Will orthotics help heel pain when running?

This morning I received an inquiry from a runner in Marin who is training for the Dispea. He asked a common question:

"I have severe left heel pain especially after a 5-8 mile run. I am training for the Dipsea. Advice? Should I consider orthotics?"

Answer:
Custom orthotics can certainly help to alleviate many forms of heel pain including the most common type which is plantar fasciitis. Custom orthotics in fact are one of the best ways to slow do pronation and decrease stress to the large ligament on the bottom of the heel called the plantar fascia. If you over-pronate and repeatedly tug on the plantar fascia as your arch height changes, you get inflammation of the plantar fascia... known as plantar fasciitis.

A long run can place a tremendous stress on the plantar fascia and the heel bone. Most people with plantar fascitis will have pain in the bottom of the heel on days following running. Usually the pain is worse with the first couple of steps when they get up out of bed. They can also get a sharp pain in the heel when they start walking after sitting at a desk for a while.

Custom orthotics are one of the best treatments for this type of running-related heel pain. But that doesn't necessarily mean that it is best to get custom orthotics and keep running. You must get an evaluation with a running focused podiatrist first.

The concern is that you might have something worse than plantar fasciitis. In this case, the runner reports heel pain that is "severe" following long runs. Plantar fasciitis would usually be worse (and more annoying) the day after a long run, but not necessarily severe. It would be important to get x-rays and take a look at the heel bone (calcaneus) to be certain that you are not at risk for stress fracture in the heel bone (calcaneal stress fracture).

It is also possible that there is a cyst in the heel bone that is causing the problem. In the simplest of terms, a calcaneal cyst is a hollow or fluid filled pocket that develops within the heel bone. When running, the walls of the cyst can flex slightly causing pain and inflammation in the heel bone itself. In some cases the heel bone can flex so much that it cracks or fractures. This is actually much worse than a calcaneal stress fracture.

With a quick set of x-rays and an exam by an experienced running podiatrist, heel pain can be effectively treated. With all of the conditions that effect the heel, the sooner the best treatment is chosen and starts, the faster you will finish your goal race, wether it is the Dipsea, the Vineman or the San Francisco Marathon.


Dr. Christopher Segler is an Award Winning Foot & Ankle Surgeon, 5-Time Ironman Finisher and a sports medicine podiatrist who makes house calls for busy runners, triathletes and active professionals in San Francisco, Marin, the East Bay and the Peninsula. If you have a question about running related heel pain, you can call him directly at (415) 308-0833. You can also learn more about custom running orthotics at AnkleCenter.com and DocOnTheRun.com.

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Custom Orthotics For Runners by San Francisco Podiatrist

Running places a tremendous amount of stress on the feet and legs. When you train for a marathon, the goal is to create just enough stress to stimulate an increase in running endurance without so much stress that an injury results. Running injuries like shin splints, stress fractures and tendonitis are common as mileage and intensity increase during training.

Slight imbalances in the foot and ankle can result whenever there is too much pronation. Other mailalignments (such as a forefoot that is slightly tilted relative to the rearfoot) can lead to increased stress to certain bones in the feet. At the same time, any of these biomechanical problems can increase tension and overuse of tendons that lead to tendinitis.

Although I get lots of requests to make orthotics for marathon runners and triathletes here in San Francisco, I am often surprised how many athletes don't really understand what an orthotics is and how it works. A custom orthotic made for a runner is not just an arch support or a shoe insert with extra cushion. Custom orthotics are custom made footbeds (custom built based on a foot doctor's prescription) that control abnormal motion and correct mechanical imbalances.

You can learn more about custom orthotics on our website or by simply watching the video below.



