San Francisco Podiatry Video


Monday, October 27, 2008

Top 10 Ways to Ruin a Marathon

1. Buy New Running Shoes

Question...What could be better than sporting shiny new shoes for your finish picture? Answer...Sporting a finisher medal without limping.  By now, you should know better than to wear new shoes or socks on race day.

2. Try on A New Outfit

Equipment is essential for a successful event.  This mean shoes, socks, shorts, top, number belt, watch or GPS.  All of it should follow the No-New-Gear-on-Raceday rule. Not even a new top.  Not even a more aerodynamic hat.  Comfort above all else will spell success.

3. Change Your Plan

If you trained for the race, you have been likely training for many months.  That means you have planned for months. Do not be tempted to switch gears or change plans on race day.  If you are planning for a 4:00:00 marathon it is O.K. to shoot for 3:55.  But do not follow the 3:40 pace group thinking you will “gain an extra time cushion.” This is a recipe for disaster. Stick to the plan, Stan!

4. Keep Up With the Joneses

The folks around you might be faster than you.  Then again, they just might be dumber. Do not attempt to keep up with someone simply because he or she “looks like” someone you “should” be able to beat.  Let them disappear on the horizon. You just might pass them on the side of the road in the final few miles.

5. Go Out In a Blaze of Glory

No matter what you do, you will be on fire when the gun goes off. Most will blast off the line. You will be tempted to follow.  If you have a GPS, watch it closely and stay on pace. It is worth noting that most world class distance runners produce negative splits when they compete. Follow the experts.  Start slow and finish strong.

6. Don’t Drink and Run

You can go for a long, long time without food before you starve.  Water is not the same.  You must stay hydrated. Hopefully you experimented on you long runs. Drink too much and you will be hurling on the side of the road.  Drink too little and you will be sapped. You will be walking before you know it. Drink responsibly.

7. Forget to Fuel the Machine

The “wall” that most marathon runners describe occurs between 18 and 22 miles. The reason for this physiologic barrier is that that is when most people run out of calories. They just plain run out of gas. You must eat on the run. Not Krystal, but GU, Cliff Blocks, Powerbars, or what ever magical but nasty form of energy intake you prefer. Just don’t try a new one on race day.  Wear a number belt with elastic loops that holds your gels and they will be in the holster, at your side and ready to keep you fed.  I eat GU every 40-45 minutes. Keep track of when it is your time to eat, and eat as you approach the water stop so you can discard the wrapper and wash it down at the aid station.  

8. Just One More Long Run

Every endurance athlete struggles with the idea that one more workout or one more long run will somehow make you more “ready.”  Hope that your competition does this, but don’t do it yourself. The taper you have been prescribed by your training plan must be followed.  It is not optional if you want optimum performance. Trust that you are prepared.  Save it for race day.

9. Stay up Late 

No matter what you do, you will have trouble sleeping on the eve of the race.  This is normal. Just don’t make it worse by watching television until you are “tired enough” to fall asleep. Counts sheep or mile markers, or whatever you do.  Get all the rest you can.

10. Forget the Point

On the morning of the your big event, try to remember why you got out of bed every morning to go on long runs. Remember why you ran in the heat, the rain, the dark and the cold. Try to remember why you registered for a marathon in the first place. Keep in mind that it wasn’t just to finish at a certain pace.  Don’t forget to have a good time. Take the time (but not too much) to thank the volunteers at the water stations, the lone sentry standing there all day just so you will not have to think about where to turn, and the folks at the finish cheering and screaming your name. 

Take time to enjoy all of the event and your big day. Just keep in mind that you are ready.  Best of luck of luck from and all of us at the Ankle and Foot Center of Chattanooga!

Christopher Segler, DPM, AACFAS

Award Winning Foot and Ankle Surgeon 

Stay Fit. Go Long. Run Fast. Be Strong.

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

Sunday, October 26, 2008

How Does the Foot Cause Knee Pain in Runners?

Iliotibial Band Friction Syndrome is the second most common overuse injury among endurance athletes. Also know as Iliotibial Band Syndrome, IT Band Syndrome, and ITBS, it is a common cause of knee pain in runners and cyclists. In fact, ITBS has been reported in up to 12% of distance runners.

