Sesamoid injury in a runner?

I recently got from a question from a runner who had been ramping up for the California International Marathon in Sacramento and started having pain in the ball of the foot at the big toe joint...

"Hello Dr. Segler, I have been training for my first marathon and read that hills would be a great way to get super strong. I really wanted to do well and finish in under four hours so I started do hill repeats on Fillmore Street in San Francisco. Things were going great and I really felt like all the training was starting to pay off. Then one morning I got up and noticed this little aching pain in the bottom of my big toe joint every time I stepped on my right foot. It seemed to be worse on the hard tile in the kitchen. I have been really ramping up the miles and I am worried that this may be a stress fracture. Can you tell me the best way to tell if this is a stress fracture or something else? It hurts right in the ball of the foot under the big toe joint. Here is a picture of where it seems to hurt the most. Thanks!"


Great question! And thanks for sending the pic.. Here is your answer...

Pain in the ball of the foot can occur under the big toe joint for several reasons. Based on your description and the location of the tenderness, I would be most worried about the following conditions:

1. Sesamoiditis: inflammation of the sesamoid bones under the big toe joint (first metatarsophalangeal joint). You stand on these two little bones. Because they get stressed more when you run uphill, you may develop sesamoiditis when doing lots of hill repeats. If you push right on the hard little bones, and one hurts more than the other, it is probably sesamoiditis.

2. Flexor Hallucis Longus tendinitis (FHL tendonitis): strain, inflammation and/or micro-tearing of the tendon that pulls the big toe down against the ground allowing you to push off when you run. The sesamoid bones are actually embedded within the FHL tendon. If you push right under the big toe joint and the whole area is tender (and doesn't really hurt more on one specific sesamoid bones) it may be FHL tendonitis. If you pull upward on the big toe (away from the ground) you will stretch the FHL tendon. If this hurts, FHL tendonitis is likely.

3. Sesamoid Stress Fracture: a tiny little crack in one of the sesamoid bones from too many hill repeats and or too much running volume. If this is the cause of your foot pain, it will hurt more on one sesamoid than the other, it will also hurt when you pull the big toe upward, and your foot will most likely be swollen and/or bruised. The best way to diagnose a stress fracture of the sesamoid bone is with an MRI. X-rays don't always show stress fractures right away. X-rays will only show a stress fracture in a sesamoid that has fractured or completely cracked. Based on your story, however, this seems unlikely.

Get better as fast as possible and good luck in your marathon!

Learn more about sesamoiditis, FHL tendonitis and sesamoid stress fractures at www.AnkleCenter.com

Dr. Christopher Segler is a nationally recognized expert on running biomechanics and foot surgery. He has been invited to lecture to foot surgeons, sports medicine doctors, podiatrists, triathletes and runners in training all over the United States, as well as Canada, New Zealand, Portugal and Turkey. If you have foot pain caused by a running injury, you can send a picture of where it hurts and a brief description to him. Your picture and answer to your question will then be posted on our blog so others can learn how to deal with running injuries as quickly as possible and keep running pain free. You can email your pic and question to DrSegler@DocOnTheRun.com If you have a quick question about a running injury and you are not in San Francisco, you can actually call him directly as 415-308-0833. He schedules house calls for runners and triathletes in San Francisco, Marin and the East Bay through DocOnTheRun.com.

PRP Injection vs. Cortisone Injection in a runner with Achilles tendinitis?

Today I received a call from a runner who wants to know whether his painful Achilles tendon would get better faster if he had a cortisone shot or the newer Platelet Rich Plasma (PRP) injection.

Cortisone injections are one of the oldest and most common treatments for tendon pain when inflammation arises due to running and over-training. However it is not always the best treatment.

What you need to understand about cortisone injections (also known as corticosteroid injections) and PRP injections is that they are both very effective at reducing Achilles tendon pain, but for very different reasons. They are essentially opposite ends of the same spectrum.

Corticosteroid injections stop the inflammatory process cold. If you're trying to remove pain, swelling and inflammation, cortisone injections are a great tool. The problem is that if you have a small tear in the tissue that needs to heal, you have essentially stopped the healing process. In addition, the corticosteroids are well know for breaking up collagen bonds. Because your Achilles tendon is really a huge cable made of collagen, corticosteroid injections can weaken the tendon and make it more likely to rupture or completely tear.

PRP injections work in the opposite way. The PRP injection takes all of the growth factors that are present in your blood stream (within the platelets) and concentrates them many times. The powerfully concentrated growth factors are then injected directly into the injured tendon tissue in order to stimulate new blood flow, unlock the body's natural healing response and directly stimulate healing of the injured tendon. If there are small micro-tears in the Achilles tendon, a PRP injection will be much more effective than corticosteroid injection.