Dr. Christopher Segler is an award winning foot doctor practicing podiatry and specializing in running biomechanics in San Francisco. He specializes in house calls to help busy athletes who don't have tim to get the foot doctor. He makes housecalls all around in San Francisco, Mill Valley, Palo Alto, Berkeley, Corte Madera, San Rafael, Oakland, and San Jose. If you are a runner with a history of nagging injuries, arch pain, flat feet, or tendonitis, he can come right to you to make your custom running orthotics that will not only decrease your risk injury. If you just have a question about custom orthotics made for runners, you can call Dr. Segler directly at 415-308-0833.

Do I Have Gout in the Big Toe Joint

Gout is one of the most painful conditions I see as a Podiatrist in San Francisco. Usually gout attacks the big toe joint. The question is, how do you tell if you are having an attack of gout in the foot?

When gout happens the first thing you will notice is pain, swelling and redness around the joint. In the foot this is most often the base of the big toe in the joint podiatrists call the "metatarsaophalangeal joint." Gout can happen in any of the joints in the foot, but usually it the big toe joint.

When gout develops, you get uric acid crystals forming and being deposited in the joint itself. If untreated, the crystals may continue to form and lead to the buildup of a chalky paste-like substance called tophi. You can see the huge lump on the bottom of the big toe joint in the picture above. All of that is uric acid crystals in the joint.

Because these sharp needle-shaped crystals end up in the joint, it can be incredibly painful to move the joint. Every time you move the big toe, it is like having a thousand little needles poking the inside of the joint. This of course hurts.

In response, your body reacts with inflammation. That is where the classic pain swelling and redness comes in. The foot will be warm to the touch, red and very painful. Many gout sufferers will say they can't even have a bed sheet touching the foot because it is so painful.

The biggest problem with trying to tell if you actually have gout is that gout mimics two other conditions: infectious arthritis and Charcot. Charcot arthropathy is an emergency that can look like gout, but is actually more serious. It is most common in people with diabetes. Infectious arthritis is where bacteria (instead of uric acid) is invading the joint. Both of these are emergencies. With either, it is important to start treatment right away to prevent further damage and the potential for losing the foot to an amputation.

Many people who have had multiple attacks of gout can seem to tell when it is coming on. However, if you have never been diagnosed with gout, it is important to see a foot specialists who can make sure you don't have a more serious condition.

The most accurate way for your podiatrist to diagnose gout is through a small procedure called joint aspiration. In this way, the uric acid crystals in the joint can easily be identified. More importantly, your foot doctor can rule out a bacterial infection. Blood tests and x-rays may give clues that you have had gout, but can be unreliable if used alone to diagnose gout.

Once you have been diagnosed with gout, your podiatrist will likely make recommendations on modifying your diet to prevent it from happening again. You can view our recommendations on a Gout Diet here. If you are given a prescription to treat the gout, you will be given written instructions that you should follow closely.

Dr. Christopher Segler was selected in 2010 as one of "America's Top Podiatrists." He has a podiatry house calls practice in the San Francisco Bay Area. To learn more about gout, visit the Gout page on our website. If you have gout and need pain relief right away, he makes podiatry emergency house calls 24/7. If you think you might have gout and would like to speak directly with him to ask a question, you can call him (415) 308 0833.

Ironman 70.3 California Race Report by San Francisco Sports Medicine Podiatrist

On Saturday March 27, 2010 I officially started the triathlon season with my first half Ironman.

The Rohto Ironman 70.3 California in Oceanside, CA is one of the most popular events on the 70.3 circuit and this weekend I got to find out why.

Given that I have competed in many full Ironman distance triathlons (but no half-Ironman events) I really only had three main goals for this race:

1. Finish injury-free! (bad form for a podiatrist to get injured while running)
2. Finish in 5 hours 30 minutes or less.
3. Test the engine and see what I need to do to prepare for the 2010 Ironman season.

PRE-RACE DAY:
Early that morning I went out for the obligatory short ride and transition run. It felt great to loosen up all of the 8-hour car ride stiffness sustained from the drive down from the San Francisco Bay Area. The weather was perfect! I picked up my registration packet and went back to the room to meet Paige and Alex and go for a swim with my favorite 2 year-old.