The most frequent complaint of ITBS sufferers is pain at the outside of the knee. They will typically report that the pain will come on at a predictable distance and then worsen throughout the remainder of the run. This pain usually goes away at rest. In its later stages, the same pain may begin with other, less stressful activities, such as stair climbing or even walking. 

So what exactly is ITBS?  The Iliotibial band is a thick reinforcing band of tissue that stabilizes the outside of the thigh and upper leg. When the knee is bent at about 30 degrees, the IT band changes position and moves backward behind a prominence (the lateral femoral condyle) at the outside of the knee. In short, ITBS is inflammation of the outside of the knee from repeated friction as the knee bends and the IT band snaps back and forth across this bony prominence, becoming irritated. 

There are many reported causes and contributing factors to ITBS. Those who are bow-legged, have high arches, a tight iliotibial band, or a limb-length discrepancy are more at risk.  All of these conditions can increase the amount of shock transmitted through the leg to the knee. The knee then has to absorb all of this extra force by bending more and more friction from the IT band results.

So how do you make sure you don’t become the one out of ten runners that will develop ITBS? As with most overuse injuries…avoid overtraining. One study actually found 42% of all ITBS cases to be associated with training errors such as increasing miles too quickly. Nearly half of those cases caused by training errors could be attributed to a single excessive harmful training session.

Other ways to prevent ITBS include the use of custom orthotics to correct for deficits in pronation.  If you are bowlegged, have high arches, or a limb length discrepancy, orthotics can correct the biomechanical shortcomings you were born with, increase running efficiency, and help prevent injury. If you have any of the aforementioned conditions, also avoid shoes that decrease pronation such as “stability” or “pronation control” shoes.

Stretching is a mainstay of prevention of the initial injury or re-injury. To stretch the IT band, stand with your hand out in front of you, holding onto a surface such as a counter for balance. Cross your right leg behind the left leg. Now lean to the left and you will feel an increasing stretch at the right hip. Hold this stretch for 15 seconds. Perform the stretch three times for each side. 

If you do develop IT band syndrome, icing and anti-inflamatories are the usual treatments. The most successful treatments have included immobilization, icing, stretching and a quick return to activity. Interestingly, running at faster pace has been correlated with a lower incidence of ITBS.  This is because the higher cadence requires the knee to remain flexed at a higher degree and decreases the amount of friction to the IT band.  This being the case, you should shorten your stride and pick up the cadence. 

Including IT band stretches in your routine can help to prevent the knee pain common with ITBS. If you have high arches or are bow-legged, use your orthotics and avoid motion control shoes. Avoid running along on a down-sloping road (such as always facing traffic). Train sensibly and stick to your training program. Do all this and the one out of ten runners who get knee pain from ITBS…won’t be you!

Christopher Segler, DPM, AACFAS

Award Winning Foot and Ankle Specialist 

Stay Fit. Go Long. Run Fast. Be Strong.

Saturday, October 25, 2008

Do I Really Need "Running Socks"?

Runners need their feet to run. To enjoy running, their feet must function properly and efficiently.  To run fast, a runner’s feet cannot be a distraction. For all of this to work, the feet must be pampered and cared for. That is the whole point of this series; to prevent injury through caring for the runner’s main tool for transferring energy into speed…the feet.

Shoes are critical, but socks can be crucial as well.  The longer the run, the bigger the goal, the longer the race, the more important the socks become. Proper socks can achieve several things. Socks can prevent injury. Socks can reduce fungal infections that runners are prone to develop. Socks can increase blood flow to the muscles and enhance performance. Socks can even help you to recover faster. Socks increase comfort and allow you to feel better at the end of your run. 

One of the obvious ways socks can prevent injury is through blister prevention. There are a couple of ways this happens. Cotton fibers are excellent at retaining moisture. In fact, cotton can retain 14 times the amount of water as some synthetic fibers. This is not a good trait for a running sock. The excess moisture can weaken the outer layers of the skin and make you more likely to develop blisters. In addition, the fungus that causes athletes foot and thick yellow fungal toenails just loves a warm, dark, moist environment…like your sweaty socks.  By contrast, socks that are made of synthetic fibers can wick moisture away from your skin and allow it to evaporate, decreasing the chances of these problems.

Aside from reducing the moisture that makes the skin susceptible to blisters, they can actually decrease the mechanical irritation that causes blisters.  There are also many double-layered socks that allow the friction to occur between the two layers instead of between the sock and your skin.  In essence the idea is to let the sock take the beating instead of your skin. 