One injection turns the inflammation off while the other turns the healing on. Each has its place, just make sure you explain all of your running goals with your sports medicine doctor when considering either of these injections for your aching Achilles tendon.

You can learn more about what happens before your Achilles PRP injection by clicking here and what happens after your Achilles PRP injection by clicking here.

Dr. Christopher Segler is a 6-time Ironman Finisher and an award winning foot and ankle surgeon. He even does house calls for busy runners and triathletes in San Francisco, Marin and the East Bay. If you have a question about foot pain related to running, you can call him directly at 415-308-0833. For more information on Achilles running injuries, visit www.anklecenter.com.

What is this new pain in the ball of the foot? Question from a runner in San Francisco

Today I got a question from a runner in San Francisco. She says...

QUESTION:

"I wanted to get in touch about another issue (!) I'm having with my foot. Honestly, always thought it'd be knees that went...not my feet! Basically here is what happened:

*had been running again, but not heavy mileage...like 3-miles a few times a week along with perhaps some slower jogs (1 - 2 miles).

*but, then I participated in a TRX class where we did TONS of plyo stuff. squat jumps, etc. the next day, I noticed this pain.

*the pain is on the same foot as my tendonitis was. not sure if it's relevant. I decided to take a photo to show you where the pain is! hope that's not creepy ;) I did some research online, briefly, and thought maybe it's a bursitis?? I don't know, but the class was 3 weeks ago and I've been icing it, not running and the pain is not decreasing, if anything it's getting worse. I haven't been running, just doing the elliptical at the gym and cycling. Cycling does not exacerbate it at all, thankfully!

Also, do I need to get x-rays and stuff to rule out a stress fracture, etc.?

Anyway, thanks for your time!

Gretchen
San Francisco


MY RUNNING DOC's ANSWER:

Thanks for sending the pic and providing the description of the pain in the ball of your foot!

Based on your story and the location of the pain, it is most likely predislocation syndrome. Predislocation syndrome is capsulitis (inflammation of the joint capsule) in the ball of the foot, most often at the second metatarsal phalangeal joint (the joint at the base of the second toe). The capsulitis is what causes the pain, but the real issue is a strain or even tear in a reinforcing structure of the joint capsule called the plantar plate.

I actually see this all the time in active people who spending a lot of time on eliptical trainers. At the back stroke of the eliptical trainer, your heel comes up and the toes bend way up stressing the plantar plate. The plantar plate is a small ligament that reinforces the bottom of the metatarsal phalangeal joint capsule (the joint at the base of the toe in the ball of the foot).

To get it to calm down you have to avoid stressing the plantar plate. Avoid anything that causes you to bend the toes up, such as an eliptical trainer, running uphill, etc. You can also tape the toe down to decrease stress on the plantar plate. Ice, contrast baths and compression socks can decrease the inflammation.

This of course all assumes that your pain is caused by predislocation syndrome. The other common possibilities include a Morton's neuroma or a metatarsal stress fracture. It is pretty easy for any sports medicine podiatrist to tell on physical exam.

Given that 1) most stress fractures show nothing on x-ray until it has been at least 6 weeks, and 2) any sports medicine doctor who specializes in running injuries could tell you with relative certainly whether this is predislocation syndrome or not without an x-ray, I think a physician should just do a quick check and get you heading in the right direction.

Thanks for the question!

Dr. Christopher Segler
Doc On The Run
Podiatry House Calls for Runners
San Francisco, Marin, East Bay

If you have a question about foot pain caused by running, you can email a picture (pointing to the painful area) directly to DrSegler@DocOnTheRun. Tell me how it happened and I will post a an explanation so you will know what is most likely ruining you run. Your name will be changed, and you will never be identified by your real name, so as to protect your identity and shield you from any possible accusations of making a preventable marathon training mistake. I will also never, ever share your email address with anyone.

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.

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

Want to learn more about running with heel pain?

FREE LIVE webinar with Doc On The Run:

Sign Up NOW

Click here to reserve your spot for the FREE Live Webinar!

Top 5 Reasons to Avoid the Emergency Room When You Sprain Your Ankle In San Francisco

Ankle sprains are the most common of all sports injuries. Everyday nearly 10,000 people show up with painful, swollen rolled ankles. Although the Emergency Room may seem like a logical choice when you sprain your ankle, there are five reasons that you might want to reconsider.