Because the swim portion takes place in the Oceanside Harbor, athletes are not allowed to swim at the site before race day. No big deal as swimming is swimming and it all looks pretty much the same on race day… arms, legs, and churning confusing.


Because the bulk of the bike leg winds through Camp Pendelton, competitors are not allowed to ride on the bike course. This would be the first race where I would have basically know clue of what to expect on the bike.

I just figured I would treat it like one of my group rides in Marin with my biking buddies in the Bay Area. I usually don’t really know the routes I am being led on when we head somewhere new, so this should feel similar. I’d try to just take it as it comes and pay attention to my heart rate and perceived exertion.

RACE DAY:
We rented a condo right by the harbor which made race morning stress-free as can be. Up at 4:00 a.m., peanut butter and jelly sandwich down, make coffee, shower, get dressed, pump up bike tires, fill aerodrink bottle, gather gear, etc.

It seems like every race lead to some item forgotten in transit to transition, and this was no exception. I had everything meticulously organized. But just as I was headed out of the door I realized it was cold and decided to put on a fleece jacket. In doing so I forgot to put my backpack on again.

So I headed out into the dark and streamed in line with the other 2300 or so athletes heading to transition. I found my spot and racked the bike. When I got ready to lay out my running gear, I realized the conspicuous absence of the back pack.

No big deal as the condo was only about ¼ mile away. I did a warm-up jog back to the condo and grabbed the back pack. Paige, Alex and I then headed back to transition so I could add my towel, running shoes, hat and number belt to the #589 pile in transition.

With everything in place, just had to wait for the start.


SWIM 1.2 MILES:
The goal for the swim was simple. Relax and swim 1.2 mile in 40 minutes without getting worn out or beaten up.

My swim wave was relatively early and I got to start right at 7:00 am. The cannon went off and away we went. The water was clean, clear and way warmer than San Francisco Bay! It seemed like no time before I was rounding the red turn buoy at the mouth of the harbor. I drafted a little, but mainly tried to stay clear or the flailing arms and kicking feet that surrounded me.

When I got back to the boat ramp, I checked my watch and saw success! Swim time of 39:33, no black eyes, and no one kicked me in the head. I felt great knowing I could get out on the bike without having to extract an impacted earplug (at least this time).

Transition 1:
After the 600 foot long run in a wetsuit, I made it to the bike. Stripped the wetsuit, put on my socks, helmet, Garmin, sunglasses and away I went!

BIKE 56 MILES:
The bike course was great! Lots of gentle rollers, some big long climbs interspersed with plenty of flat stuff where I could get on the gas. I can say with confidence that the course is beautiful as it wind through the Marine Corps base. Big green mountains, wildflowers and blue ocean dominate. There is also the occasional “Tank X-ing” and “Live Fire Zone” signs just to remind you where you are. The soldiers volunteering on the base provided (no surprise) perfect order and execution at the aid stations.

I kept a constant low-stress level on the bike course. I went hard, but easy enough that I knew I could still run the half marathon. After 2 hours 45 minutes and 9 seconds (20.35 mph average) I was back in Oceanside and ready to run.

RUN 13.1 MILES:
The run course is a mostly flat out-and-back two-loop affair. The best part was that it runs along the ocean and passes directly in front of the condo where I could see Paige and Alex waiving and cheering from the balcony.

I really wanted to make sure I finished in under 5:30 total. So after some quick math I knew I could coast in as long as I maintained an average pace of 9:00 per mile for the entire half marathon. I went about 9:30 min/mile pace for the first mile to try get moving and loosen up my legs. Then I started to gradually increase the pace.

About two miles from transition I saw my old motorcycle road-racing partner Fred Provis cheering for me out on the course. Fred is one of those guys who can make anyone feel like a champion. He definitely put a spring in my step. The next few miles felt much better. By the first turn around I knew I would make the finish on target.