Not only can socks help remove the moisture that can predispose you to athlete’s foot or other fungal infections, there are now socks that have actually been shown to decrease the amount of fungus that can grow.  These socks have copper fibers incorporated into the material.  In lab tests, the copper creates a “hostile environment” for fungus and bacteria and decreases their growth.

Socks can help you run faster and farther with less effort. You may have noticed more and more marathon runners and Ironman triathletes wearing knee-high compression sportsocks.  Mariska Kramer-Postma, female Champion at 2008 Ironman Louisville, was one of the many elite athletes at that event sporting these compression socks. They work by exerting an almost consistent compression pressure onto the entire lower leg thereby increasing blood flow by approximately 40%. 

The main feature of the compression sportsocks that produce such a considerable increase in blood flow is the consistent pressure. This distinguishes them from traditional compression socks (which are supposed to improve the venous return of blood back to the heart). Is there any science behind the socks? Yes. A study comparing the effect of compressive running socks with standard running socks found that sport specific compression socks increased run time by 6% and the VO2Max by 3%.  A follow-up study found that 47% of marathon runners perceived their long runs to require less effort.  In addition, 60% found relief of common aches while running distances.

Socks can even help you to recover faster. When you run you work your muscles intensely enough to get tissue damage. It is of course that very tissue damage that leads to increases in muscle fiber strength and development.  A by-product of this damage is swelling. The swelling can be dramatically reduced by wearing compression stockings. Less swelling equals faster recovery.

So what does all this mean to the average marathon runner? Most importantly, wear running specific socks made of synthetic wicking materials such as Coolmax ®, Ultramax®, or any of the other many proprietary brands available. Don’t wear cotton. If you are prone to athlete’s foot infections try the Copper SoleTM antimicrobial technology found in Aetrex socks. If you feel the need for speed, compression socks just might be for you. According to published studies you could shave 12 minutes off a 4-hour marathon. Or you could run with less exertion and recover faster. 

All of these highly technical pieces of equipment are worth trying.  Of course, you will find high-tech running socks, as well as new shoes, at your local specialty running shoe store right here in San Francisco.  Always see an expert if you are looking to try some new socks or other running gear.  (Along those lines, feel free to email me at for a list of recommended running shoes.)

If you discuss your needs with your local experts, they will guide you smoothly down the path to the finish chute. Just remember… Never, ever experiment on race day. Test out your new socks on a short run to see how your feet feel with the new set-up.  When the big day arrives, you’ll knock their socks off!

Dr. Christopher Segler is a marathon runner Ironman triathlete and award winning foots specialist in San Francisco. He specializes in the treatment of busy athletes by offering convenient house calls, direct access to a true expert and extended patient visits to help prevent injury and recurring sources of pain that interfere with training. You can learn more about the best trteatment of sports medicine injuries at

Friday, October 24, 2008

Running with Pain in the Ball of the Foot

Like any other type of pain, a sharp or aching pain in the ball of the foot can be distracting when you run. Although there are many conditions that can cause pain in the ball of the foot, there are only a few that are common among runners.  Stress fractures are frequent, and may be worrisome, but differ from some other conditions.  Unlike stress fractures that often seem to be related to more diffuse pain, several other conditions are easier to localize. 

For example, if you have a bunion, you will know exactly where the pain is (at the big toe joint).  If you push on that area when it is inflamed, it will hurt. Similarly, you can have very specific pain at the second toe joint. If you have a sharp pain on the bottom of the second toe joint, you may be suffering from a common condition called predislocation syndrome. As the name suggests, the condition is a syndrome that occurs before the toe begins to dislocate. In order for a toe to dislocate, the joint supporting structures must fail. 

The bones in the toes (phalanges) connect to the bones in the foot (metatarsals) at joints appropriately called the metatarsophalangeal joints. The bones are held together and also allowed to move by a number of soft tissues attachments including the joint capsule (which holds the fluid in the joint to provide lubrication) and ligaments (that keep the joint stable). The toes mostly move up and don’t usually move very far down.  As a result, the structures on the bottom of the metatarsophalangeal joints are more prone to stress, strain, and injury. 

