San Francisco Podiatry Video

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Tuesday, December 16, 2008

Young Woman Dies in White Rock Marathon

On December 15, 2008 during the Dallas White rock Marathon, a 29-year-old woman collapsed and was pronounced dead, the race director said.

According to the Dallas morning news, Marcus Grunewald, director of the 39-year-old Dallas White Rock Marathon, said that the young newlywed woman’s death was the first in the event since 1986. In that race a 47-year-old man collapsed after suffering a heart attack and died during the marathon.

Witnesses to the event said the woman appeared to be running fine until mile 21, just a few miles from the finish, when she suddenly stumbled. She was helped to a nearby curb and then lost consciousness. "Her body was cold," one witness said. "She was already gone."

The race director told the Dallas Morning News that due to the marathon's 66-degree weather, higher than the race's average, medical aid and water were readily available along the race route. Although heart attack is suspected, the exact cause of death had not been determined. An autopsy was pending.

This tragic event illustrates the importance of checking with your primary care doctor before training for any endurance event. Undiagnosed heart disease or other underlying medical conditions can lead to disaster.

Even if you have been training for months without any episodes or warnings of trouble, distress of running faster during an organized marathon can lead to enough over-load to cause a heart attack.

After running for many miles particularly at your maximum capacity, dehydration can lead to electrolyte changes that can contribute to a heart attack. It is critical to make sure they don’t have any underlying heart disease before considering when these events.


Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His podiatry practice is at Don On the Run Podiatry House Calls in San Francisco, Marin and the East Bay. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting
http://www.AnkleCenter.com .

Monday, December 8, 2008

Posterior Tibial Tendonitis: a Pain in the Arch

When you run, your foot hits the ground, you pronate to absorb impact and then you supinate to push off again. All of this is possible because of a muscle in your leg call the tibialis posterior. This muscle deep in the back of your leg forms a tendon call the posterior tibial tendon that attaches to your foot. It attaches to the navicular bone in the instep of your foot, right at the top of your arch.

In the very simplest of terms, this tendon helps to hold up the arch. It is really much more complex than that, but we won’t bore you with the details. All you really need to know about this is that when you get posterior tibial tendinitis it can quickly progress and become a surgical problem.

The good news for runners is that it one of the things that least frequently affect us. It most often affects people who are middle-aged. It also is often associated with high blood pressure, obesity and diabetes. Not exactly the picture of a runner. Interestingly though, one study showed women get it four times more often than men.

This is one thing to watch out for if you have fleet feet. It seems many who get this problem are already flat-footed long before it starts. Excess pronation (common in people with flat feet) puts tremendous stress on the tendon. Running increases the stress and strain several fold. The result is repetitive overuse that can set the condition off.

When too much stress is placed on this tendon, it can become inflamed. Continued inflammation can weaken the tendon and cause it to stretch out. This can lead to a torn or ruptured tendon with a complete collapse of the arch. Not good.

So how do I know if have posterior tibial tendonitis? One clue that you might be getting this problem is pain from the ankle bone to the arch on the inside of your leg. If it is inflamed and you stand up on your toes on that foot, it will likely hurt much worse. If you stand only on one leg and do this, it will be even more painful. You might even have some swelling around the ankle or arch.

If you notice these symptoms you need to get it checked out by an foot and ankle expert. This is not one of the ice-it-and-will-go-away kind of problems. Neglecting it can (and often does) lead to surgery. It is preventable as well as easily treatable in its early stages. Orthotics can limit the force of pronation and help to decrease the risk of injury to the tendon, especially if you over-pronate or have flat feet. And as always, make sure you are wearing the right type of running shoes for your foot type.


Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His Bay Area based podiatry practice is Doc On The Run Podiatry House Calls. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting http://www.AnkleCenter.com .

Marthon Champion Dies at Age 41

On Monday it was announced that Australia's double Commonwealth Games marathon gold medallist Kerryn McCann has died from cancer at age 41. She has long been regarded as one of Australia's best female long-distance runners. She was first diagnosed with breast cancer in 2007. Apparently the cancer spread to her liver four months ago.