By the second lap I was in a comfortable groove. I fought the urge to push the pace knowing that I might invite injury, or blow it and end it walking. Given that I had a goal of getting a qualifying slot for Ironman Arizona (as well as doing Ironman Canada five months from now) I knew I should be sensible and just keep the pace steady.

About a quarter mile from the finish I realized I was still slowly creeping up on another guy in my age group. I had been behind him for about 5 miles. For some reason passing him suddenly seemed important.

Right after I crossed the bridge to the harbor, I kicked it in high gear and shot past him. Confident that I was far ahead, I slowed down. Next thing I knew he flew by on my right as we entered the last 50 feet of the finish shoot. I started chasing him as he peered back at me over his right shoulder.

I was picking up speed as we approached the finish line. Then the poor guy suddenly stood bolt upright, grabbed he right hamstring and started limp-running to the line just ahead of me. When I crossed the line he was holding onto a volunteer with one hand his his hamstring with the other. I patted him on the back and said “You reeeeeeally earned that one!”

My total time was 5:29:42. I made my goal with 18 seconds to spare. And most importantly (unlike the guy in front of me), I was injury free. Best of all, I went to watch the roll down... and secured my Ironman Arizona slot. See you in Tempe in November!

Let the training begin...


Dr. Christopher Segler is an Ironman triathete, marathoner, and an award-winning Sports Medicine Podiatrist in San Francisco. He has written extensively on the subject of podiatric sports medicine and running injury prevention. His San Francisco Podiatry practice focuses on house call appointments for busy professionals and athletes who want to prevent or recover from running injuries. He offers the convenience of podiatry house calls at Bay Area homes and offices so that his clients don’t have to lose time going to the doctor or getting custom orthotics. You can learn more about common running injuries at AnkleCenter.com and Doc On The Run.com.

San Francisco Podiatrist on Difference Between Heel Pain and a Heel Spur

Heel pain is the most common form of foot pain that causes people in San Francisco to make an appointment with a podiatry clinic. In fact, nationwide, about 40% of all visits to podiatrists are due to heel pain diagnosed as plantar fasciitis. As a podiatrist in San Francisco myself, the thing that I find interesting is that most people with plantar fascitis think they must have a heel spur to have heel pain. But that’s not always true.

So what is the difference between plantar fasciitis and a heel spur?

To begin with, let’s explain how to tell if you have plantar fasciitis. Anyone with plantar fasciits will have pain in the bottom of the heel or in the arch. In most cases this pain is worse when you get up and step out of bed in the morning. The heel may also hurt when you get up from your desk after working at a computer for a couple of hours.

As you start to walk, the first step is usually a sharp pain or sudden ache in the bottom of the heel. After a few steps, the heel pain starts to subside and feels better. In many cases, it may not even hurt at all while you are walking around or even running. But when you sit still and get back up again to start walking, that’s when the heel pain returns.

If you have this kind of morning heel pain and simply push on the bottom of the heel (and it hurts) you most likely have plantar fasciitis.

Many people in the San Francisco Bay Area seem to believe that heel pain is due to a sharp heel spur poking down and causing pain. But in fact about half of all people who have this kind of heel pain don’t have a heel spur at all. And about half of people with no heel pain, happen to have a heel spur that will show up on x-ray. So the two problems aren’t necessarily related.

The most common cause of heel pain is plantar fasciitis, which is simply inflammation of the plantar fascia. The plantar fascia is a big ligament attaching to the bottom of the heel and extending out to the toes. If you put too much stress on the plantar fascia, it can become inflamed where it attached to the heel bone.



With improper biomechanics, such as excessive pronation (flat feet that roll inward as the arch collapses) the plantar fascia ligament may tug away at the heel bone. With tension applied to the plantar fascia, the attachment may cause the heel spur to form.

The way this happens is that the ligament pulls the covering (called the periosteum) of the heel bone away. A small blood clot forms and then becomes calcified as it heals. If this happens again and again, the heel spur gradually grows. Because the heel spur is caused by the pulling on this big ligament, you can understand why a heel spur points out toward the toes and not down toward the ground.




