San Francisco Podiatry Video


Thursday, September 18, 2008

Achilles Tendonitis in a Runner: How to Prevent It.

According to Greek mythology, when Achilles was born his mother tried to make him immortal by dipping him in the river Styx. However, when she dipped him in, she forgot the spot on the heel she held him by, which left one small area unprotected. In the end, Achilles was struck by an arrow in his vulnerable heel and was killed. Achilles shares his vulnerability with the rest of us entirely mortal runners, and that is why the tendon which connects the calf muscles to the heel bone bears his name today. The Achilles tendon is the largest tendon in the entire human body and is very strong, but it is also the tendon we rupture the most often. Anyone who is active can suffer from Achilles tendonitis, a common overuse injury and inflammation of the tendon.

If you are out running hills and feel a sharp pain or dull ache in the back of the leg down near the heel, this could be Achilles tendonitis.  That said, not all pain in the back of the leg or heel is Achilles tendonitis. If you have a tender swollen knot at the back of the heel where the tendon attaches it might not be Achilles tendonitis.

There is a condition called Haglund’s disease (commonly known as “pump bumps”) which is really bursitis and inflammation of the soft tissues near the attachment of your Achilles tendon. In some cases there may be an underlying bony enlargement as well. In most cases the tender bump is red, painful and more irritated by a stiff heel counter (the back of the shoe).  If you have no pain doing toe raises and most of the pain is related to shoes rubbing on the area, it is more likely just bursitis.  Bursitis is inflammation of the fluid filled sac that eases friction between tendons and bones. This will usually calm down with icing and shoes that don’t press on the area.

If you feel along the course of the tendon (where it is mobile just above your heel bone) and you have tenderness, this is most likely Achilles tendonitis. Don’t ignore this. Ice the area and decrease your activity level. Avoid hills or speedwork until it subsides.  If it doesn’t quickly get better, see your podiatrist. Otherwise you might end up sidelined for four to six weeks. 

The best way to prevent Achilles tendonitis is to stretch and warm up before intense workouts.  As mentioned earlier in this injury prevention series, a little self-restraint, the right pair of running shoes, and a good training program (such as the ones on the Chickamauga Battlefield Marathon training website) can help you stay injury free. Always stretch before speed workouts, hill repeats and long runs. Stretching helps to keep the tendon pliable, preventing micro-tears. In addition, stretching can improve blood flow, enabling a speedy recovery if you do become injured. Stretching is most effective after a short warm-up; never stretch aggressively when you muscles are cold. This can increase your risk of problems.  Include these stretches in your workout routine s follows: 

Stand upright about one large pace away from the wall with your feet parallel and about hip width apart. Keep your feet in line as shown.  Place your hands against the wall, at shoulder height. Move your right leg half a pace forward. Lunge forward on your right leg so that the knee is brought directly above the ankle. Stretch your left leg back as far as is comfortable with the foot and heel remaining flat on the floor. Slowly lean forward to stretch the left leg calf muscles and tendon. Hold the stretch for 10 seconds, relax, and repeat on the other leg. This is for prevent…do not stretch as illustrated if you have pain. You can also view demonstration videos of these stretches at

Symptoms of Achilles tendonitis can include mild pain after exercise or running that gradually worsens, a noticeable sense of sluggishness in your leg, and episodes of diffuse or localized pain, sometimes severe, along the tendon during or within a few hours after running. Other symptoms can be swelling, morning tenderness in the Achilles tendon, or stiffness at the back of the leg that generally diminishes as the tendon warms up with use.

Treatment depends on the degree of injury to the tendon, but normally includes rest. It may even mean a total withdrawal from running or exercise for a week, or simply cross-training with another exercise, such as swimming, that does not stress the Achilles tendon. Treatment can also include non-steroidal anti-inflammatory medication or orthoses, which are devices designed to help support the muscle and relieve stress on the tendon, such as a heel pad or shoe insert.

Other treatments are bandages specifically designed to restrict motion of the tendon, stretching, physical therapy, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors that work against the Achilles tendon. If the tendonitis is mild, simple modifications of activities may help. Decreasing mileage, running on flats instead of hills, and backing off the activity level until there is no pain with exercise can allow the tendon to heal. In general ice is much better than heat for tendonitis.

Some medications can increase the risk of Achilles tendon ruptures (complete tear).  If you are taking steroids (prednisone) or flouroquinalone antibiotics (Cipro, Levaquin, etc.) you should not exercise unless you have discussed this with your treating doctor.  You may have seen in the news where the FDA recently posted a strong “Black Box” warning about these antibiotics and the associated risk of tendon ruptures.

