Can I Continue Running With This Blister?

We receivd an email inquiry from Julie who is currently training for a marathon. She recently injured on of her little toes and wants to resume her training.

She explains. "I have had this blister now for a week. I had also tripped over a bike rack which bruised my toe as well. I am on antibiotics and they took X-rays to confirm my toe was not broken. It was not broken but very infected. I was training for a marathon and want to know if I can continue running or do I need to wait longer for it to heal."

As a sports medicine podiatrist the primary concern with a blister is of course to help the blister heal as quickly as possible so that the patient can resume marathon training without any significant loss of fitness.

The basic tenets of blister treatment involve the following:

1. Provide mechanical protection of the blister. This means to use any combination of reduced activity, shoe modification, padding, etc. to stop rubbing and irritating the wound. If you continue to apply shear forces and friction, the blister will take much longer to heal, and could even get worse.

2. Optimize a moist environment of the wound to facilitate healing. This means that you want to keep the wound properly hydrated. The wound has to be moist, but not too moist. If a blister is actively draining, the dressing should absorb the exudate to prevent the excess moisture form breaking the tissue down further. If the wound is too dry, then a dressing should be used that will add moisture sufficent to promote healing.

3. Reduce the bioburden of the wound. "Bioburden" is a term used by wound care specialists that refers to the well-know negative effects of bacteria colonizing a wound, or worse yet, infecting a wound. Your skin is covered in bacteria. This not a comment on hygiene; it is a natural state. Any open wound will quickly become colonized with bacteria as well. If there is an excessive amount of bacteria feeding in the wound, the wound healing process slows. Many wound care products are designed to impede the growth of bacteria or wash the bacteria away. But not all are created equal. Some commonly used wound-cleansing substances such as dilute bleach, hydrogen peroxide and povidone-iodine kill off bacteria, but unfortunately are also toxic to the cells trying to heal the wound at the base and edges of the blister.

Much worse than a "colonized wound" is an "infected wound." The difference is that an infected wound is one where the bacteria is actually directly damaging the tissue. This is the case described above.

It appears from the picture and description provided that this runner's toe has not been caused by the exceeding common friction from running shoes, but is in fact a traumatic injury, more likely causes by a direct blow when tripping over a bike rack.

When this kind of injury occurs two things can happen.
1. The toe (or at least on of the phalanx bones within the toe) can easily break.
2. The nail plate can become separated from the nail bed leading to a nasty infection.

This type of injury has to be treated much differently than a standard friction blister.

The first concern is to treat the infection. This might be accomplished through the administration of prescription oral antibiotics, drainage of the blister and removal of pus in a podiatrist's office, and perhaps, even remove of the nail plate. Deciding which of these are appropriate would require an in-person evaluation with a podiatrist.

The second concern is the possibility of fracture. Little toes get broken all the time with the kind of injury described. The reason this is so worrisome is that if one of the bones in the toe is broken, the infection in the skin and surrounding soft tissue could easily spread to the bone resulting in osteomyelitis- also known as a bone infection. Bone infections are serious and are the primary cause of amputation of toes.

Before returning to running this runner (and her doctor) would have to be certain that the toes wasn't broken and the infection was well on its way to healing. Once that has been accomplished, it would be necessary to have a podiatrist who treats runners often evaluate the runner's shoes and determine the best way to offload the toe so that it could continue to heal with any irritation. She should then be able to get back to training for her marathon.

Dr. Christopher Segler is sports medicine podiatrist who practices in San Francisco. He is an active runner and triathlete who is competing in 1 marathon and 4 Ironman triathlons in 2012. His practice is limited to active runners and triathletes. You can learn more about running injuries at www.DocOnTheRun.com and www.AnkleCenter.com

Ironman Texas Race Report

The Woodlands, TX. May 19, 2012

About 12 hours after finishing Ironman St. George (affectionately referred to as “my flogging in the desert”) I was back home in San Francisco staring at the screen on Ironman.com where I kept reading the words again and again...

“General Entry for the 2012 Ironman Texas is SOLD OUT. Ironman Foundation spots are still available! CLICK HERE to register via the Ironman Foundation.”

My sane-self says, “$1300 sure seems like a lot of money for an entry fee.”

