going to be like to get out of Lake Tahoe and hop on a bike when it was this cold.  To make matters worse, as we were driving back to the cabin, it started to snow.


At the cabin I took a hot shower and later sat in the hot tub to warm up. There was ice on the deck and railing. The snow slowed, the stars began to twinkle. It was serene and beautiful. It just wasn’t Ironman weather.

Sunday September 22, 2013
Race Day

I woke up at 3:45 AM. I quickly put on my clothes, grabbed my gear and headed downstairs. Two peanut butter and jelly sandwiches and two cups of coffee later I was ready to go. We left the house of 4:30 AM heading for the squaw Valley parking lot to catch the shuttle buses to the swim start. 

Once I got to transition it was a simple routine. Drop the special-needs bags and put air in the tires. I pealed the trash bags off my bars and seat.  I kept the trash bags to cover my feet.  I had been warned that the sand was going to be extremely cold.  Knowing that my wetsuit was going to be much warmer than my blue jeans, I slipped into my wetsuit, but kept my sweatshirt on.   I heard someone say that it was 25°.

I put the trash bags over my feet and then put my socks back on to help insulate me from the sand when it was time to head down to the start. 

I dropped my green morning clothes bag and then went onto the beach in search of the 1:30-1:40 swim corral.  Normally (when untrained) I would swim 2.4 miles in about 1 hour 25 min. to an hour and a half.   But I figured with the altitude (and my paltry 30 hours of acclimatization) I would be lucky to make it in 1:40.

Swim 2.4 Miles

By the time the cannon fired and the athletes started filing into the water I was really cold. In fact, I was shivering. It was the first time I have ever been shivering while wearing a wetsuit. I wished that I had brought a neoprene swim cap and booties. 

As my wave started to approach the starting gait, I wandered over toward the fence to discard my socks and trash bags. And then the gods smiled upon me. There in the sand was a size large pair of ScubaPro neoprene booties. I quickly put them on and tucked them under the legs my wetsuit.

I suddenly felt much better and in the water I went. I checked the clock only to make sure the new how much additional time and needed to account for to ensure that I made it in before midnight. It was about 10 min.
As I waded into the water I found it interesting that sixty-something degree water actually feels considerably warmer than twenty-something degree air. But that didn’t last for long. 

There was an eerie fog hanging over the surface of the water that made it nearly impossible to see the buoys. Not being in any particular hurry I was not overly concerned about this. I figure all I had to do was keep moving in the right general direction in order to eventually get there.

I wasn’t swimming particularly hard because I didn’t want to strain anything. After all, I was in no shape to be doing this anyway. But after about 15 minutes I was shivering so much I was actually concerned about my capacity for finishing the swim. So I then decided to try swimming hard for about a quarter of a mile to see if I can get my heart rate up high enough to bring my core temperature up.

Note to self: if not accustomed to altitude, swimming hard at elevation is a bad idea. 

After only 5 or 10 min. of cruising through the pack of swimmers at a brisk pace I started having some mild spasms in my lungs. This quickly subsided when I slowed back down. 

I would just have to be cold.

I’m almost ashamed to say that this was actually the first time I have ever set foot in the water of Lake Tahoe. Probably not a great idea in terms of Ironman preparation but it is the truth.

The thing that I did notice more than anything else is that Lake Tahoe is ridiculously beautiful. It was cold but I was still enjoying it. I could see all the way to the bottom. And every time I took a breath I could see the freshly snowcapped mountains peering through the fog. Physically it was unpleasant. But aesthetically it was wonderful. I would consider it almost a fair trade.

On the 2nd loop I could see better, but I was getting hypothermic. My swimming was simply reduced to watching the buoys drift dry and thinking, “OK #8...I can make it #7.  OK #7...I can make it #6.  OK #6...I can make it #5.”

Soon enough I was out of the water. 1 hour 31 min. Not great, but good enough.

“One down. Two to go!” I thought. 

T1

I came out of the water andf I was thrilled to see the SF try club wetsuits stripping crew. It was really great to see familiar faces. That was when I was no longer curious if I was hypothermic. I knew it. 