It is reported that she died in peace at her home south of Sydney with her husband and three children by her side. "On behalf of the entire athletics community, I would like to pass on my sincere condolences to the McCann family," Athletics Australia President Rob Fildes said in a statement. "Kerryn will fondly be remembered for being an extremely popular team member who represented her country on 14 occasions, across an athletics career that spanned 22 years."

In 1996 at Atlanta and 2000 at the Sydney Olympics McCann competed in the marathon but saved her best performances for the Commonwealth Games.

She won the gold medal in Manchester in 2002 and later defended her title in Melbourne Australia four years later with an incredible last-lap effort against Kenyan Hellen Cherono. At that time she was 38.

She will be missed by the running community throughout the world.


Dr. Christopher Segler is an award winning foot surgeon and Ironman Finisher who treats elite athletes. His podiatry sports medicine practice is Doc On The Run: San Francisco Podiatry Sports Medicine House Calls. To learn more about increasing your speed and avoiding running injuries like tendonitis, shin splints and stress fractures, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting http://www.AnkleCenter.com .

Sunday, December 7, 2008

Os Trigonum Syndrome: A Rare Form of Posterior Ankle Pain

The day that Jessica came into the office she was worried. Not only was she worried, her mother was worried as well. Jessica is a 26-year-old healthy runner with a penchant for training and a high tolerance for pain.

She was in the middle of training for an upcoming marathon. Her mother had noticed her limping about and recommended that she go see somebody. She came in because she was worried about her Achilles’ tendon. She had heard that could be very serious.

I asked her about her training routine. She said that she typically ran 8 miles at a time on a very hilly course area. She felt that this was a good training strategy given that the upcoming marathon would contain a lot of hills. She wanted to make sure that she would be ready. But running up and down all of those hills was aggravating her condition.

She could remember exactly when her pain started. It’d been getting progressively worse. She pointed at the back of her ankle, but it wasn’t right at her Achilles’ tendon where she had the most pain. It was actually deeper in the back of the ankle.

I poked and prodded and couldn’t find any pain or tenderness anywhere around her Achilles’ tendon. However, if I squeeze the back of the ankle, away from the Achilles’ tendon, she had a great deal of pain and tenderness. Next, I put my thumb underneath her big toe. I had her try to push down with her big toe as hard as she could. And when she did, she had the same kind of pain in the back of the ankle.

We took some x-rays and noticed that she had a portion of bone that was not completely fused to the back of her talus bone. This is a condition known as os trigonum syndrome or posterior ankle impingement syndrome.

We got an MRI that reassured us that she had no issues with her Achilles’ tendon or the tendons to go to the big toe area. The flexor hallucis longus (FHL) tendon which pulls the big toe down against the ground when a runner pushes off can sometimes become torn or irritated and have the same type of presentation. But her FHL was fine.

However, not everything was fine. There was a great deal of swelling with in the talus bone (the bone that connects the foot to the ankle), as well as an accessory bone at the back of the talus called the os trigonum. These two pieces of bone in her ankle were connected with some soft tissue attachments which were very irritated.

Os trigonum syndrome is not a common injury. However one study showed that runners who to do a significant amount of downhill running have an 18% chance of acquiring posterior ankle impingement syndrome. And when it does occur, it can be debilitating.

Runners who develop this problem might have no pain at all when walking on level ground. It starts to become painful when they walk on uneven ground. It becomes much worse when they run on hills. This is because the foot needs to point further down (plantarflexion) and the soft tissues can become irritated or even get caught and pinched between the talus and the calcaneus (the heel bone). This causes a great deal of inflammation and pain.

Not only will there be pain, but many will also have swelling and stiffness in the back of the ankle that may extend all the way to the Achilles’ tendon. That is why many patients who think they have Achilles tendinitis might actually have this problem instead.

Although this is not the most common running injury we see, it is important to get it treated. Chronic inflammation can lead to pain that interferes with activities ranging from normal walking to running. Anytime you suspect an Achilles tendon injury, it is important to be evaluated.

