Can I run a marathon with a metatarsal stress fracture?

Hello Running Doc,

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

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

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

Thanks for any advice!
Erin M.
Oakland, CA

👉 Need a complete plan to heal your stress fracture and keep your fitness?
Click here for the full stress fracture guide for runners

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

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

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

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

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

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

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

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

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


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


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

Can I play basketball with these blisters?

Question:
Hi MyRunningDoc!

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

Thanks!
JM

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

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

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

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

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

 

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

 The painful area is outlined on the pad.

The outlined area over the blister is cut away.

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

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

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

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



 

How Can I Tell if My Foot is Broken?

Hi My Running Doc,

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

Thanks!

David, Houston, Texas.

👉 Need a complete plan to heal your stress fracture and keep your fitness?
Click here for the full stress fracture guide for runners

Hi David, 

Bruising is a Bad Sign

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

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

Myths about Foot Fractures

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

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

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

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

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

Diagnosis and Treatment Options

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

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

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

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

What to Consider in a Minimalist Running Shoe

Hi “My Running Doc!”

I recently read the book “Born to Run.”  after reading it, I became intrigued and have decided to try some minimalist running shoes. However a lot of stuff that I read online says that might get injured if I run barefoot or in minimalist shoes. 

As a little background, I am experienced marathon runner and have been running for decades. I have a neutral foot type and never had any serious running injuries. 

Do you have any recommendations on how to safely choose minimalist running shoes so I can run with a more natural running form to convert to more of a minimalist style?

Thanks!

Peter

San Francisco, CA

Hello Peter,

Great question!  There are a number of different types of minimal running shoes that  you can choose from.  But before you can make a reasonable choice on which you would be right for you you have to understand the basics of “minimalist shoes.”

I define a minimalist running shoe as one that has lightweight construction, minimal support and a decreased forefoot to rearfoot drop. 

In case you’re not familiar with minimalist running shoe construction is important to point out that the “ forefoot to rearfoot drop” is the difference in height of the heel as compared to the forefoot. Standing barefoot is a 0° drop.  A running shoe with a zero-degree drop is flat. Any shoe that has no more supporting material under the heel than under the forefoot will have a 0° drop. 

A standard running shoe has a 12 mm drop. This means that there is 12 mm of material under the heel, lifting the heel up relative to the forefoot.  Proponents of minimalist running argue that all this extra material under your heel is what forces you to land as a heel striker when you run in these type of running shoes.

Vibram FiveFingers® are the shoes that many people think of when they hear about barefoot running.  The argument for this type of shoe is that you get the most sensitive ground feel, and hence a running experience that is the most consistent with true barefoot running. However you are protected by a pliable rubber outsole. These shoes certainly fit the criteria of a minimalist shoe in that they have very little support, they’re very light weight and they have a zero-degree drop (meaning the heel is no higher than the toes.) 

Given that most people are accustomed to walking and running in shoes that have a slightly elevated heel, they can at risk of injuries like Achilles tendinitis and even potentially stress fractures if they switch to rapidly to a barefoot running style.

There are other shoes however which will help you learn how to run without the drastic change in forefoot to rearfoot drop.  Another extremely  popular minimalist running shoe is the Saucony Kinvara. The Kinvara has a 4mm drop, is very light (7.7 oz.) and is very supple.  it allows a good ground feel and lends itself the natural running form however it still maintains a modest amount of support. It allows a bit of insurance in the sense that if reform starts to fall apart and you begin to convert into a heel striker you at least have some cushion to protect you.

Another good option is Newton Running shoes. Newton’s are unique in that they have elastomeric lugs under the forefoot that help encourage you to land as more as a forefoot or midfoot striker.  For a neutral runner like yourself, the Newton Gravity Trainer would be a good choice. It weighs 9.1 ounces and has a 3mm forefoot to rearfoot drop. Newton running shoes are designed specifically with the intent to help runners learn how to convert to more of a natural running style. In fact Danny Abshire, the founder of the company is also authored a book which helps teach runners to convert their running style away from heel striking to potentially more efficient stride. 

I think Danny has the right approach. I myself run in Newton running shoes for speed workouts and for tempo runs.