Any podiatrist in San Francisco can simply take an x-ray of your heel to tell whether or not you have a heel spur. But the reality is, it doesn’t matter.

In the last 7 years, I have only surgically removed 2 heel spurs. Both of them were broken and wouldn’t heal. One was an young ironworker in San Francisco who fell off some scaffolding while working on the Golden Gate Bridge retrofit project. The other was a woman in her sixties who has some osteoporosis and broke the heel spur while doing high impact aerobics.

But most people with plantar fasciitis can get better on their own, even if they have a heel spur. In the vast majority of cases, spending a few minutes doing our San Francisco Podiatry Heel Pain Recovery Stretches will make the heel pain go away. The spur just simply doesn’t usually need to be removed in surgery.

Dr. Christopher Segler is a nationally recognized expert on conditions affecting the heel bone. In 2006 he was awarded 1st Place at the National Meeting of the American Podiatric Medical Association for his research on diagnosing heel bone infections with magnetic resonance imaging (MRI). He offers podiatry house calls in San Francisco for busy athletes and people who just think it is ridiculous to take half a day off work just to see a foot doctor. You can reach him through Doc On The Run: San Francisco Bay Area Podiatry House Calls.You can also learn more about the causes and available treatments for heel pain at AnkleCenter.com.

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San Francisco Podiatrist Posts Video on 1 Hour Ingrown Toenail Relief in San Francisco

Ingrown toenails are easily the most common reason that a podiatrist will see a doctor for pain in the toe. Ingrown toenails can be prevented with some simple tips:

1. Cut normal nails straight across.
2. Keep your nails just shorter than the end of the toe.
3. Avoid shoes that cramp the toes.

The most common way people cause ingrown nails is by cutting them too short. This is often in an attempt to relieve a painful ingrown nail before it becomes infected. Unfortunately, this usually backfires. But even if you try to take it out and make the ingrown toenail worse, you can still get relief. This video explains how you can get ingrown toenail relief in San Francisco in only about an hour, even without going to a podiatry office.





Dr. Christopher Segler is a San Francisco Podiatrist and toenail surgeon. He treats podiatry emergencies (such as ingrown toenails) like they really need treatment now. He drives around San Francisco seeing patients at home, in their offices or even tourists on vacation in their hotel rooms. No one needs to suffer with a painful infected ingrown toenail. If you need immediate relief from an ingrown toenail in only an hour, you can reach him directly at (415) 308-0833. You can learn more about ingrown toenails at San Francisco's Podiatry House Call Site and San Francisco's Best Podiatry Patient Information Site

Training With a Heart Rate Monitor...How To Get Results

Your capacity for exercise and endurance is limited by the rate at which you can deliver oxygen to your muscles. Although training does condition your muscles to move you over the road at a faster rate and longer distances, it is the condition of the heart that needs the most attention for longevity and continual gains. Just as you monitor your run times to gauge overall performance, it makes sense that any endurance athlete would want to monitor and hopefully train the primary pump that runs the whole system.

Heart rate monitors were created to observe, measure, and record the heart rate. With a heart rate monitor an athlete can easily track progress in training the cardiovascular system to efficiently deliver oxygen to her muscles as she runs.  The simple act of measuring something will almost always improve its outcome.

There are three basic goals runners seem to shoot for 1) running at a faster pace over a given distance, 2) running a longer distance while maintaining a certain pace, 3) increasing fitness to be healthier and hopefully live longer. Increasing the efficiency of your heart can help all three.

There was a time when a heart rate monitor was perceived as a highly advanced gizmo reserved for the pros. Today at road races all over the world, they are as common as a wristwatch. In many cases, they are one and the same. Most heart rate monitors combine the features of a wrist watch, stop watch, etc. with a chest strap that records data from the heart and transmits it wirelessly to the wrist where you can get real time feedback about your heart rate. 