A torn Achilles tendon is serious. Interestingly, it is not always painful.  However, there is usually significant weakness and difficulty standing up on the toes if this has occurred. Any suspected torn tendon can be serious and should be evaluated by a podiatrist. In rare cases surgery may be needed to repair the tendon. 

If you happen to be a marathon or half marathon runner in training for battle in Chickamauga; warm up, stretch, and stick to your training program.  Do not run through the pain if you think you have Achilles tendonitis.  If you are a Trojan War hero in battle, and you see any arrows coming your way, stay low and keep moving!

Christopher Segler, DPM, AACFAS

Award Winning Foot & Ankle Surgeon

Doc On The Run Podiatry House Calls in San Francisco


Shin Splints...what are they? How to Prevent Them.

Oh My Aching Legs...Shin Splints

Shin splints are the most common overuse injury among runners.  Either you, or someone you run with, have likely suffered from this painful malady.  Like most running injuries, shin splints are largely preventable. However, if not prevented, they can derail your training program and put your dream race in jeopardy.

Shins splints are an inflammatory condition of tibia (shin bone).  The result is pain in the front or inside of the lower leg that usually gets worse with prolonged running.  It may not hurt much in the first couple of miles, but will often evolve into a dull ache or throbbing pain as you run.  It may be sore and tender for days following long runs.  In most cases, it is tender when you press along the front or inside of the shin over the middle one third of the leg (halfway between the knee and ankle). 

This is an injury that is caused by unaccustomed and excessive exertional forces to the legs...otherwise known as overtraining. The term “overtraining” confuses many people.  I will often have patients who say they don't think they are overtraining, but suffer from classic overtraining injuries.  Most often, it is a novice runner who is increasing mileage rapidly in preparation for a race.  They seem to think that they can't be "overtrained" because they just started training. In this case it is not the total miles, but the sudden increase in stress from a rapid increase in either intensity or distance, that creates the stress known as overtraining. The stress overcomes the body's ability to compensate and injury results.

Let’s say a new runner suddenly goes from running 2 miles a day, 5 days a week (10 miles per week), to running 3 miles a day, 5 days a week (15 miles per week). This would be a 50% increase in weekly mileage.  If this novice runner has not yet prepared the musculoskeletal system with the requisite level of base fitness to deal with the stress of running, even though it is only 1 mile added each day, such an increase may cause an overuse injury.  Additionally, most novice runners start improving both speed and endurance at the same time. The simultaneous increase in speed and distance can produce a dramatic increase in stress to the bones, muscles, ligaments, and supporting connective tissues.

The other scenario occurs with the seasoned runner. Although the experienced runner may have an extraordinary level of base fitness, it is still easy to develop overuse injuries.  These folks are more likely to add speedwork sessions, intervals, or hill training that can be enormously stressful to the legs. There is also the temptation to "go longer" on a given run if the sun is shining and you happen to feel particularly spry that day. The other time is when you delude yourself by remembering that after your last extra-long run you felt great, even if it was months ago.

In addition to the simple case of "overdoing it," there are other circumstances that can predispose any runner to shin splints. Running on hard surfaces such as concrete, running down-hill, and running only on one shoulder at the side of the road have all been related to shin splints. In addition, excessively worn running shoes, or running shoes that are the wrong type for your particular foot type and running style can also contribute to shin splints. The right running shoes in good condition can support the foot/legs and decrease the stress that can lead to shin splints.

Other biomechanical risk factors for shin splints include flat feet, high arches, and having one leg longer than the other (limb length discrepancy). Although these problems are inherent in a runner's make-up, they can be corrected. Wearing the proper shoes is most important. If that is not enough, a podiatrist can evaluate you to see if you need custom orthotics to correct the condition. In my practice, most people actually do not need custom orthotics, but are just using the wrong shoes, or making errors in their training program. 

To prevent shin splints, increase your mileage gradually; 10% increases in weekly mileage are an old standard and generally safe. Otherwise follow a training program such as CTC's Marathon or Half Marathon Training Program. Wear your orthotics (if you have them to correct for flat feet, high arches, or a limb length discrepancy), but make sure they are in the right shoes. Replace the shoes when the outsole becomes worn, or when the midsole starts to collapse causing wrinkles in the back of the heel of the shoe.  Avoid prolonged training on concrete.  Run on the crown of the road, or alternate sides of the road.  If you do hill training, start with running up, but walking down. Don't do intervals or any kind of speedwork without the guidance of an expert (the local traithlon clubs and running clubs have a whole bunch of friendly ones who will likely guide you at the scheduled CTC sessions).