However I also incorporate a couple of different kinds of running shoes based on the workouts that I am doing. I run in Kinvaras for some moderate runs.  I also run a more of a typical cushioning type of running shoe when I do long runs, or any run where I expect that I might walk. Reason for this is simple. Most people it is spent their lives in elevated heel shoes can develop a tight Achilles tendon. Walking in shoes with a 0° drop can lead to Achilles tendinitis quite rapidly. As someone who trains continually and almost always has an Ironman on the schedule I can afford to develop any issues. I consider using multiple types of running shoes as cross training for my feet. I believe it decreases the risk of injury.

If barefoot running form is a new adventure I hope you will find it to be helpful in developing a more efficient stride and ultimately a more enjoyable running experience. 

Dr. Christopher Segler, DPM is a marathon runner, 11-time Ironman triathlon finisher and is Board Certified,  American Board of Podiatric Medicine.  He lectures at medical conferences to help teach other podiatrists and sports medicine doctors about barefoot running biomechanics and the treatment of competent running injuries. His practice is limited to runners and triathletes. He performs remote consultations for runners all over the world via telephone and Skype. He also sees patients in person in both San Francisco, CA and Houston, TX.  If you have a question about a running injury that doesn't seem to be getting better, you can reach him directly at 415-308-0833. 

Heel Blister: To Pop or Not To Pop?

 

Hi Dr. Segler,

I've had this blister on my heel for the past three days and it has gotten slightly larger.  I'm wondering if I should allow more time for it to heal or pop, drain, etc?  What's the fastest way to get it healed?

Sincerely,
Ryan M. 
San Francisco, CA

Answer:

Hello Ryan,

A blister on the inside of the heel can be painful when running or even walking.  If you are currently training for a marathon, the last thing you want to do is stop running just because you have a blister on your heel.  But obviously the blister has to stop getting bigger before it is going to heal.

There are only a couple of reasons that a blister continues to get bigger.

1. Friction. If you are continuing to rub the inside of the heel in the same way that cause the blister to form in the first place, the blister will continue to get bigger.

2. Compression. If you repeatedly press on the blister,  the fluid with in the blessed blister will try to disperse outward. Since the fluid is all contained inside the blister, this will continue to separate the layers of the skin from the pressure applied to the blister when the fluid tries to move. This causes the blister to continue to enlarge.

The redness at the border of blister tells me that the fluid is being compressed and further separating the layers of the skin (indicated by red arrows). This of course hurts and makes the heel blister bigger.

If you pop or drain the blister, it will increase the risk of infection. If you pop (or drain) the blister it will feel slightly better in the short term, but it might take slightly longer to completely heal.  As long as all of the irritation to the blister is removed, your body will resorb the blister fluid and heal the blister.

The blister in these images appears to be flat enough that it could be offloaded with some simple pads that could be obtained from a local pharmacy.  The idea is to place felt pads around the blister. By removing the pressure that is being applied to the blister when you walk, it will stop enlarging and it will start to calm down.

If a pad is applied to the heel, it will place all of the pressure around the blister, instead of on the blister. This will significantly decrease both the compression and friction of the blister.  If the oval pads that you find at the pharmacy are not large enough, you can simply cut two of them in half and then apply two separate half-oval pads to completely surround and protect the blister.

Here is an image of the proper pad placement with the red area indicating a blister:

Once the blister has completely healed your next task will be to identify the cause of the blister.  Obviously will not want this to happen again. If you have just gotten a new pair of shoes you want to make sure to break and then more gradually the next time. If your shoes were to loose, obviously want to tie them slightly tighter so that your heel isn't sliding around inside the running shoe. And if the blister happened after running a race (where you were dumping water on your head to stay cool) or from running in the rain, you want to make sure that you avoid getting your feet as wet the next time.

Heal that heel fast so that you can get back to running!

Dr. Christopher Segler, DPM is a runner, 11-time Ironman triathlon finisher and is Board Certified,  American Board of Podiatric Medicine.  His practice is limited to runners, triathletes and other active young adults. He travels frequently lecturing to other physicians at podiatry conferences about the treatment of complicated running injuries.  He performs remote consultations for runners all over the world via telephone and Skype. He also sees patients in person in both San Francisco, CA and Houston, TX.  If you have a question about a running injury that doesn't seem to be getting better, you can reach him directly at 415-308-0833. 