The most significant structure on the bottom these joints, is a thick reinforcing area called the plantar plate.  Whenever you move or force the toes upward (such as when you stand up on your toes) the plantar plate resists this movement.  Stress fractures result from increasing the duration of impact faster than the bones can develop the strength to withstand the impact. In a similar way, the soft tissues that support the bones can also become injured. 

For example, if a runner is concerned about the impact of running and starts cross training excessively, injury can result.  Elliptical trainers are a common culprits. The best feature of an elliptical trainer is that it is very low impact. The worse part is that with every swing of the trainer, the athlete’s foot is dealt an unnatural position that puts a great deal of pressure on the ball of the foot as the foot swings backward.  With all of the repeated forcing of the foot up on the toes, the plantar plate on the bottom of the foot can become stressed to the point it develops very small tears. If not rested and allowed to heal these can get worse. 

When most runners come to see me with this problem, they will describe pain in the ball of the foot that is significantly worse when on an elliptical trainer or walking barefoot of hard surfaces such as tile.  It may ache after a run but usually does not hurt much during a run on flat ground. They will also usually describe a “fullness” in the ball of the foot, which they may or may not recognize as swelling. There is almost never any particular recall of how the problem began.

Sometimes, if the condition has been getting worse for a while, it appears that the second toe is sitting just a bit higher than the third toe.  This indicates a weakness in the plantar plate and joint supporting structures on the bottom of the foot. If the inflammation is allowed to continue, these structures will become weaker. With the continued application of force (repeatedly forcing the toes up through the backswing of the elliptical trainer) the plantar plate may tear completely. Then, the toe dislocates.

Fortunately, I have only seen this one time. The patient came in with his second toe pointing at the ceiling and sitting on top of the metatarsal.  He was in excruciating pain and required immediate surgery to reposition the toe and repair the torn structures. 

All of this is, of course, preventable.  Just remember that cross training is good, but it is possible to over do it. Elliptical trainers are great and highly recommended, but resist the temptation to set it at a steep angle. Although setting the machine on a steep angle can make the workout tougher, and hence shorter, it places enormous stress on the plantar plate. Do the same with your treadmill…keep it relatively flat to decrease strain on the ball of the foot. 

If you do start to notice a sharp or aching pain in the ball of the foot, get it checked out ASAP. If you seek treatment early you will likely only need ice the area, take some anti-inflammatories, and tape the toe to stabilize it. You will almost certainly still be able to train and participate in your goal race.  If you ignore what your body is trying to tell you, then you might end up working as a volunteer, handing out refreshments on the course. 

How to Prevent and Heal an Ankle Sprain

An early morning run out on the trails. The smell of fall is in the air, the sound of crisp fallen leaves crunching under your feet. It seems that it is finally cooling off after a long scorching summer.  You look forward to enjoying more brisk morning runs as your end of season race approaches.  Suddenly your foot rolls out from under you. You catch your balance, but nearly fall. You look back on the trail and there is a stick emerging from under the color of rusting leaves, barely visible.  You turn and run off hardly paying attention to the aching in you ankle.  It doesn’t hurt, except every time you land on a root, a pinecone or even an acorn.  The next day the ankle is sore and swollen with a mild throbbing pain with the first few steps. You don’t think much about it. After all of the ankle sprains you had before, how would this be any different. A little ice, dig out that ace wrap and you think you’ll be good as new.

Ankle sprains are the single most common injury in sports. They can lead to considerable disability, premature arthritis and long-term pain. Worse (if you are a runner) they can keep you from running. Thankfully for runners, in most cases they are avoidable. 

So what exactly is a sprain? A “sprain” is an over-stretching of a ligament that results in tears. An ankle sprain is classified by the location of the injured ligament as well as severity. 85% of all ankle sprains involve the lateral ligaments (those at the outside of the ankle).  There are three lateral ankle ligaments.  Of the three ligaments the anterior talofibular ligament (ATFL) is far more frequently injured than the others. 

A Grade I ankle sprain is a minor injury typically involving only partial tears of the ATFL.  There is usually little loss of function with this type of injury, such as described in the opening paragraph. A Grade II sprain involves a complete tear of the ATFL and may include stretching or partial tearing of the other ligaments.  This will involve more pain, difficulty walking and a risk of long-term problems with ankle instability if not correctly treated and rehabilitated.  A Grade III sprain is a severe ankle sprain.  Most people with a Grade III sprain cannot walk. They usually also have significant bruising and swelling. These injuries require intensive treatment to get back to activity. 