My obsessed self counters, “But you know, you ARE going to be in Houston on that day anyway.” The insanity continued, “And it isn’t like you really ran the whole marathon in St. George, so really you are perfectly capable of having a better day in less than two weeks. This would also be the perfect training day for Ironman France.”

My sane-self says, “Perfect training day for France...what...how?!?!?”

My obsessed self interjects. DO IT! DO IT NOW! Quickly...before the sane one intervenes!”

“Click.”

And just like that, I was registered. Hardly time for a recovery ride before I would re-pack the bike and head for Texas.

My friend Henry lives in Houston and we have raced many Ironman events together. I called to let him know I was racing. He was thrilled.

I asked if his friend Josh was racing as well.

Henry said, “No, Josh never signed up. But he just did the New Orleans 70.3. In fact, we did the whole race together, start to finish. It was a blast! It was his first triathlon. But, actually they cancelled the swim, so he stall hasn’t done a big event swim yet. I think he is going to do Texas next year, but not this year.”

I said, “Well great...maybe you and I can do Ironman Texas together. It would be great if we could cross the line at the same time for once.”

Henry said, “I’m in!”

About an hour later Henry called back. He said “So, I told Josh that you said he was a “loser” since he didn’t sign up for Texas. He just got on his computer and signed up for a community fund slot! So I guess the three of us are doing it together!”

I immediately felt terribly guilty.

But I was suddenly really looking forward to a laid back race where the three of us would just spend the day together working up a Texas-sized sweat.

Having just finished Ironman St. George, and with Ironman France 3 weeks away, my race plan and priorities were simple...

1. Don’t get injured.
2. Finish.
3. Have a really fun time.

At 5:00am I quietly sneaked through the front door of my sister’s house and in to the dark humidity that is the early Houston morning. I climbed into Henry’s truck and bid good morning to both Henry and Josh.

Before I knew it we were in transition inflating tires, filling aerodrink bottles and building anxiety.

The sun rose as we walked the mile or so to the swim start. We discussed strategy.

“Ok. Let’s just all stay together through the swim, and then we can head out on the bike course together.”

The water in Lake Woodlands was much warmer than last year, so no wetsuit. The organizers were allowing donning of rubber, but only with the stipulations that they start 10 minutes later than the rest of the field and be disqualified from Kona slots and age-group awards.

About 1-minute before the cannon went off, the three of us kicked our toss-away flip flops in the growing pile at the edge of the boat ramp. We waded in and started treading water near the back of the 2800-or-so strong pack.

“BOOOM!” the canon fired, and thrashing commenced.

Josh almost immediately started to have a bit of an issue. He was sort-of
hyperventilating and a bit panicked. It was after all, his first mass start.

Henry and I both waited. “No problem Josh, we have 2 hours and 20 minutes. We’ll just let everyone go. Take your time.”

We had him hang on to a rescue kayak until the mass splashed ahead. Josh was unnecessarily apologetic. Soon, the crowd was gone and we continued on.

About 20 minutes later, the 10-minute-delayed-wetsuit swimmers caught us. “No problem Josh, we have 2 hours and 20 minutes. Lets just let them pass. Everything’s cool. Take your time.” We again had him hang on to a rescue kayak until the wetsuit group went by.

The rest of the swim was calm and uneventful, albeit slow. Josh was still having some trouble calming down and catching his breath so he kept up a consistent breast stroke. He couldn’t swim freestyle without his heart rate going back up.

While we were drifting along the swim course, I did notice that the water quality was better than last year. Last year I couldn’t even see my elbows when I was swimming. I also ended up with a sinus infection for a month (as did just about everyone else I talked to after that race). So I was hopeful that the slow pace and slightly clearer appearing water would let me escape with an excess intake of water-borne pathogens.

When we exited the water, I had no problem finding my bike. There were only about a dozen bikes racked when we hit T1. I guess there is at last one advantage of a swim that takes 2 hours 8 minutes and 12 seconds.

We had a quick pow-wow in the change tent.

Knowing that this was a new adventure for Josh, I suggested pacing. The plan was for me to lead with Josh and Henry staying far enough apart to avoid drafting. Since I have a power meter, I would lead keeping an even sustainable pace based on wattage.