Marathon Blister. Should I pop it?

Question:
Hi MyRunningDoc!


I have been reading your site. This blister formed on my heel yesterday. It is huge and painful. I am running in the Avenue of the Giants Marathon on May 5, 2013 and really can't take a break from marathon training. Should I pop it?

Thanks!
W.H., San Francisco CA

Answer:
Thank you for your inquiry! That is certainly a Giant of a marathon blister. I can see how that would hurt and put a damper on your final marathon training.

There is always an advantage and a disadvantage to draining in any blister on the foot that pops up during training.

With a blister that large and a marathon that close, it is unlikely that you would be able to run the marathon without significant pain. In fact the blister is so big it would probably pop during the marathon anyway.

With most small blisters, it is typically better to let them go away on their own. If you do not drain a small blister and can keep it from getting rubbed when you are running, the fluid will gradually recede and the blister will re-adhere. It will eventually peel away revealing healthy skin underneath. It is also the least likely to get infected because you don't open the blister allowing bacteria to get inside the skin.  This actually will heal the fastest and is the safest approach.

Things get tricky when a running blister on the foot gets big.

When you have a big running blister that causes a great deal of discomfort when you run, it actually hurts because the fluid is getting pushed and compressed.  If you step on a water balloon, the balloon will squish outward under your foot. The balloon will push out and stretch as far as it can unless it pops.

So when you run on a blister like this one pictured here, the blister fluid actually pushes and continues to separate the layers of skin at the edge of the blister. This of course causes more irritation and more fluid accumulation, making the blister even bigger as you continue to run.  The only way to stop this process is to stop irritating the blister on the foot. One way to do this of course is to stop running.

If you can pad the blister and keep the pressure off of it you might be able to continue training without the blister getting any bigger.  That would be hard to do given the location of this blister on the inside of the foot and heel. It will be almost impossible to remove all the pressure from the heel inside the running shoe.

If you pop the blister, it will hurt more for the first day or two.  You can decrease the amount of discomfort by using moleskin or another type of blister cover that will stop the friction from rubbing the overlying skin. It may also be helpful to put some padding around the blister in order to decrease irritation.

If you decide to pop your blister, it is always best to drain the blister by making a small hole at the bottom edge of the blister down toward the bottom of the foot so that the fluid will continue to drain downward and out of the blister as it re-accumulates. Typically some more blister fluid will accumulate inside the blister for several days after you pop it.

The skin on the top of the blister is not what is painful. It is the skin underneath. Some people start to drain the blister and realize this and then trim off the entire top of the blister. If you are to do that in this case, it would leave an open sore about the size of a half dollar. This would of course leave an enormous raw spot that would be very painful whenever you run during training. You foot would be killing you during the marathon.

In these types of cases it is often better to simply drain the blister and leave the top of the blister intact to function as a biologic dressing. This will take slightly longer to heal than if you don't drain the blister.  However this assumes that you are of course going to continue to run, train and complete the marathon that you have planned.

It would be best to be evaluated in person or by a podiatrist or arrange a remote consultation with a running injury expert in order to get more detail, before making your final decision.  You can also learn more about blisters from running by clicking here.

Dr. Christopher Segler, DPM a marathon runner, podiatrist and 10-time Ironman Triathlon finisher who is is Board Certified, American Board of Podiatric Medicine.  He believes the best podiatry practice combines cutting edge technology with the old-school convenience of house calls. He makes podiatry house calls for runners in San Francisco, CA and Houston ,TX. He also does remote consults for runners who live outside of the United States. If you have a question, you can reach him directly at 415-308-0833. You can learn more about running injuries at www.DocOnTheRun.com 

I have Achilles Tendinitis and it hurts when I run. Can I do Yoga?

Hi Running Doc!

Question:  I have Achilles Tendinitis and it hurts when I run. I stopped running and have been trying to get the Achilles to heal. But I still want to exercise to stay fit and sane. I like Bikram Yoga. So my question is: can I do yoga without risking further injury to my Achilles tendon?
                        Thanks!
                        Aching Achilles in Berkeley.

Answer:  As a runner and sports medicine podiatrist, I firmly believe that injured runners heal fastest when they remain as active as possible.  This true for Achilles injuries as well.