Fortunately, the minor sprains are the most common variety. Most people who have had an ankle sprain, have actually suffered several ankle sprains. Many of these folks actually have sprains so frequently that they don’t even think of them as injuries. The reason for this is that when the ATFL (the primary stabilizing ankle ligament) becomes weak or completely torn after an initial sprain, the ankle becomes unstable. Then merely stepping on an uneven surface, a rock, or a tree root can cause the ankle to roll.  Those that have been through this become accustomed to this instability.  In many cases, they have rolled the ankles so many times that the nerve fibers in the area have been damaged and it hardly even hurts.  So if it doesn’t always hurt, why does it matter?

It matters because even minor sprains have the potential to cause far more serious damage. Every time the ankle rolls (whether you fall down or not) there is a risk of a number of small fractures of the talus (the bone at the top of the foot that moves up and down in the ankle). These fractures can lead to pain, locking of the ankle, or pre-mature arthritis with damage to the cartilage that cushions and absorbs shock. It is also possible to tear other ligaments that stabilize the tendons at the ankle and control the motion of the foot. 

The good news is that distance runners, particularly those who run on roads, are at low risk of an ankle sprain while training.  But there are times when the risk goes way up. Trail running and cross-country running significantly increase the risk due to uneven terrain. Often these surface irregularities are not even visible due to grass, leaves and other forms of ground cover.

Interestingly, during organized road races (on very flat paved roads) there are lots of ankle sprains.  The reason for this is that runners trust the road to be flat, but they cannot see very far ahead.  Think about a marathon start.  You and several thousand other excited highly trained runners finally getting to head away from the start and out on the course. You could reach your arm out in any direction and touch a different person.  During the first few miles, most of your focus is on the people around you, just trying not to bump into them while attempting to maintain your desired pace.

All it takes is a dropped water bottle, a centerline reflector, or a small pothole.  Step on one of these while you are staring at the back of the runner in front of you and your ankle can roll right out from under you.  So that brings up the obvious…keep your eyes on the road. If possible, try to keep a little distance so you see a water bottle just before you step on it. If you run on the crown of the road, avoid the paint and that will keep you off the reflectors.  If it is raining, stay way off the paint…it is extremely slippery when wet and can easily send you to the ground. Wearing worn out shoes have also been shown to contribute to ankle sprains, but you should know better by now. 

If you know that you have unstable ankles, get checked out. There are many ways to reduce your risk of further injury and recurring sprains. Strengthening exercises can re-train the muscles surrounding the ankle to work in sync and take over some of the lost function from the injured ligaments. There are also ways to tape or brace and restore enough stability to allow for running without any difficulty. If you do suffer an ankle sprain, the standard initial treatment is P.R.I.C.E (protection, rest, ice, compression, elevation). However, the key is rehabilitation, not just decreasing pain. Most people underestimate the significance of an ankle sprain and the importance of restoring the function of the ankle through a proper ankle rehab program. When properly treated, ankle sprains recover well, and most of the time without any surgery.

With fall training weather comes renewed delight with running as the trees start to change.  Keep your eyes on the road or the trail (as the case may be).  Just don’t let the roots trip you up and watch out for the errant pinecone or acorn. 

Thursday, October 23, 2008

Runners, Blisters and Black Toenails

The vague stinging and burning sensation emanating from a blister can easily detract from your focus during a marathon. The more you think about it, the worse it gets.  The next thing you know, your pace is off, you speed up and slow down because of this unpleasant distraction. When you walk through a water station, its just gets worse, and you start to limp. After the race, running is out of the question. You may even limp for days while back at work.  This is almost always preventable.

Skin injuries are very common among marathon participants. In fact, a 12-year study of injuries at the Twin Cities Marathon found skin problems (blisters, black toenails, abrasions) to be more common than musculoskeletal complaints (sprains, stiffness, stress related injuries). A whopping 91% of all skin injuries were blisters.  In the most comprehensive study ever reported regarding injury among marathon runners, 7-27% of runners who sought treatment after a race were being treated for blisters.  But don’t be confused...common does not mean unpreventable.