My typical average power output for a flattish Ironman would be 250 watts. Since Josh was on a road bike I suggested we head out at 225 to see how he felt.

At the first aid station, I looked back and they were gone. In a few minutes they caught up and said I had just dropped them. “No problem, let’s try 200 watts.”

I dropped them again. So we tried 175 watts. I dropped them again. Then 150, and I dropped them again. We then found 135-140 to be sustainable. And on we pressed through the Texas countryside.

The bike course was super-hot, but had some lovely shady sections. The terrain is varied enough to keep the boredom and saddle issues at bay.

At about the 100 mile mark, I rolled through an aid station and noticed Josh and Henry were gone. So I waited. And waited.

About 15 minuted went by before I saw them coming. They stopped at the medical tent about 50 yards behind me and I saw henry take of his helmet and lie down.

“Uh oh.”

I rode back to find out what was going on.

Josh says, “He’s done. Henry has been throwing up on the side of the road for like 10 or 15 minutes.”

I walked under the canopy and Henry simply shook his head and said, “I’m out Bro. Make sure Josh makes it to the finish.”

And then there were two.

Away we rode to finish the last 12 miles before starting the run.

After 7 hours and 23 minutes in the saddle, we were in the change tent and heading out on the run.

As we started the marathon Josh was feeling good and looking great. But as soon as I started to run, or even jog for that matter, my stomach rebelled. It was like a repeat of the last 15 miles of St. George. We only jogged a couple of miles at a 12 min pace, before my stomach just shut down completely. The only pace I could maintain was a fast walk of 4mph.

At that pace we would get in before midnight, but it was going to be a very long day.

And that was exactly what happened...6:45:14 for the run.

But we made it. As Josh and I rounded the last corner before the chaos of the finish chute, I said, “OK Josh, this is it, 100 more yards and you’re an Ironman. Now run...and go get that medal!”

We both started to run, and Josh peeled away like he had been shot out of a cannon. I was just down the straight part of the finish chute when I heard Mike Reily shout “Joshua Johns, YOU ARE AN IRONMAN!”

It was a really great way to finish indeed.

Right after I crossed the line I heard “DADDY!!!” and saw my four year-old son Alex. I handed my finisher medal to him across the fence. He promptly handed it back and said, “Can I have that instead?” pointing to the glow stick necklace.

“Sure! After waiting 16 hours and 37 minutes for me, I guess you can have whatever you want!”

Dr. Christopher Segler is a 9-time Ironman Triathlon Finisher who helps marathon runners and triathletes heal chronic injuries that don’t respond to conventional treatments. He also lectures at medical conferences about the treatment of complicated running injuries. He believes that if your doctor tells you you have to stop running, you should fire your doctor. You can learn more about self-diagnosis of running injuries and cycling injuries at www.AnkleCenter.com and www.DocOnTheRun.com

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!

Ironman St. George 2012 Race Report

Since the Houston Marathon a couple of months ago, my sports medicine practice has been too busy to keep up with the training. Overworked and moderately trained, I even had to skip Ironman 70.3 Oceanside due to a sinus infection. That particular illness left me with a period of about two weeks with zero exercise.

Since that time I had been ramping back up on the run training and putting in about 150 to 200 miles per week on the bike. However, I have only been swimming one time since last October. That short swim in San Francisco Bay at least let me remember that I did know how to swim, while pointing out my lack of fitness.

Yet in spite of my significant lack of condition, I decided to show up for Ironman St. George and take my beating like a man.

On race morning my alarm went off at 3:45 AM. I had my coffee, banana and peanut butter jelly sandwich. I grabbed my things and headed off to transition.

While walking through transition, I saw Meredith Kessler. “Hey Doctor Chris!” she said. I stopped and said, “OK Meredith, I can feel it, it’s going to be just like Ironman Canada. I will be just heading out on the marathon and you will be coming in for the win. So when you hear me screaming Go Meredith Go you will know you have another championship under your belt.

I checked my run gear bag in T2, dropped off the special needs bags and waited in line to board a school bus.

After about a 20 minute bus ride from T2 to the swim start, a engaged in the standard routine of finding some friends to talk to while waiting around for the start, trying not to feel anxious.