The key with the Achilles tendon is making sure that the tendon is healing and that no further damage is taking place. Continued damage to the Achilles (such as repeated micro-tears) is what leads to tendinosis. Achilles tendinosis always precedes an Achilles tendon rupture.

In most cases of Achilles injury in a runner, there is a period of severely reduced activity. Sometimes a Platelet Rich Plasma (PRP) injection may even be necessary to stimulate healing. In the very worst cases, Achilles tendon surgery may even become necessary.

But once the injury is reversed and healing begins, it is important to get back to activity. If you are at the point where your doctor thinks the tendon is on the mend, it may be OK to add some Yoga to your routine.

With a healing Achilles tendon Yoga is mostly OK. However, there are a few Bikram yoga poses that are concerning, and should be avoided such as:
Garudasana (Eagle Pose)
Dandayamana - JanuShirasana (Standing Head To Knee Pose)
Dandayamana - Dhanurasana (Standing Bow Pulling Pose)
Tuladandasana (Balancing Stick Pose)
Tadasana (Tree Pose)
Padangustasana (Toe Stand Pose)

None of these poses are really likely to rupture the Achilles if done flawlessy. The problem is that if you have your Achilles completely taught (while attempting these poses) and then begin to lose your balance, it may be more than the tendon could take.

If you are doing Hatha Yoga, you should simply keep the risky poses mentioned above in mind and then sit out or modify any Hatha poses that your feel would put your Achilles in a precarious situation.

It is a great question! With any running injury the big trick is not just stopping activity, but being creative in identifying the activities you continue to keep the blood flowing, the mind calm and the healing in progress.

Dr. Christopher Segler, DPM is a sports medicine podiatrist and 10-time Ironman triathlon finisher. He is Board Certified, American Board of Podiatrc Medicine. His sports podiatry practice is limited to runners, triathletes and endurance athletes with complex injuries. He specializes in running injuries that don't heal with the conventional "just stop running" approach. His practice is unique in that he offers remote consultations all over the world via Skype. He travels constantly and is available to treat frustrated injured runners in person in both San Francisco, CA and Houston, TX. If you have an injury that isn't getting better, you can call him directly at 415-308-0833 or 713-489-7674. 

SF Tri Run Clinic: Foot Issues

Thanks to everyone from the SF Tri Club who joined us Monday evening for the Run Clinic. This was the second clinic in a series designed by Dino and Katie (our fearless Run Coordinators).

The point of the clinic was to discuss some of the keys to training that might help one avoid injury, particularly those running injuries that can wreck a triathlon season. We talked about running shoe selection, common training errors and barefoot running biomechanics.

There were many great questions from our Peeps. I will be posting those questions here, with answers, for all those who could not make to the Presidio Sports Basement for the clinic.

In fact, here's one now...

Question: What ARE the most common preventable running injuries?

Answer: The most common injuries I see in San Francisco runners and triathletes (that are preventable) are:
1. Stress Fractures
2. Achilles Tendinitis
3. Plantar Plate Injuries
4. Peroneal Tendintis
5. Sesamoiditis

See you out in the water, on the track, or on the road!

Dr. Christopher Segler is an SFTRi Club member, 10-time Ironman Finisher and Sports Medicine Podiatrist. He is Board Certified, American Board of Podiatric Medicine. His practice caters to active runners and triathletes in San Francisco, Berkeley, and Mill Valley. If you have a question about a running injury, you can call him directly at 415-308-0833.

Review of the Ruster Sports Hen House Bike Case

I love to race in Ironman Triathlon events. I don’t know why, but I do.

I hate to travel to Ironman races, and I do know why.

I love my bike and I don’t like to be separated from it for the two week period surrounding a race. Historically, I have always used Tri BikeTransport to get my bike to and from races. It is a great service. They will get your bike safely from your home city to the Ironman event with a minimum amount of hassle.

The only problem is that in most cases I have had to drop my bike off approximately a week before the race. That leaves me with the unappealing option of doing my final rides on my mountain bike. It also seems to take me about an hour or so to get my bike from my house to the drop-off point and back. It is also expensive. In the last few years I have spent over $1000 getting my bike to and from races.