So what exactly is a blister anyway? A blister (in the case of a runner) is an accumulation of plasma under a pocket of otherwise intact skin that results from repeated mechanical irritation: friction. The repeated rubbing of a sock or shoe against the skin actually causes the top layer of the skin (epidermis) to separate from the layer below (dermis). Fluid seeps from the injured tissue and fills the space, creating the soft fluid filled sack that hurts when ever you step on, push against or otherwise antagonize it.

In mountaineering, there is a saying that frostbite can only result from inadequate equipment or poor planning. No one heads up to the summit of Mount Everest to test out a fancy new pair of mittens. And no one should head out on a marathon course to test out a pair of socks they bought at the expo after packet pickup.

The easiest way to avoid blisters is consistency of equipment, pace, and conditions. Lets talk equipment. In general, cotton is one of the worst materials for endurance athletes-so don’t use it. Socks made of synthetic fibers that wick moisture away from your skin help decrease moisture that can make the skin more vulnerable to friction. There are also specialty socks that have dual layers to decrease the friction against your skin. If you seem to be prone to blisters, you can (and should) experiment with some of the many high-performance socks that are available. Experiment in training, but never on race day. 

Your shoes must be broken in as described in the article on shoes. They should be dry when you start the race. Shoes should fit snug (no heel sliding around). I usually alternate my shoes so that I don’t run in the same pair two days in a row.  This allows time for them to dry out completely before I run again. If it is raining, not much you can do. If it is hot, try not to soak your feet when you pour water over your head. 

If you seem to always get blisters on long runs, something is wrong. You may not have the right size shoes or may not be lacing them correctly. The location of the blisters can often speak to the cause of the problem.  For example, if you walk 50 feet and run 50 feet for the marathon, all of that stopping and starting will cause blisters on the ball of the foot. Try to keep an even pace. Although your running style and gait pattern can contribute to blisters, this is rare. Ask for help and seek the advice of an experienced runner, specialty shoe store or podiatrist. Many people swear by moleskin, body glide, or vaseline. All can help, for different reasons, but these can also cause the skin to retain more moisture to varying degrees. 

Black toenails are almost always caused by tight shoes. If your shoes are fitted correctly but you run down hills (a lot) then your toenails can repeatedly bump the end of the shoe. Whether you hit it once with a hammer or thousands of times on the inside of a shoe, the cumulative trauma can still cause bleeding and bruising of the toenails. The nail plate may be sore and just pinkish right after the race, but often turn dark purple or black after only a day or two. If it is very tender, the blood can often be drained to relieve the pressure. 

As race day approaches you should be fine tuning your plan and equipment. No major overhauls. If you try new shoes or socks, do it on a short run.  If that goes well, try a slightly longer run. Keep in mind an episode with a bad blister now could stall your training and derail your event. Proceed with caution and good common sense.  Shop the expo and have fun. Treat yourself to some fancy new gear, high performance socks and whatever else your heart desires. You will have earned it after all that training.  Just don’t use any of it until your first recovery run after the big day. Use the tried and true, and you will walk tall and proud after you cross the finish, instead of hobbling to the medical tent.

Do I Have a Stress Fracture?

It’s a warm afternoon and Kendra is out for a run.  Not a long run, just a few miles, a moderate pace.  She has been training religiously.  After work she likes to run through the Marina. There is something serene about the sound of her stride on the path, the wind off San Francisco Bay. The prefect way to leave the stress of work behind, and think about her upcoming marathon. Visualizing the finish, picturing in her mind’s eye the finish clock; just ahead of her goal time, getting that medal, all the work paid off.  Suddenly her day-dreaming is interrupted by a vague ache in her left foot. It seems in perfect cadence with the sound of that foot hitting the boardwalk. She wonders what happened.  It isn’t bad though, and she finishes her run. 

The next day, she gets out of the shower and notices that her left foot looks a little swollen. There is a hint of color on the top of her foot, not quite a bruise.  She starts to worry.  Later that day she has another run planned.  But by the end of the day, she finds herself taking her left shoe off at her desk. She wonders why it aches whenever she walks down the hall. That evening, after work she heads out for a run, but the aching turns into a throbbing pain only a mile into the run.  She turns around and runs back to the car, wondering if she will have to cancel the hotel room and try to get a partial refund for the entry fee.

This is the classic story of a stress fracture. They happen with all kinds of athletes ranging from pathologically over-trained gymnasts to casual runners. The reason is simple. The amount of stress applied exceeds the body’s ability to withstand the load. And something has to give. 