1. LONG WAIT

The average time a person waits in the emergency room is over six hours. If you have an ankle sprain, the wait could be even longer. The reason is simple. A sprained ankle is not a life-threatening emergency. Every person who shows up in the Emergency Room with a suspected heart attack, stroke, appendicitis, or whomever gets transported to the hospital via ambulance is marked as a higher priority. Its easy to understand when you’re sitting at home reading this, but not so easy if you are sitting in the ER waiting room with a throbbing ankle.

2. COST

Care provided in the ER is expensive. In fact, the ER is the most expensive place for the delivery of health care in the United States. The hospital knows that many uninsured patients show up there with very real emergencies that cost a fortune to treat. If a guy with no insurance gets run over by a car, the ER can’t simply turn him away just because he can’t pay. As a result the Emergency Room fees are priced high enough to recoup some of the costs of indigent care. In a sense, when you go to the ER, you are paying your bill and the bill for the guy next to you who can’t pay. You could expect to pay as much as $1,500 for an ankle sprain work-up in the emergency room. If you sprained an ankle and are searching for the most expensive option, this would be it.

3. ANKLE SPRAINS ARE LOW PRIORITY

The fact is that ER docs are busy saving lives. When your complaint is just a painful swollen ankle, you can’t expect to get the same sort of attention as the patient in the stall next to you who’s going into cardiac arrest. You aren’t going to die today from an ankle sprain. In the ER physician’s mind, an ankle sprain is no big deal and one that can be treated later by a specialist. You can only expect basic first aid and a referral to a specialist. You just cannot expect specialized care in the Emergency Department.

4. MISDIAGNOSIS

ER docs are the most skilled at treated lief-threatening emergencies. But they are not that focused on non-life threatening injuries. You really wouldn’t expect the best treatment for a stroke from an ankle surgeon. By the same token, you can expect an ER Physician to provide the best treatment for your sprained ankle. An award winning-study at the University of Utah found that subtle fractures of the ankle are more than 10 times as common as previously thought. These fractures are frequently misdiagnosed as ankle sprains. Don’t expect an emergency doc to diagnose this type of ankle injury correctly. Without the right diagnosis, you won’t get the best care.

5. INADEQUATE TREATMENT

The number one risk for continued pain, ankle instability and continued ankle problems is inadequate ankle sprain rehabilitation. Because the ER docs don’t focus on ankle injures, they typically give you some basic first aid, a brace and instructions to follow-up with an ankle specialist. The ER doc fully expects you will get the care you need from an ankle specialist later. But many people don’t. The reality is that the final stages of ankle treatment are the most important. You must have an ankle expert guiding you back to strength and health.

If you sprain your ankle, you should know that most ankle sprains will fully recovery...if treated correctly. You need the best treatment to make a full recovery. If you want to see yourself running instead of limping on a weak ankle, you have to start with expert care. Knowing that the ER will send you to a specialist anyway, you can save weeks of recovery, just by starting with an ankle specialist to heal your ankle sprain fast.

Dr. Christopher Segler is a San Francisco based foot surgeon and nationally recognized foot fracture expert. In 2004 he won an award from the American College of Foot & Ankle Surgeons for his research on the accurate diagnosis of difficult to identify fracture patterns in the foot called Lisfranc's injuries (also called tarsometatarsal fracture dislocations). In 2005 he won an award from the American College of Foot & Ankle Surgeons for his research on the accurate diagnosis of difficult to identify fracture patterns in the ankle called Lateral Process Fractures. If you suffered an ankle sprain that needs the very best treatment as fast as possible, he can see you at your home with an emergency house call visit at your home or office. You can also learn more about the typical experience of an ankle sprain patient in San Francisco here. If you have an ankle sprain and just have a question about whether or not it needs to be treated, you can reach him directly at (415) 308-0833.

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.

Good News for Ironman Arizona Athletes!?!?

This week, the dam that holds the water in man-made Tempe Town Lake burst. That may seem like bad news for a triathlete. Unless you have ever been swimming in that lake.

There is a reason that they don't let people swim in the lake right next to the University campus. The stagnant water is just plain filthy. The first time I went for a dip there was in 2007 at Ironman Arizona. The day before swim practice began I walked up to the edge and saw a two-foot long carp munching on some pond scum.

I asked another athlete about the water quality. He said, "My understanding is that the city has organized a method to fight the stagnation in the lake by allowing 2000 athletes to splash around in the water this weekend." Great.

During the swim I made an effort to leave the water in the Lake. A guy a met at registration was not so lucky. He took in a couple of accidental gulps. That small error led to several bouts of vomiting out on the bike course.

Although I do hope the dam is repaired in time for Ironman Arizona 2010, I have to say that I also hope the unintentional draining of the lake will mean the cleanest water conditions on record for the race. But even if the water looks clean, I plan on keeping my mouth shut during the swim.