For all of these reasons I have never traveled with my bicycle, unless on my way to a specific Ironman event.

In the past couple of years I have been to Hawaii several times. I have never taken my bicycle there. I have always been nervous at the thought of packing my own bike. I have been worried about the unpredictability of baggage handlers. I’ve always felt like it was a waste of money to pay for the ridiculous baggage fees incurred by bicycle owners.

It always seems like a shame to be in Hawaii and only be able to run and swim.

But I have recently found a new remedy for all of these problems.

A couple of months ago I purchased a new bike case: the Ruster Sports Hen House Bike Case.

The case is a soft sided bicycle travel case which is specifically designed by a professional triathlete/engineer named T.J. Tollakson. He actually created the case to address all the concerns that I expressed above.

The ingenious case is actually 2 separate pieces so that the wheels fit in one bag in the frame, forks, aerobars, etc. fit in the other bag. Both of these pieces of luggage are less than 62 linear inches: the crucial number to beat when avoiding excess baggage charges on the airlines.

The case is extremely well-made and I expect my grandchildren will love it when they transport their bikes to races 50 years from now. Until they are born, I will fly often with my bike tucked safely in the bomb-proof case.

The Hen House is made of ballistics nylon with heavily reinforced padding. Pipe-insulation is included to further scratch-proof the whole thing. The zippers are super-strong as well. The shoulder straps make carrying the bike case and wheel case a snap, even while chasing my 4-year old through the airport.

Although my bike is on the larger side (size 58) there is still plenty of room to pack my cycling shoes, clothes, and wetsuit. Adding the clothes and wetsuit to the bag simply increase the padding and keeps the bike even safer. The wheel bag is sturdy and stiff enough that my carbon race wheels with Powertap all fly worry-free.

I feel like my bike is totally safe and secure.

The picture above was taken as soon as I landed and collected my bags in the Las Vegas airport on my way to Ironman St. George. My beloved Cervelo is nestled in the Hen House. Safe and sound on her maiden voyage!

On that particular flight, I was flying on Southwest Airlines. When I got to the check-in counter at San Francisco International Airport the agent looked at the bag and said that’ll be 50 Dollars Each Way for the bicycle.

As I removed the shoulder straps and tucked them inside the bag, I smiled and said, “I don’t think so… It’s less than linear 62 linear inches and weighs far less than the maximum weight requirement.”

“Oh! No problem. Enjoy your flight….” she said.

Total Charge: $0
Total savings: $100

The Hen House was off to a great start!

A couple of weeks later I was going to Ironman Texas. I packed all of my clothes AND all of my sons clothes in the two bags. I had no additional luggage to check.

Total Charge: $100
Total savings: $200

The biggest advantage I discovered on my Ironman Texas trip was in terms of time savings. I timed the bicycle disassembly and reassembly process involved with packing the bike in the Hen House. Less than 30 minutes each. (This was even on the day after the race, where admittedly, I wasn’t moving too fast.)

So I quite literally rode my bicycle on my final bike ride in San Francisco AND packed the bike in the Hen House in less time than it would have taken to drive the bicycle to and from the drop-off point for Tri-Bike Transport.

I flew to Texas the next day. I unpacked the bike and reassembled it in less time than it would have taken me to drive to the event to pick up my bicycle.

No more carbon separation anxiety.

Next week I will apply the ultimate test. I will be flying from San Francisco to Nice to race at Ironman France. The Delta website says that bringing my bike should set me back $300...unless...I can work within the rules and avoid the gargantuan bike case!

I expect to pack all of my belongings in the Hen House with my bike and save $300. After this particular trip the case will be paid for by the baggage fee savings alone. If I compare this to the bike transport companies, I would have saved nearly $1000 over these three trips.

Most importantly, the next time I go to Hawaii I am bringing my bike!

Disclosure: Dr. Christopher Segler is a sports medicine podiatrist and foot surgeon practicing in San Francisco California. He sometimes writes reviews about products he loves. He did not get paid to write this review. He has never met TJ Tollakson, and has no affiliation with him. Dr. Segler paid for the Hen House bike case in full, at retail price and believes it has been worth every penny. He did not get any sort of discount, nor anything else of value, for writing this review. Buy a Ruster Sports Hen House...travel cheap, fast and happy!