Above all, stick to your training program, put in the miles (but respect the rest days) and you, and your shins, will be ready for the big race.

Christopher Segler, DPM, AACFAS

Award Winning Foot & Ankle Surgeon

Doc On The Run San Francisco Bay Area Podiatry Sports Medicine House Calls


Pick the Perfect Running Shoes

Running Shoes...Your Injury Prevention Gear

Proper running shoes prevent injury. I am a foot and ankle surgeon. I am also an Ironman triathlete. I wear the very best running shoes. The very best for me, that is. Which of course implies that there is also a very best running shoe, just for you, as well. The shoes that are best for me are specific to my activity level, running style and foot type. For you to find the shoes that will help you to run most efficiently, and also help to prevent injury, you will need to know your running style and foot type as well.

At this point, I will let you in on a secret.  You don't need to see a foot doctor, or even read the rest of this article, if you might be in a hurry (because you are afraid you will miss one last run today). If you go to one of the few local specialty running shoe stores in your town, you will get free advice about which shoes are best for you. I can say, they know what they are talking about. Now, if you want to learn anyway, read on.

When considering new running shoes, take past experience with shoes into account, but don't bank on it.  The shoes you love now, may look similar and even have the same name next season, yet the fit and characteristics may be completely different.  If you have logged a lot of miles with a given model, you may want to buy more than one pair now. The reason is that manufacturers will frequently make unannounced design changes. These changes can vary from width, to cushioning, to major structural midsole alterations. I used to run in a shoe I loved, and then they suddenly changed the last (the form on which the shoe is constructed) and made the toe box smaller.  The result was a shoe with the exact same name, that I couldn't wear anymore.

If you have a pair of shoes that always causes blisters, heel pain, or shin splints, obviously, you should try something else. Having said that, if you have any pain from your shoes when you run now, you should drop those shoes in one of the "Keeping Chattanoogans On Their Feet" shoe donation bins around town. We have the locations listed on the Community Partners section of our If you do donate your old running shoes, I will personally see to it that they stop slowing you down, and go to help one of the 4,000 homeless people in Chattanooga. Treat yourself to a new pair!

Most runners have a rough idea about their foot type and this will determine what category of shoes will provide the right combination of cushion and support for your feet while you run.  The three main types are "Motion Control," "Stability Cushioning," and "Cushioning." Motion Control shoes are best for “over-pronators” who’s feet roll inward when they walk and run. Often associated with flat feet, theses athletes have arches that flatten out completely when running. These folks need the added support of Motion Control running shoes to prevent injury. Stability Cushioning shoes are best for “Neutral Runners or Natural Pronators” with a medium arch. These feet disperse shock effectively when they walk and run. They need a shoe that maintains this natural pronation, protecting against over-pronation and preventing injury. Cushioning shoes are best for “Under-pronators or Supinators” who’s feet don’t roll inward when they run. These feet are often associated with high arches and are prone to shin splints and pain in the big toe joint. This foot type is often rigid and does not effectively absorb shock. They need flexible shoes with maximum cushioning against impact when running.   

The wrong shoes can, and will, lead to injury. If you see an expert (found in a good running shoe store that maintains an excellent reputation among your local running community) you will get the right shoes. Then you just have to make sure you replace them before they are worn out and can no longer provide the shock absorption and/or support your body needs. Even if you use custom orthotics to correct some of the biomechanical limitations your foot type creates, worn out shoes will still lead to injury.

One of the most common questions I get from patients is "how many miles can I run before replacing my running shoes?" I typically recommend safely replacing running shoes every 200-300 miles.  Your mileage may vary. For example, I am 6'2" tall and weight nearly 200 pounds. I over-stride on downhills, which is high impact. I also usually either run on asphalt hills or concrete flats. Both are poison to running shoes. Now, if you weigh less, don't over-stride, and avoid hills and concrete, you may be able to go 500 miles. Go more than that and you are flirting with disaster. 