Even though Jessica did not have an Achilles’ tendon injury she did have an injury which could be treated effectively. In most cases, immobilization and physical therapy can calm it down. In rare cases, surgery is needed to take out the accessory bone and inflamed tissue. In any event, with this type of problem it is never a good idea to stick your head in the sand and foolishly hope you’ll cross the finish line in record time.


Dr. Christopher Segler is an Ironman Triathlon Finisher and award winning foot doctor specializing in elite athletes. His podiatry sports medicine house calls practice is based in San Francisco. You can reach him directly at 415-308-0833. You can register for a FREE membership and will receive the monthly newsletterFinisher’s Circle,” which provides expert advice on increasing your running efficiency and preventing injuries and foot pain by visiting http://www.AnkleCenter.com .

Saturday, December 6, 2008

Training Programs: Your Map To Success


How many miles you have to run in order to finish a marathon? If your answer was a quick 26.2 miles, that’s not exactly correct. The reality is that most people who decide to run a marathon will run hundreds of miles before completing that marathon. The last 26.2 miles makes up a small percentage of the actual mileage in training that goes into completing that event.


Of all of the trainable aspects related to any sporting activity, endurance is the one that an athlete can affect more than any other. On day one, before any training begins, a runner may be able to run a 100 m sprint at 65-70% of his or her potential speed. This same runner on day one might only be able to run about a mile without stopping. However, after a period of months of training, it would certainly be reasonable for this person to run 26.2 miles. This would indicate a 2600% increase in endurance. Those same sort of gains in performance can simply not been made by any human being regarding speed. 


Distance running is for most people a lifestyle change that provides enormous benefits. In order to accomplish any goal in distance running, whether marathon half marathon or 10K, it takes a great deal of training and daily dedication. In order to achieve any goal, particularly one regarding a distance running event, it is critical to have a training program that can be followed consistently. In a sense, a training program is your roadmap to safely completing a given event. 


The goal of any training programs is to get you across the finish line in your desired time. If your goal is to simply complete a marathon, slowly and progressively increase your mileage at a very slow pace and you will eventually be able to run 26.2 miles. The problem with this strategy is that most marathons have cut-off times. This means that you not only need to complete the distance, but must do so within a specific time frame.  If you have a dream of qualifying for the Boston Marathon, this timeframe is much shorter. That means that you will need to train not only for endurance but also for relative speed.


Regardless of the specific training program that you choose, they all combine certain elements. The long run is a staple of distance running training programs.  The definition of a long run is relative. It simply must be long enough to stimulate an increase in endurance. 


This brings up a question that I get from beginning marathon hopefuls.  Why is it not just advantageous to go run 20 or 25 miles on a regular basis and just gradually try to increase speed?  There are both physical and mental reasons why this strategy will fail. First, the amount of muscle and tissue damage that occurs on very long runs is significant. Second, it is very difficult to increase speed while running very long distances. Basically speed and endurance are opposing strengths that cannot be built simultaneously. Third, the overreaching limits to maintaining a goal pace is in the brain. And the brain must be trained as well. 


When you run at a fast pace, particularly for long distances, there are very specific physiologic limiters in play. Your body can only store so much glycogen in its muscle. You also only so much fat burning capacity. Your body also has resistance to muscle damage as well as limitations mechanical inefficiency.  


When any of these specific physiologic limits become reached, your brain takes over. Chemical signals are sent to your brain when you are running low on muscle glycogen. Your brain also makes calculations on physiologic set points such as core body temperature and decreases output when your brain fears injury. Your brain is capable of picking up chemical signals related to muscle damage.   We know that these markers exist in your bloodstream and are actually the ones measured when you have a heart attack. When your brain notices an increase in temperature, or an uncomfortable level of chemical signals related to intense exercise or tissue damage, fatigue sets in, and your brain forces the body to slow down.


This does not mean that you cannot adjust each of these given tolerances that your brain will allow. Through training, your body can become used to a higher set-point of core temperature. Through specific speed work and training your body, your brain can become accustomed to higher levels of chemical markers and tissue damage without fear of injury and without forcing your muscles to shut down. This is why almost all training programs consist of base training/endurance phases, progression phases, and peak phases. 