What is the Best Way to Diagnose Gout in the Big Toe Joint?

An attack of gout that affects your big toe joint may be one of the most painful conditions you can have in your foot. When gout strikes, you get pain, redness, swelling and extreme tenderness...usually in the big toe joint. If you think you have gout, you probably want to make sure that you get the right diagnosis. Getting the correct diagnosis is important for two reasons.

1. You want to make sure you get the best treatment as quickly as possible.
2. You don't want to have to change your diet and start the dreaded gout diet unless you're absolutely certain that you actually do have gout.

Gout is actually caused by uric acid crystals accumulating in the foot. The crystals actually get deposited as the precipitate out of your bloodstream and become embedded with in the big toe joint, a bursa, or even within the tendons near the joint at the base of the big toe.

There are 5 ways to diagnose gout in the foot
1. Physical exam by a podiatrist
2. X-rays of the foot
3. Blood tests to look for high uric acid levels
4. Joint fluid analysis from the big toe joint
5. Cytology (fluid analysis under a microscope)

This video, posted by San Francisco's Housecall Podiatrist, discusses all of the ways in which your doctor can arrive at a diagnosis of gout. Because gout is a condition in which uric acid crystals actually get deposited in the soft tissues of your foot in your big toe joint, it is important to actually identify those crystals in order to accurately make the diagnosis of gout.

Physical exam (even by a podiatrist) is not 100% accurate simply because gout also mimics other conditions such as an infection in the soft tissues around big toe joint, infectious arthritis of the big toe joint, or even conditions that affect diabetic patients such as Charcot foot, where the foot bones start to break. All of these conditions can present themselves with redness swelling and extreme pain around the big toe joint. Physical exam by itself is just not the best way to diagnose gout.

Foot X-rays are almost always performed in a doctor's office when you have a red hot swollen foot in order to make sure that you don't have a dangerous infection or a fracture in the foot that could be just appearing like it is gout. But x-rays of the foot won't typically show much when an attack of gout has recently started.

Blood tests in order to determine whether or not you are one of the patients that has a high level of uric acid in their bloodstream (and more prone to gout) are not really effective at determining whether or not the pain and swelling around your big toe joint is really caused by the crystals in your joint. In fact, often times these tests are negative, misleading doctors to think that you might not have gout.

A more reliable way to determine whether or not the pain in the big toe joint it's actually caused by count crystals is to perform a joint aspiration where the fluid is removed from the joint to see if there is any chalky white material that looks like collections of gout crystals. This is much more reliable than physical exam, foot x-rays, or even blood tests.

But by far the most reliable way to make the diagnosis of gout is through cytology. This is where your doctor takes the joint fluid that was removed through joint aspiration and then sends it to the pathologist so that they can look for the actual gout crystals under a polarized light microscope. If you do have an attack of gout that is causing the pain in your big toe joint, the pathologist will be able to see needle shaped uric acid crystals within the joint fluid. This is a 100% accurate method of diagnosing gout in the foot.

Dr. Christopher Segler is an award-winning foot and ankle surgeon and sports medicine podiatrist practicing in the San Francisco Bay area. He provides housecalls for people with gout in San Francisco, Marin, Mill Valley, Tiburon, Oakland, Berkeley and Palo Alto. To learn more about the causes and treatment of gout in the big toe joint, visit the gout information page at www.AnkleCenter.com. if you would like to learn about how to get the fastest treatment possible for gout, you can learn more at www.DocOnTheRun.com.

Houston Marathon Race Report

2011 was a year plagued by urgent sports medicine consults and surgery. With a sports medicine practice structured to provide rapid access to aching athletes, my own training seemed to get buried. So I planned 2012 to begin as a year of racing myself back into shape.

The Chevron Houston Marathon, just two weeks into the new year seemed a great place to start. This was my third year registered for Houston, but would be my first attempt at this event. I was a no-show for both the 2010 and 2011 editions of the marathon, again forced to stay in San Francisco to take care of patients.

Just two days before my departure this year I would have a work matter come up that threatened to thwart my marathon again. I re-booked the flight, so I could fly in at the last minute. Sleep deprived running would be better than no running. A plane with a “broken hose inside the wing” left me anxious and sitting at LAX for an extra 5 hours, but eventually I made it to Houston.