The volunteer looked me straight in the face and said, “Can help you get out of your wet suit?” And I just stood there thinking about it. I knew that I had to get out of my wet suit yet I did not want to peel off the neoprene and be exposed to the cold anymore. Fortunately she was smarter than I was and just started helping me out of it.

When I made it into the men's change tent, it was warm, but it appeared as though they were having some sort of Guinness Book of World Records contest to see how many naked men they could shove in a telephone booth. In that respect it was relatively unpleasant. But at least it was warm...

I started to untie my transition bag and realized I was having trouble. I tied the bag like shoelaces so that it's easy to get it undone. But it wouldn't budge. I thought it was that my hands were numb. So then I tried to bite into the cords with my teeth. That was when I realized the entire draw cord had frozen solid into a block of ice.

I ripped the bag open (but was not happy about this). I was worried that would end up losing some of my swim stuff since I couldn't close it back up.

I dried off as much as possible and got into every layer I had packed in my bag. Tri shorts, tri top, arm warmers, compression socks, my new/used cycling top, SFTri windbreaker and glove liners. I put on a fleece hat under my aero helmet, with vent holes taped shut.  

I ran out through transition to find my bike and get going.

Ride 112 Miles

I figure getting on the bike and starting to pedal would help me warm up. I was wrong about that. It wasn’t until I hit the big hills about two hours later that I stopped shivering. 

But all said, it was going well.  I was being conservative, watching the watts and keeping well within the limits that I knew I could sustain.  I just kept telling myself, “All you have to do is NOT do anything stupid and you can make it.”

Near the end of the first loop of the bike course I did something stupid.

I was on the final climb, creeping uphill at about 3 mph. I was only passing the long line of athletes who had given up and traded pedaling for walking. And I was barely going faster than those who were walking their bikes. 

I head my head down, intently focused on pedaling and keeping enough momentum to make it to the top of the climb. Suddenly I heard, “GO SF Tri!, GO SF Tri!” It was a huge crowd of SF Tri members, many of whom were in their Sf TRi colors. Except for Miguel Mendoza...he of course was wearing a Buzz Lightyear costume. 

Miguel ran up next to me and started shouting Go Chris Go!!! You can Do it! GO, GO, GO!!!!!!” 


And so I went...

I upshifted two clicks, stood of the saddle and went as hard as I could. It seemed as though Buzz himself was catapulting me to the top of the hill.  I flew by the long, crawling line of bikes at about 10 or 12 miles per hour.  

I heard some waning cheers as I crested the final hill to start the descent.  As soon as I sat back in the saddle, I felt a sharp pain radiate from my butt cheek at the way to may left knee. I instantly knew I had pulled my hamstring. 

With every rotation of the cranks it felt a sharp twinge. “Way to go idiot!” I said to myself, “You just blew it.” 

I knew my day was over.  There was no aid station on the descent or I would have stopped. While on the descent I started trying to determine the cleanest exit. 

Knowing the course and the extent of road closures I was fairly certain that if I pulled out any time soon I would be waiting for most of the day just to get a trip back to Squaw from the Sag Monkey. 

Since I had nothing to lose, I figured I should just try to make it for the next 10 miles to see if the pain got any worse. It did, but not by much. 

So then I thought I would go another 10 miles to see if it continued to get worse. It didn’t.

When I was on the road approaching Squaw Valley I got passed by one of the pro women. It was Angela Neath on her final loop.  A year ago I attended a workshop and met Angela. That weekend I did a long run with her and her boyfriend. “GOOOOO ANGELA, GOOOOOOO!” I shouted.

Just seeing her inspired me. I thought I could at least finish the bike. As Angela turned left toward the bike finish I continued onto the second bike loop. I realized that if I altered my position just a little, my hamstring didn’t hurt very much. So I just focused on keeping the low-pain position and a high cadence. 

A few hours later, rolling by the lake at the bottom of a short hill I saw “100 MILES” painted on the road. I knew I would finish the bike. This realization was the spark I needed. It grew like a freshly kindled camp fire into the sudden roaring belief that I “might” actually be able to make it through the run, too. But only if I had enough time. 

T2

I stopped at the dismount line and handed my bike to a volunteer. Limping toward the change tent I realized that most of my limp was actually due to my back and neck. The awkward position required to quiet the hamstring had really cramped my back and neck. 