Dr. Christopher Segler is a sports medicine podiatrist in San Francisco currently training for Ironman Canada and Ironman Arizona. He makes house calls in the bay area to treat stress fractures, Achilles tendonitis, and other triathlon-related injuries. Learn more at San Francisco's best running injury prevention site.

Should I take Calcium if I have a Stress Fracture in my Foot? San Francisco's Running Doc Explains

If you are running and get a stress fracture, you likely want that bone to heal as quickly as possible. When you break a bone in the foot, the bone has to heal just like any other injury. Although calcium is the mineral that makes bones strong and visible on x-rays, it is not the only factor in bone healing. For this reason it is particularly important to make sure that you eat a healthy well-balanced diet when you are healing a stress fracture in the foot.

We know that your body needs many different nutrients to heal a stress fracture. For example, vitamin K is important in the clotting process right after a bone breaks. Vitamin C is essential to collagen formation that is an early step in the formation of soft bone callus that precedes the deposition of calcium where the bone broke. Calcium gets laid down in the repair of the fracture, but supplemental calcium won't be absorbed well without Vitamin D. Lysine is an amino acid that helps you incorporate calcium into the bony matrix as the fracture heals.

The medical literature is conflicting about whether or not supplements help bones heal faster. However there is general agreement that know that adults need about 1000 mg of calcium and 800 I.U. of Vitamin D daily for good bone health. Many nutritionists suggest that you will get all of this in a standard healthy diet. Having said that, there is very little risk and much potential benefit with taking some extra calcium.

Obviously your body will be working harder to repair the fracture by laying down calcium as the bone heals. You could take some Calcium and Vitamin D to help make sure you healing fracture has all the calcium needs. Just be certain that the Calcium supplements you take also have Vitamin D.

Dr. Christopher Segler is a runner, multiple Ironman Finisher and Sports Medicine doctor in San Francisco who focuses on running injuries. If you have a question about a possible stress fracture in your foot from running. you can post a question or call him directly at 415-308-0833. For more info on running injuries see San Francisco's best running injury site.

Do I Need X-Rays if I Sprained my Ankle?

San Francisco's Ankle Expert Explains When You Need X-Rays

If you are out trail running in Marin or Golden Gate Park and roll your ankle, your first thought is going to be whether or not you will be able to run with a sprained ankle. If the ankle is bruised and swollen, you will also probably wonder whether or not you need an ankle x-ray. This video explains how ankle surgeons and emergency room physicians decide whether or not you need to have x-rays after an ankle sprain.



Every single day thousands of people wait in line at the Emergency Room to get x-rays after they roll their ankles. After all that waiting, the ER doc will typically send you to an ankle specialist anyway. By seeing an ankle expert instead of going to the ER, you can be sure to get the best treatment for your ankle sprain. If you sprained your ankle, see an ankle expert today!

Dr. Christopher Segler is a sports medicine podiatrist who specializes in the diagnosis of sprains and fractures of the foot and ankle. Has has won multiple awards from the American College of Foot and Ankle Surgeons for his research on fractures of the foot and ankle that are often misdiagnosed as sprains. As a runner and triathlete himself, he believes that non-surgical treatment is best whenever possible. You can learn more about ankle sprains at the Bay Area's best ankle sprain info site. YOu can also learn more about ankle sprains and x-rays here. You can reach Dr. Segler at 415-308-0833.

How to Tell If You Have a Stress Fracture In the Foot by San Francisco Running Podiatrist

Last year just a few weeks before Ironman Louisville, I got an out-of-state call from a very worried triathlete. He said he had been ramping up his training for the big race. He had slowly been building milage over the past year. But then he started to get an aching foot when he ran. Slowly it turned into throbbing foot pain when he would run. And by the time he called, it was starting to hurt even while he was walking.

He was really distressed.

As a runner and prior Ironman finisher, he had been running long enough to know that a stress fracture in the foot was one of the most likely injuries that could force him to stop running. He was worried he wouldn't even be able to show up on the starting line at Ironman Louisville. The good news is that we were able to manage the stress fracture and he did complete the race without incident.

Training for any distance event (whether a half-matrathon, marathon or Ironman) can lead to a stress fracture in one of the metatarsal bones of the foot. But if your foot aches, there are some simple ways to tell how likely it is that you have a running-related stress fracture. This video explains how you can tell if you might have a stress fracture in the foot.

To learn more about stress fractures, visit the most comprehensive running injury site in San Francisco. All of the running education information has been created by San Francisco's Award-Winning Foot Specialist and Ironman Triathlete Dr. Christopher Segler. He's not just a running specialist who writes about running injuries, but he is a real runner as well.