If you are a physics geek, you know about Wolf’s Law. This law states that when the load applied to a particular bone increases, the external cortical (load-bearing) portion of the bone becomes thicker and stronger as a result. In short, the bone will remodel itself over time, becoming stronger and better able to resist that sort of stress. This increases the bone’s capacity to withstand longer and longer runs throughout a period of distance run training. It is also the rationale behind weight-training, and other exercise programs to fight the gradual bone-loss associated with osteoporosis. This of course is a good thing.  However, it is possible for this to backfire. And when it does, a stress fracture will result.

When someone comes in to my office with a stress fracture, they usually have some vague pain in the top of the mid-foot, but can’t seem to pinpoint the discomfort. They have some swelling, but not a great deal. They seem to remember some bruising, but only when prodded.  They usually don’t connect the bruising with the onset of pain. They do always seem to discern that running makes it significantly worse.  They have also (interestingly) continued to run on it anyway. 

Some are smarter than others, and some are tougher than others. I see the full range. The sensible ones come in after only a few aching runs, and having noted some swelling that seems to get worse walking around at work. Some will run until they can barely walk. I had one of theses hobble in after running on it for eight weeks.  It was a mess. After some creative surgery and a bone stimulator he is almost back in action, yet the season is all but over. It just doesn’t have to be that way.

Stress fractures are prevented, first and foremost, by sensible training. Your bones must have the right combination of load (gradually increasing long runs), rest (including light days and adequate sleep), and good nutrition in order for Wolf’s Law to prevail. Otherwise your body cannot increase the strength of the bones fast enough to stave off the tiny little crack in the bone that is a stress fracture. 

When a stress fracture first occurs, (like in Kendra’s case) the crack is not even visible on X-Ray. It can take 4-10 weeks for it to actually show up. If however you continue to run, all of that pounding causes the tiny little crack to become a big crack and then fracture all the way through. This leads to two pieces of bone that may or may not want to get together again. This is clearly visible on X-Ray, but not good.  This can lead to surgery (which by the way, is lots of fun for me, but not so much for the patient).  

The characteristics that are proven risk factors for stress fractures are female gender, wide pelvis, high arches, and a limb length discrepancy (one leg longer than the other). Running only one side of the road with a steep shoulder  (always facing traffic), wearing the wrong types of running shoes (not enough cushion/too much stability), and running on hard surfaces can also increase the risk. Those prone to shin splints, those who ignore the rest days and run hard on light days, and those who run on hills excessively are also more likely to encounter problems. 

I personally believe that a Type-A personality peppered with a combination of blind determination and a penchant for goal attainment is also a solid risk factor, but this has never been studied. The reality is that all distance runners have some measure of these traits or they wouldn’t think it is a good idea (much less fun) to train for a marathon.  But that is why we follow a plan…with planned rest days…to protect ourselves from the innate desire to train more, run longer and “ensure success through greater effort.” 

If you think you might have a stress fracture (pain worse with running, goes away with rest, maybe some swelling and/or bruising) get checked out.  It is easy to fix when it first starts without too much lost training.  If however you ignore that aching, sometimes throbbing, pain with each stride, you may find yourself in Kendra’s position: thinking of cancelled hotel rooms and partial refunds.  Instead, play it safe so you can be back on the road, dreaming of the finish chute, friends and family screaming encouragement, a new shiny medal hanging around your neck. 

Wednesday, October 22, 2008

Runners Heel Pain

Heel pain is common complaint in runners. Actually, heel pain is common in all people.  40% of all visits to podiatrists in the U.S. are because of heel pain.  Of all of the different causes of heel pain, the vast majority is due to a condition known as plantar fasciitis.  This is the most frequent cause of pain on the bottom of the heel and is an inflammation in the band of tissue (the plantar fascia) that runs from the heel to the toes. This condition is most often caused by a tight achilles tendon or poor foot structure such as overly flat feet or high arches. It can also be caused by wearing non-supportive footwear on hard surfaces, spending long hours on your feet, or obesity. 