In training you should think of your heart rate monitor as the tachometer in your car. You need to know what the normal idle speed rpm is (Resting Heart Rate (RHR)) as well as the redline rpm (Maximum Heart Rate (MHR)). Once you know the numbers, you can watch the tachometer, make sure you aren’t just idling, but be sure not to redline either. 

Your MHR (redline) is basically fixed and will decrease about 1 beat per minute per year. You can figure out what that is today by testing the motor. Keep in mind that this should never ever be attempted without consulting your primary care doctor or cardiologist first! This is not a joke. You can die of a heart attack if you have a heart condition attempting to run your heart rate up during the MHR test.

Once your doctor gives you the “okey dokey” put on your heart rate monitor and find a hill 200-300 meters long. Warm up with some easy jogging. To find your MHR, sprint up the hill and jog down. This is an all out effort up the hill.  The only rest you get is the slow log back down the hill. Complete six laps up and down. The highest number you generate is your MHR. 

Next you need to figure out your RHR (idle speed). This is an indicator of your fitness and it will decrease over time as your develop a higher level of fitness. If you are a 400 pound couch pilot who’s idea of exercise is wrestling a bag of pork rinds from the clutches of your spouse, your RHR may be 100. If you are Lance Armstrong, it may closer to 30.  Most well conditioned runners are somewhere in the 50’s or 60’s.

You figure out your RHR number by putting on your heart rate monitor before you get out of bed. Just lay there and rest for two or three minutes and record the lowest value. Try it on several consecutive days. Stress, illness, dehydration and caffeine can all artificially elevate your RHR. 

Once you have those two numbers you can figure out your training zones. Most heart rate monitors come with a chart to help you figure this out. There are many online calculators as well. If you are old school, you can do the math:  ((MHR-RHR) x Percent level) + RHR = BPM. For aerobic (increasing distance) training stay in the 70-80% range. For hard workouts stay in the 80-90% range.

Now you can go train! As you watch your heart rate monitor you can adjust speed, effort and energy output. Hard days (such as intervals and tempo runs) should be at about 85% of your MHR. The hard training days have the most effect on training your heart to pump harder and more efficiently, eventually leading to reductions in your RHR. This is where tempo runs and intervals come in. Just don’t do hard days back to back. 

If you figure out your training zones and make an effort to stay within them, you will improve. When your RHR starts to go down, you will feel it. You will be able to run the same distance with less effort. You will be able to cover the same distance in less time. This is because of the increased efficiency of the heart. It simply improves with exercise and gets worse with disuse. Elite runners have hearts than can pump more blood with each contraction. Because it moves more blood with each contraction, it has to contract less often to pump the same amount of blood through the system.  That is why their heart rate might be in the low 30’s while sitting still.

The type of monitor you choose is as personal as running shoes. Pick the features that will help you train. They range widely in features and price. You can get one for way less than $100 but you can also spend several hundred dollars if you choose. I train with one that also includes a GPS unit and a cadence sensor. This way I can track not only my heart rate, but also my pace, terrain or even cadence (if on the bike). The only thing it doesn’t record is temperature and humidity. Keep in mind that your heart rate is affected by temperature, humidity, stress, exhaustion and other environmental factors. Don’t freak out if it seems a little off when training conditions change. 

One other limitation of heart rate monitors is that they can have a slight delay. This means that during a long run, if you pass over a hill, the rate may continue to go up for a short time after the hill is done. This isn’t really a delay in the device, it is just your heart trying to catch up with the effort. 

Having said that, heart rate monitors are an extremely valuable training tool. Not only will one allow you to train more effectively by staying within the appropriate training zones, but it will also allow you to document progress. Because endurance sports take so much time and commitment, any clear evidence of progress can provide additional motivation to put your running shoes on and head out the door the next morning. 

Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His Bay Area Sports Medicine Podiatry practice offers 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 or www.MyRunningDoc.com.