Swim 2.4 miles

Because I had only been swimming one time in the last 6 months my strategy was simple: get in the very back of the pack, find some clear water, and stay out of the way. I was actually looking forward to the swim, because I knew that it would be a real adventure. I was confident that I would complete the swim however was unsure how long it would take even my poor physical condition. I decided that I would relax and enjoy the day instead of worrying about time specific goals.

I treaded water amongst a group of athletes who looked far more nervous than I was. The cannon went off and away we went.

The swim went relatively well until I made the first turn. Only moments after I rounded the red buoy, I felt as if a large barge had floated by, bumping us in its wake. A few moments later and I encountered the same sensation again. It was then that I realized these were actually swells, not rescue boats causing wake. At that point, I still enjoyed it, thinking that it would make it more of an adventure.

But as I rounded the next red buoy things changed. The buoy, which normally looks like a floating pyramid, was being blown so hard in the wind that it appeared to be upside down, tugging at its mooring. Just as I was making the corner, I watched a rescue kayak flipped over on top of a group of swimmers. A large rescue boat was bobbing precariously and drifting out of control toward the athletes.

Rounding the second red turn buoy sent us heading down a one mile mile straightaway, directly into 3-5 foot swells. This was more adventure than I had bargained for. It seemed like about half the time I would swing my arm over my head I would drop off the side of a wave swinging into empty air. The waves were so big that I couldn’t even see the course.

At one point I started to tread water in order to wait until I was on top of a wave to see the course. I spotted a yellow buoy and took off after it. I would later learn that some of the course buoys had been ripped from their moorings and were blown off course. This made sense since I felt like it one point I was swimming 90° to the proper direction.

Further down the reservoir I noticed that there were about 30 or 40 athletes standing on a tiny sandstone island. I assumed that they were all standing there in order to get a visual and figure out where the course was going. But as I approached them I realize no one was jumping back in. They were all waiting for a rescue.

It was about this time that I heard another athlete screaming. I looked up and there was this guy treading water with a look of terror on his face. He looked at me and said, “how do I get a rescue boat?”

“Waive your arms above your head!” I said.

He responded with, “I can’t I have to tread water.”

I tried to reassure him, “Well you are wearing a wetsuit so you couldn’t possibly sink even if you wanted to. It will be okay. Now I’m sorry but I have to go.”

He was waving one hand over his head as I swam away.

A little bit later I started floating the try to get on top of a wave and get a visual on the end of the straightaway. I saw 4 or 5 yellow buoys stretching way down the reservoir. I couldn’t believe that I had that far to go before I made the last turn. I had already been swimming for an hour and a half. I am usually out of T1 at this point. Did I get lost?

Eventually I made the last turn and headed toward the swim exit. I crawled out of the water it one hour and 58 min. My slowest time by a long shot.

As soon as the wetsuit strippers pulled off my wet suit, I was freezing in the breeze. Not wanting to re-visit my hypothermia episode of Ironman Canada, I elected to sit in the sun and out of the wind for about 10 minutes in order to dry off before I got on the bike.

Bike 112 miles

For the first 40 miles or so we seem to be heading either uphill or directly into a headwind. Every time I looked down, I was going either 6 or 7 mph. I’m normally going about 20.

Another athlete pulled up next to me and said, “Do you realize that we might not make the bike cut-off?”

Given that I am usually in the top 20% on the bike leg, that was a thought that simply never would have never occurred to me.

I looked at him and said, “Well, when we hit that downhill I plan on making up some time.”

He expressed his concern about the wind and getting blasted in the crosswinds on a speedy descent with deep dish wheels. We were both riding 80mm rims. He explained that he had not been riding much in windy conditions with those wheels.

“Well today is your lucky day,” I said, “I ride in the wind all the time. The gusts are terrain dependent. All you have to do is stay about 100 feet behind me and watch for when I get blasted across the road. It will help to be ready for the coming gust. You probably won’t crash, even if it feels like you will. You just have to be prepared. Watch me and you’ll be ready.”

Up over “The Wall” and away we went! At one point I looked down and I was going 50.5 mph. We were making up time indeed. The downhill must’ve gone for 10 or 15 miles. Suddenly I wasn’t so worried about the cutoff anymore.