There are five basic workouts that are put together in various combinations in order to comprise a training program.  The first is the long run.  This workout has one specific purpose and that is to get your body used to moving over ground for a very long distance.  The progression is very gradual and you should not do more than one long run per week.


The second workout is the quarter-mile repeat. A marathon runner will typically do anywhere from six to 16 repeats, with two minutes rest in between, during one session. The idea with these runs is that by only going one quarter mile at a time, your body gets used to moving at a very quick pace without taxing the lungs. The main focus is increasing the rate of turnover.


Tempo runs are another workout which are crucial to developing stamina.  These workouts are typically shorter in duration, maybe four to eight miles.  They’re also at a faster pace, typically anywhere from 20 to 45 seconds faster than your desired race pace. Tempo runs will make your race pace actually seem easier.  For a marathon runner, they will typically only lasts four to eight miles.


Recovery workouts are one of the elements that are least frequently utilized. They are also crucial. If you are putting in heavy miles there is no such thing as a recovery run. Running puts enormous stress on the legs. If you are running very low mileage, it is possible that running at a slow pace can serve a recovery function.  However, cycling is a much more efficient and effective recovery workout. A side benefit of cycling is that it breaks up the monotony of running. In a sense it will also provide you a mental break from training.


The fifth workout is a rest day and it is also often neglected.  Most training programs include at least one rest day per week.  The definition of a rest day means that you do not train. You do not go hiking, cycling, or perform manual labor. Think lazy. Rest means rest.


The following is a sample training schedule for a beginner half marathon. This schedule assumes that you already have running for a couple of months 2-3 miles a day at least 3 days per week. 



Wk Mon Tues Wed Thurs Fri Sat Sun Total mi 

1 2 mi easy Rest/XT 2-3 mi easy Rest/XT Rest/XT 3 mi long Rest 7-8 mi

2 2 mi easy Rest/XT 3 mi easy Rest/XT Rest/XT 3-4mi long Rest 8-9 mi

3 3 mi easy Rest/XT 3 mi easy Rest/XT Rest/XT 4 mi long  Rest   7 mi

4 3-4mi easy Rest/XT 3-4 mi easy Rest/XT  Rest/XT 4-5 mi long Rest 10-13mi

5 4 mi easy Rest/XT 4 mi tempo Rest/XT Rest/XT 5 mi long Rest 13 mi

6 4 mi easy Rest/XT 4 mi tempo Rest/XT Rest/XT 6 mi long Rest 14 mi

7 4 mi easy Rest/XT 4 mi tempo Rest/XT Rest/XT 7 mi long Rest 15 mi

8 4 mi easy Rest/XT 5 mi tempo Rest/XT Rest/XT 9 mi long Rest 18 mi

9 3 mi easy Rest/XT 6 mi tempo Rest/XT Rest/XT 11 mi long Rest 20 mi

10 3 mi easy Rest/XT 7 mi tempo Rest/XT Rest/XT 7 mi long Rest 17 mi

11 4 mi easy Rest/XT 8 mi tempo Rest/XT Rest/XT 12 mi long    Rest 24 mi

12 4 mi easy Rest/XT 9 mi tempo Rest/XT Rest/XT 8 mi long Rest 21 mi

13 4 mi easy Rest/XT 8 mi tempo Rest/XT Rest/XT 10 mi long Rest 22 mi

14 4 mi easy Rest/XT 8 mi tempo Rest/XT Rest/XT 13 mi long Rest 25 mi

15 3 mi easy Rest/XT 4 mi tempo Rest/XT Rest/XT 6 mi lo ng Rest 13 mi

16 3 mi easy Rest/XT 2 mi tempo Rest/XT Rest/XT Half MarathonRest 18.1 mi

Easy: means run at an easy pace.

Tempo: means run at a pace 20-45 seconds/mile faster than your goal race pace.

Long: runs should be run 1-2 minutes/mile slower than your goal race pace.

Rest/XT: means rest if you bad, cross train if you feel good.

Rest: Rest is best the day after your long run. 