But I know from experience that all of my back and neck issues will relax from running just the opening few miles. I decided that I would head out on the run course. If the only thing I got was to loosen the back and neck, it would be worth it, even if I had to DNF.

Run 26.2 Miles

When I saw the clock I realized I had 6 hours and 28 minutes before midnight. I did the math. 

At Ironman St. George last year a long day of drinking vile “Perform” taught me an unpleasant, buy useful lesson. Even when throwing up 2-3 times per hour, I can walk 4 miles per hour. That means I can walk a marathon in 6 hours and 33 minutes.

I thought to myself, “If you can just run 10 miles, only 10 miles, at 5 mph, you can walk the rest and get in before midnight. 10 miles in 2 hours. On a good day, you can run 13 miles in less than 1 hour and 30 minutes. 10 miles in 2 hours should be a snap. That is the new goal...10 miles in 2 hours. And you won’t have to come back in a year seeking redemption. Instead, you could be in Hawaii!”

I started to run. 

I watched my Garmin making sure to stay exactly on pace...11:30 per mile. This would allow me to walk through the aid stations and still stay on target. 

“Just run 1 mile. Stay on pace. Just run 1 mile.” I kept telling myself.

As I passed the first aid station I realized I was now standing up straight. My neck hurt, but my back was better. “Just 2 miles, run 2 miles.”

As I pushed off to start running again, I felt a sharp jolt in the back of my leg. Burt once I was actually running, it didn’t really hurt. 

Peter and others from the SF Tri club began cheering as I passed by. I was running.  Peter gave me a high-five. 

“Just run 3 miles.”

“Just run 4 miles.”

When I made it to mile 5 the pain in my hamstring was escalating. It was hurting with even the slightest up hill. But I knew I would make it. 

I ran all the way to the turnaround and at mile 11, then I started to walk. And I almost started to cry. 

I couldn’t believe that for 50 miles on the bike I had only thought about the logistics of my impending, unavoidable DNF.  I had even thought of the story I would write on the blog (in place of this one) discussing excuses, ill-preparedness and failure. 

But I had just run eleven miles and would walk to the finish with time to spare. 

Night fell. Cold descended. I reapplied all the layers from the morning bike ride. Used cycling jacket, windbreaker, glove and fleece hat. A volunteer handed me a headlamp. 

I was cold, and it was dark, but I was going to finish.

On the final 3 miles it was foggy and really cold. I was shivering, pretty much the same as when I came out of the Lake early this morning. But I was in motion. The volume of noise increased as I made the final few turns through Squaw Village.

I walked amidst the cheering crowds and I fought back the nearly overwhelming urge to retain my dignity by jogging down the finish chute.  One foolish act was enough. “Just walk...no jogging...no further injury.”

The lights were bright, the cheers were loud and the hands were many that offered a victorious high-five as I walked to the finish. 

As I crossed the line I heard Mike Riley say “Christopher Segler...YOU...ARE...AN IRONMAN!”

And just like that, Ironman #12 was done.  16 hours, 28 minutes and 23 seconds. 

A volunteer wrapped me in a mylar blanket. She asked if I was okay. Someone else said “congratulations” and placed a medal around my neck. I said, “I’m okay, but really, really cold.” My teeth were chattering. 

“We need to get you to medical,” she said.

I nodded. 

Once I got the medical tent, they had a “warming area” where I waited for help. I was cold, tired and really hungry.  I just wanted to go to bed. 

After a few minutes, I stood up and one of the medical personal said, “wait...where are you going?”

“I am going to get my bike and my gear bags. I am going home.”

She replied, “...but, where is your bike tag, where is your family?”

I answered “my bike tag is on my bed at the cabin. I am here by myself.”

In an excited voice she said, “But you are hypothermic, you can’t just walk out of here! You could die just walking across the parking lot!”

I titled my head to one side and said, “Of all the dumb things I do, and all the ways I imagine I might die, walking across the parking lot at Squaw is just not one of them.”

“Thank you. And good night.”