I was excited to run as I would be joining my sister and my brother-in-law. It was his first marathon. My sister Laura however is a veteran.

After a few hours of sleep the three of us were up in the dark and parked in downtown Houston. The temperature was 41 degrees but forecasted to rise to about 60. Perfect!

Because 2011 was so busy with work, I hadn’t actually run more than 13.1 miles since Ironman Texas. That was eight months ago. So the plan for my race was simple. Run steady. Don’t walk. Don’t do anything dumb enough to cause an injury.

I went out for a test run about a week ago to plan my pace for the marathon. I ran 13.1 miles, from the San Francisco zoo, along the Great Highway, up through Golden Gate park and back. I covered the half marathon distance in 1:42. So I figured that a 3:40 marathon would be a reasonable goal.

The Houston Marathon is a huge event, but the organization was great. Runners were separated into corrals based on expected pace. I found the 3:40 pace crowd and waited for the start.

After the mayor spoke and the national anthem was sung, the wheelchair start was off. Ten minutes to gun-time. I took off my warm-up pants and tossed them over the fence into a growing pile of running wear that was to be gathered and donated to the homeless. It was cold, so I kept the sweatshirt on.

The gun went off and anxious shuffling commenced. Thousands of runners trying not to bump into each other, trudging through the shoot, pointed out of town. Like magic, as soon as I hit the start timing mat, running began. Almost instantly the mass was at a seemingly coordinated 8:00 min per mile pace.

As we rounded the overpass, it was a fascinating sight to see. Dawn cast an orange hue on the horizon. There ahead, as far as I could see was a street stuffed with a colorful gyrating mass of bobbing heads flowing through the street.

One mile in and I was finally warm. I bid my sweatshirt goodbye and tossed it into a pile of clothes on the sidewalk. A couple of slow runners suddenly appeared in front of me, creating a challenge to dodge them, without elbowing anyone or stepping on any heels. Time to ignore the crowd and stay on pace.

Before I knew it I was out of downtown and in the Heights. Five miles into the race I passed my sisters house, which happens to be right on the course itself. There on the sidewalk were my twin nephews who offered up a matching pair of enthusiastic high fives.

We kept rolling south through Montrose and towards West University. Bands played. People cheered. A priest stood in the street, waiving a palm frond dipped in holy water, blessing the flowing crowd of runners.

The course continued, flat as a pancake, through historic neighborhoods, under the shady tunnel of trees near Rice University and out through Memorial. As we hit Memorial Park, I had my last energy gel and knew I would make it. All I had to do was keep running and I would be in somewhere close to my goal.

Just then I saw my friends Henry and Josh cheering wildly, a great boost for the final stretch. The last few miles had the only real sequence of hills. But my frequent runs at Lake Merced, Crystal Springs and through Golden Gate Park, made them seem like speed bumps. In the last 4.5 miles I passed 162 runners, but only got passed by 10.

Right turn on Shepherd then left on Allen Parkway. The crowds got bigger, the cheers louder and the buildings of downtown steadily grew into the sky. As I felt the headwind pick-up, I realized it was the wind funneling between the skyscrapers. I was downtown, just blocks from the finish. I felt great and was tempted to turn up the juice, but then the voice of reason rang through me head…”you haven’t run more than 13.1 miles in 8 months. You have Ironman St. George and Ironman France coming up...DON’T DO ANYTHING STUPID!”

And so I stayed on pace. Round the corner and down the longest finish chute I have ever seen. Across the line in 3:41, actually a new PR. Today, I will call that success.

2012 is officially off to a very good start.

Dr. Christopher Segler is a marathon runner, 6-Time Ironman Finisher, and sports medicine podiatrist in San Francisco. He lectures to other foot and ankle surgeons at medical conferences on the topic of complicated running injuries. His practice focuses on runners and triathletes who have complicated injuries and cannot seem to get an accurate diagnosis. You can learn more about foot and ankle injuries at www.AnkleCenter.com and learn more about housecalls for runners in San Francisco at www.DocOnTheRun.com. He performs second opinion consultations for runners and triathletes world-wide through www.RunnerSecondOpinion.com