Next is a sample training schedule for an advanced half marathon runner. This schedule assumes that you already have been running for at least a year, have already run at least one half marathon, currently run 4 days a week and can comfortably run 8 miles as long run.  



Wk Mon  Tues Wed Thurs Fri Sat Sun Total mi

1 4 mi easy XT 20 min 3 mi tempo 4 x 400 Rest/XT 3 mi long Rest 11 mi

2 4 mi easy XT 30 min 4 mi tempo 4 x 400 Rest/XT 3-4 mi long Rest 12-13 mi

3 4 mi easy XT 30 min 4 mi tempo 4 x 400 Rest/XT 4 mi long Rest 13 mi

4 4 mi easy XT 40 min 5 mi tempo 6 x 400 Rest/XT 4-5 mi long Rest 14-16 mil

5 5 mi easy XT 30 min 5 mi tempo 4 x 400 Rest/XT 5 mi long Rest 16 mi

6 5 mi easy XT 40 min 6 mi tempo 6 x 400 Rest/XT 6 mi long Rest 18 mi

7 5 mi easy XT 60 min 6 mi tempo 6 x 400 Rest/XT 7 mi long Rest 19 mi

8 5 mi easy XT 60 min 7 mi tempo 6 x 400 Rest/XT 9 mi long Rest 22 mi

9 5 mi easy XT 40 min 8 mi tempo 3 x 1600 Rest/XT 11 mi long Rest 26 mi

10 5 mi easy XT 45 min 6 mi tempo 6 x 400 Rest/XT 7 mi long Rest 19 mi

11 5 mi easy XT 45 min 8 mi tempo 3 x 1600 Rest/XT 12 mi long Rest 27 mi

12 5 mi easy XT 60 min 6 mi tempo 4 x 800 Rest/XT 8 mi long Rest 21 mi

13 5 mi easy XT 60 min 8 mi tempo 6 x 400 Rest/XT 10 mi long Rest 24 mi

14 5 mi easy XT 40 min 8 mi tempo 4 x 1600 Rest/XT 13 mi long Rest 28 mi

15 5 mi easy XT 30 min 5 mi tempo 3 x 800 Rest/XT 6 mi long Rest 18 mi

16 3 mi easy XT 20 min 3 mi tempo Rest Rest Half Marathon Rest 19.1 mi

Easy: means run at an easy pace.

Tempo: means run at a pace 20-45 seconds/mile faster than your goal race pace.

Long: runs should be run 1-2 minutes/mile slower than your goal race pace.

Rest/XT: means rest if you bad, cross train if you feel good.

6 x 400: (Quarter mile repeats) means six separate 400 yard runs 

with 2 minutes rest in between.

Rest: Rest is best the day after your long run. 


Notice that both training schedules include a great deal of rest. There are also weeks where mileage ramps up, then decreases slightly before ramping up again. The difference between the beginner and advanced versions are the quarter mile repeats. Repeats are a great way to increase speed.  They are also a great way to get injured if you have not been running for a year or so. Proceed with caution. The beginner program includes much more rest and less speed work to emphasize the fact that building raw endurance is the primary aim to making sure you can go the distance on race day.


There are virtually thousands of different variations on the themes that we have created here. You can find many different training schedules in books, running magazines and online. The key to finding a race program that works for you is to make sure that the person who designed it shares the same philosophy as you. Some trainers think that you should run the entire race without any rest at all.  Others think that it is a good strategy to walk through the water stations only. There are still other proponents of walk, run programs where you may run four miles and walk one mile throughout the race. 

Regardless of which type of program you choose, sticking to the training s the most important step you can take to making sure that you can have a successful event come race day.



Dr. Christopher Segler is an Ironman Triathlete and award winning foot and ankle surgeon with a podiatry sports medicine practice in Chattanooga. He specializes in running injury prevention, sports medicine and surgical treatment of elite athletes. You can learn more about common causes of foot pain while running as well as sign up for a FREE monthly newsletter with tips to increase your running speed and efficiency at http:www.AnkleCenter.com or http://www.MyRunningDoc.com