Dr. Christopher Segler is a 12-time Ironman Triathlon Finisher.  His podiatric sports medicine practice caters to athletes who think that there has to be way to stay fit, keep training, yet still heal an injury. He often lectures at medical conferences on the treatment of complicated running injuries, running biomechanics, and subtle fracture patterns of the foot and ankle. Next year he will be volunteering with other SF Tri Club members at Ironman Lake Tahoe. If you have a question about a running injury you can call him directly at 415-308-0833.  You can also learn more about running injuries at www.AnkleCenter.com and www.DocOnTheRun.com

Friday, July 19, 2013

How Can I Tell if My Foot is Broken?


Hi My Running Doc,

A couple of days ago I accidentally kicked the wall with my right foot. My foot still hurts and it is bruised.  I read on your website that bruising can be a sign of a metatarsal fracture. How can I tell if it is just bruised or if my foot is actually broken? I would love to have your expert opinion!

Thanks!
David, Houston, Texas.



Hi David, 

Bruising is a Bad Sign
It is true that bruising is a bad sign when it comes to foot and ankle injury. When you actually fracture a bone, the bone cracks and bleeds quite a lot. That blood diffuses throughout the soft tissue under the skin. What you see is a bruise. That is part of the reason that a bruise can be so concerning for a fracture in the foot. 

In fact the sort of bruising pattern that the picture of your foot shows is often indicative of a fracture or broken bone in the foot. Given your pattern of bruising it is more likely that you have a metatarsal fracture or a fracture in one of the bones in the little toe such as the proximal phalanx phone.


Myths about Foot Fractures

1.  If you can walk on the foot, it can’t be broken.  FALSE!

This may be one of the most widely perpetuated myths about foot injury on the Internet. I have seen many patients with serious fractures that are walking on the foot. Some patients are limping and obviously in a tremendous amount of pain while other patients with fractures or broken bones barely feel any discomfort at all. This is not a reliable indicator of whether or not you have a broken bone in your foot.

2.  There is nothing you can do for a broken toe.  FALSE!

This is also absolutely not true. While it is true that most fractures in the toe will heal uneventfully, there are things you can do to speed healing and decrease your risk of complications. Fractures of the bones in the toe can move if not properly stabilized. Certain shoes will speed healing. Taping the toes to provide stability and immobilize the fracture will also help. But some toes should never be taped together. 

Without the proper treatment of a broken toe, the fracture can fail to heal leading to what physicians refer to as a nonunion. A fracture that never heals correctly can lead to pain, disability and interfere with your ability to run or even walk without pain.  Occasionally patients that take the approach that “nothing can be done for fractured toe” just end up in surgery later.  For the most part this is avoidable if the toe treated correctly.

Diagnosis and Treatment Options

If you are suspicious that there might be a broken bone in your foot (or in one of your toes) it is best to figure out whether or not it is actually broken.  The best option is to have an in-person evaluation by a sports medicine specialist such as a sports podiatrist.  The second option is to have a remote consultation with a sports podiatrist via webcam. A third option is an attempt at self-diagnosis. This video on YouTube can show you how to perform self-diagnosis of metatarsal stress fractures. This same video would apply in your case if the pain is located where you’re bruising is in the foot.

If you see a physician in person or via webcam or you perform your own self-diagnosis and think that you probably have a fracture then you should get x-rays. X-rays will not only confirm (or rule out) a broken bone in the foot but it will also give you an idea of the severity of the problem. There are some fractures that absolutely must be treated surgically. Others simply need a fracture walking boot in order to stabilize the fracture and allow it to heal. And occasionally it is necessary to use crutches. 

But not all fractures are the same. So if you have pain and bruising after this sort of injury and suspect that you have a fracture in your foot it is important to determine whether or not there actually is a broken bone, and treat it appropriately. As long as you treat the fracture correctly you should be able to heal and then get back to running.


Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. Because he is an active marathon runner and 10-time Ironman triathlon finisher, his practice focuses exclusively on helping runners get back to running as quickly as possible. He travels back and forth between San Francisco, Houston, and Hawaii so he can often to help Texas and California patients with running injuries.  He also provides web consultations via Skype for injured runners who who are too busy to drive to a podiatry office. If you are in San Francisco and have a question about a running injury, you can reach him directly at 415-308-0833. If you live in Houston and think you have a stress fracture, your can call him at 713-489-7674. Visit our Houston Doc On The Run Practice. Learn more about stress fractures here.