If you don't count miles or calories, there are several ways to evaluate the structural integrity and wear on your running shoes. If you are a heel striker (you land on your heels first when you run) look at the back of your shoe. If you see wrinkles in the material on the back outside half of the sole, you have worn out the midsole material.  The shoes can no longer provide sufficient shock absorption and should be replaced. If you are a forefoot striker (you land and run on your toes), look at the front outside edge of the sole at the ball of the foot. If you see wrinkles in the material here, you have worn out the midsole material and you need a new pair. If you look at the back of the shoe and the sole is compressed and tilting inward, you might need more pronation control. Start with the running shoe store fro a new pair of shoes. If that doesn't work, see a podiatrist. Always bring you old shoes to be evaluated at your visit. The wear patterns provide a great deal of information about you running style and possible injuries.

Once you get your bright, shiny new pair of running shoes, you have to break them in to avoid blisters and tendonitis. Do not show up for a Saturday morning long run and expect to show off your new shoes. I usually take my new ones on my long runs, but only wear them for the first 3 miles or so, then I switch back into my old shoes. Make sure you log at least 30 miles of short "break-in runs" before you go long. Your new shoes will still be bright and shiny for that long group run. That is, if the group can keep up with your new, more efficient stride long enough to notice!

Dr. Christopher Segler, DPM is a runner, triathlete and podiatrist in San Francisco. He has a podiatry practice that caters to busy young professionals and athletes in the Bay Area. To accomodate them, he makes house calls so they don't have to miss work (or a workout) when they start to have foot pain. You can reach him by calling 415-308-0833.

Ankle & Foot Center


Train Smart and Injury Free for Your Marathon

No matter how you might characterize yourself in terms of your running ability or aspirations (marathon runner, casual, triathlete, etc.) you are at risk of running injuries if you are reading this article. The reason is that all runners who choose to run with a specific (albeit sometimes vague) goal in mind, never, ever, lack sufficient motivation to train.

Distance runners, as a breed, are different from other people. They get up and run when it is dark. They exercise when it is hot. They exercise when it is cold. And they usually do it all with a single goal in mind. That goal could be to run one's first 5K. It could be to finish a marathon. It could even be to qualify for Boston. The one common thread these goals share is that they simply cannot be achieved without sufficient initiative and dedication.

If one happened to be strong as an ox, but half as smart, it is possible that the senseless runner might show up on the starting line and actually finish one of the aforementioned events, without sufficient training. This however, would probably result in some level of injury. It would certainly be a recipe for an unenjoyable, if not painful, event. So that is where this short series of articles comes in. As a podiatrist, foot and ankle surgeon, runner and triathlete, I will (hopefully) steer you in the right direction…away from injury and toward a memorable day with a great race, and an accomplished goal.

In this series of articles, we will discuss specific common injuries and the means to avoid them. We will discuss training, shoes, common mishaps and mistakes, all in order to allow you, the running neophyte, marathon hopeful, or seasoned runner to avoid injury.

So, given that you are now likely already a couple of weeks into the your Marathon or ½ Marathon training program (…you are following a program right?) we should talk basics.  Simply put, you should have a goal and a means to get there.  That means you have a sensible, reasonable training plan or schedule to keep you on track. Lucky there are many sources which have already done this for you.  Now all you have to do is stick to it! The point I want to make is that as a highly motivated athlete (and you are, if you are reading this) you are at serious risk of overtraining.

You do not get stronger, faster, better by running yourself into the ground. Your body actually suffers tissue damage on your long runs, speed sessions, etc. You get stronger when you recover. The process of rebuilding those tissues is what leads to stronger muscles, increased biomechanical efficiency and improvement. This happens after, not during, those runs. Granted you need to put in the miles, but fight the temptation to squeeze in a few extra miles on your scheduled rest days. It will not help. Rest or cross-train as instructed in your training program! The folks with the CTC who devised the marathon and ½ marathon schedules will not lead you off course. Trust them, listen to them, and you will feel strong on race day.

I wanted to share a quote I heard long ago about marathons. "When it comes to a marathon, no one can do it for you. That medal is earned with black toenails and long runs in the dark." If you have experienced the black toenails, you have already suffered a preventable injury. I've done it myself, so don't feel bad. Next week we will talk about shoes…your first line of defense against injury.

Christopher Segler, DPM, AACFAS

Award Winning Foot & Ankle Surgeon

Doc On The Run: San Francisco Podiatry Sports Medicine House Calls

What is is a new website created only for runners and triathletes in order to provide you with all the resources you need to Stay Fit, Go Long, Run Fast, and Be Strong.  Our focus is injury prevention. With that in mind this site has been created for you...the educated active athlete. Created by award-winning podiatrist, foot & ankle surgeon and multiple Ironman finisher, Dr. Christopher Segler