Unfortunately we had to do another loop that included the brutal uphill. The wind was better on the 2nd lap but still a serious speed killer. As we got to the long climb that included “The Wall” I made the mistake of looking up. And there ahead of me, to my dismay, a full 50% of all the athletes had dismounted and WALKING their bikes up the hill.

I decided I just wouldn’t walk. I figured it would be easier to survive the lactate thrashing of grinding much easier than the ego bashing of walking. Man did it hurt.

But then we had the long downhill and flat section heading back to transition. Plenty of time to spin the spent legs out.

Back at T2, I hopped off the bike and realized I had been pedaling for 7 hours and 42 minutes. More than two hours longer than my typical Ironman pace.

The only good news was that I had been carefully monitoring my power meter and had been staying well within my limits, so my legs felt relatively fresh. While in transition, I did the math and realized that one benefit of a bike split that was 7 hours 42 minutes long is that it makes it mathematically impossible to have a run split that is longer than your bike split.

Run 26.2 miles

Knowing that the run would have some uphill and downhill section my plan was to run the flats, run the down hills and walk the uphills. Within minutes of heading onto the run course, I was passed by Meredith Kessler. “GOOOOOO MEREDITH GOOOO!” She waived and shot around the corner toward the finish chute. I could hear Mike Riley announcing her win.

Soon I was caught by Faith Bolliger from the SF Tri Club. “Can you run Segler?” I had the pleasure of riding with her for several miles. It was great to have a familiar face and someone to talk to. But then I had a long uphill in my run slowed to a walk. And away she went…

My plan was all going well until 11 miles into the run. I was craving salt and had been eating handfuls of pretzels. But then I started to eat handfuls of potato chips as well. I could tell that this was a bad idea so I decided to back off, before my stomach revolted.

Right about that time, I was walking through an aid station when a little girl who was about age 6 or 7 said, “ would you like a cookie?”

“Nooooo, none for me thanks.”

She batted her big blue eyes and looked up at me with her head tilted sideways, disappointment verging on tearfulness, and said, “But they’re home-made. They’re really good...I promise!”

And I caved under the pressure.

“You you know what, on second thought.. thank you so much for making these cookies it’s really nice of you to be out here today. I will have one. And thank you very much!”

With every bite, it was like a swirling mental conflict. It tasted so good, and yet I knew it was such a bad idea. But down it went.

Within about 5 minutes, it felt as though someone had thrown a hand grenade in my stomach.

For the next 15 miles, I walked. And every time I tried to run, I was doubled over on the side of the road heaving.

In case you haven’t tried it, it takes an incredibly long time to go 15 miles if you’re walking. But I kept up my pace enough to ensure that I would get in before midnight, lest I turn into a pumpkin.

And with less than half an hour to go I dug out the strength to run while fought back the cookie. I ran down the final stretch, into the finish chute, and heard crowds cheering louder than I could’ve thought possible. So it is true, they do cheer loudest for those that finished latest.

At 16 hours and 38 minutes I crossed the finished. And there was Meredith, the 2012 Ironman St. George Champion, who finished about 6 hours earlier. “Hey Doc!” she said smiling as she hung my finisher medal around my neck.

I started to laugh out loud. A great end to a very long day. It had been a grand adventure indeed.

Postlude

Once it was all over, I would learn of the carnage. The final episode of Ironman St. George had a 29% DNF rate...the worst ever. 80 athletes were rescued during the swim. 40mph wind gusts caused 269 fail to finish the bike. Another 61 would drop out of the run. Postings all over the web were calling it the “hardest Ironman in history.”

I’m not sure if that label is really true, but it was certainly the hardest for me. It was the slowest time for me in every single leg. Even slower than my very first Ironman.

But there is always tomorrow. So I got home and signed up for Ironman Texas...seeking redemption in less than two weeks. And this time, I think I’ll pass on the cookie.