The pain from plantar fasciitis is usually a sharp, stabbing pain on the inside of the bottom of the heel that can feel like a knife sticking into your heel. Pain from plantar fasciitis is usually most severe when you first stand on your feet in the morning.  Many people complain that the first step out of bed is the worst.  Many also have pain as they get up and start to walk after sitting for a period of time while working at a desk or computer.  This heel pain will usually subside as you walk, but can return with prolonged standing, walking or running. 

For runners, the plantar fascia may become inflamed after a period of running hilly courses or running in excessively worn shoes or the wrong type of shoe for your foot type.  Once this happens, a cycle of inflammation ensues.  There is a nerve (called the medial calcaneal nerve) that runs along on the inside of the heel bone and actually curves down around the bottom of the heel between the bone and the plantar fascia.  As you walk and place stress on the plantar fascia, the tugging of this ligament where it attaches to the heel bone stimulates inflammation.  The inflammation results in fluid being collected around the nerve between the bone and the plantar fascia.  When you get up and step on the heel, the nerve gets compressed by the collection of fluid.  This causes the sharp pain. By stepping on the heel, some of the fluid is pushed out of the area and away from the nerve.  The second step may also hurt less as even more fluid is pushed away from this space around the nerve. Once you get moving, the pain then usually subsides.  Once you go to sleep the whole cycle begins again. 

In short, plantar fasciitis is a combination of two separate problems.  First, there is a tight Achilles tendon that can lead to abnormal tension on the plantar fascia when you walk or run. Second, there is inflammation from all of the tissue damage as the plantar fascia is tearing away at its attachment to the heel bone.  You must address both in order to get better.

The main question I get from patients about treating plantar fasciitis is “will I need surgery?”   The answer to this is almost certainly not.   Based on the results I have seen among my patients at the Ankle & Foot Center of Chattanooga, 98-99% of heel pain sufferers can effectively self-treat their heel pain and get permanent relief without ever visiting a doctor.  The reason I know this to be true is that I have tracked the progress of those patients that have been seen in my office.  I see several patients with heel pain every single day in my office.  In the last year I only performed surgery on four patients for plantar fasciitis.

My treatment philosophy and practice style is simple.  I firmly believe that simple, reliable, cost-effective treatments should always be attempted before expensive and evasive treatments like surgery.  Although I am an award winning foot and ankle surgeon (and admittedly love doing surgery) I truly believe that surgery is just a bad idea if any other treatment will work.  For that reason I wrote a book called No More Heel Pain which we make available free to anyone in Chattanooga.  

The main question I get from runners is “can I run with plantar fasciitis?”  The answer is yes, provided it has been diagnosed as plantar fasciitis.  As I said earlier, plantar fasciitis is by far the most common form of heel pain, however there are other causes.  Stress fractures of the heel bone, bone cysts (weak areas) and bone tumors can all mimic the symptoms of plantar fasciitis.  The difference is that they are usually more painful when you run and will not subside (but instead get worse) while you are walking or running. These can also lead to serious problems such as a fracture of the heel bone.  A fractured heel bone will definitely interrupt your training schedule.

Provided that it is in fact plantar fasciitis, the first and most often effective treatments for plantar fasciitis include stretching, icing, and anti-inflammatory medications. A program of home exercises to stretch your Achilles tendon and plantar fascia are the mainstay of treating the condition and lessening the chance of recurrence. Achilles tendon stretches are essential to eliminate heel pain. Perform the Achilles tendon stretches twice-a-day; morning and evening. This will only take 1 minute in the morning and 1 minute at night.

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. Perform each stretch three times per side. You can find additional helpful stretching videos on our website at

Icing your heel is vital to decrease inflammation that accumulates while you walk during the day, and to prevent more inflammation while you sleep. Apply ice to the sore area for 20 minutes two or three times a day to relieve your symptoms.  Do not go barefoot.  Do not wear flip-flops or house shoes while recovering.  Only wear shoes with a moderate heel that do not bend through the arch.  Always wear shoes when walking, even in the home.  If you have our recommended custom orthotics, or over-the-counter inserts, wear them in your shoes at all times.  Most people with plantar fasciitis improve significantly after two months of initial treatment.

Keep on running, but seek help if your heel pain gets worse while you run or if the heel pain just won’t go away after trying the treatments described above.  Once you get rid of the heel pain, keep stretching your Achilles tendon periodically and you can prevent your heel pain from coming back.  No more limping out of bed before your morning run!

Award Winning Foot and Ankle Surgeon

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