Dr. Christopher Segler is a 7-time Ironman triathlon finisher. He is also a San Francisco based sports medicine specialist and foot surgeon. His practice focuses exclusively on providing the best treatments available for the rapid treatment of running injuries. His goal is to help runners and triathletes stay fit while recovering from injury as fast as possible. He makes house calls for busy athletes in San Francisco, Mill Valley, Tiburon, Berkeley, and Oakland. You can learn about running injuries at AnkleCenter.com and DocOnTheRun.com

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

When is Surgery Needed for a Ganglion Cyst in the Foot by San Francisco Running Foot Surgeon

A runner with a ganglion cyst called from San Francisco and had the simple question. "When should a runner consider ganglion surgery?" Here is the answer....

Whenever a patient has a big squishy lump on the top of the foot, big toe joint or the ankle joint, they want to know what will make it go away. The most common soft tissue mass in the foot is a ganglion cyst. Sometimes ganglion cysts will go away on their own. Sometimes the ganglion cyst needs to be drained. But sometimes a ganglion cyst in the foot needs surgery.

There are really 3 reasons that a ganglion cyst in the foot or ankle will need surgery

1. The ganglion cyst is painful.

2. The ganglion cyst is pushing directly on a nerve and can cause nerve damage.

3. The ganglion cyst is so big that it makes it difficult to wear shoes.

Unfortunately, many times ganglion cyst happen to develop in locations that are positioned close to nerves. This is really the best reason for a runner to think about ganglion surgery.

The tingling and burning pain that is often associated with a ganglion cyst is usually because the soft tissue mass is pushing against a nerve and causing the nerve to become irritated. If this continues for a long period of time, you can develop chronic pain or permanent nerve damage. The skin on the top of the foot is very thin and when a soft tissue mass develops the mass gets squished between the shoe and the bones that are close to the skin. The nerves that are located in that area can then get caught in the middle and cause pain. For this reason midfoot ganglion cysts often have to be removed surgically.

Dr. Christopher Segler is a runner, 6-Time Ironman finisher and a nationally recognized foot surgeon and sports medicine podiatrist who focuses on rapid recovery from running injuries. He is an internationally recognized expert in the treatment soft tissue masses that may appear to be ganglion cysts. His research and theories on PVNS (a dangerous soft tissue mass that is often mis-daignosed as a ganglion in young adults) have been published in the medically journals and were used as the basis for new treatment methods of these soft tissue masses. He practices podiatry, sports medicine and surgery in San Francisco.

You can learn more about the best treatment for ganglion cysts in the foot at www.AnkleCenter.com and www.DocOnTheRun.com. If you live out-of-state or abroad, you can arrange a remote consultation with a true running expert through www.RunnerSecondOpinion.com

Achilles Tendonitis in a Runner...from dropping out to 4th place.

We recently received this inspiring patient testimonial from a runner who had been suffering with chronic Achilles Tendinitis that was so bad it actually forced him to drop out of a race. Dr. Segler saw him and helped him heal the Achilles tendon with some simple treatments..and NO surgery. He didn't even need a PRP injection to heal the Achilles tendon. He went on to run a half marathon, full marathon and compete with his team to win 4th place at the PA/USATF 2011 Cross Country Grand Prix.

"I'm a runner who competes in the PA/USATF. I injured my achilles (tendinitis) last summer and needed to recover before the start of the cross country season (1st week of Sept).

This injury had been bothering me chronically for the last year and a half, impairing my training and in some occasions, forcing me to drop out during races. I called Dr Segler following a drop out from a local race last July. My achilles was very painful and I had difficulty walking. I'm generally a point-scorer for the team (top 5 runners) so my return to competition was much anticipated by my teammates.

Dr Segler came to my house and assessed my injury, explained what type of tendinitis I had and gave me a number of options and treatments (I think 12 in total). Most importantly for me, Dr Segler understood my need to not become totally out of shape before the XC season. Since he is a triathlete himself, he knows what competition means, the efforts you've put into your training, and the satisfaction of a good race. For my type of injury, most doctors would simply recommend to (heavily) use NSAIDs, rest and not run at all for a number of weeks.

Dr Segler gave me additional options to maintain a minimum level of fitness while my tendon was recovering. I followed his advice to the letter and got better in a few weeks, while maintaining some training. I returned to competition on Aug 27th, ran many of this year's XC races, and contributed to my team achieving 4th place at the PA/USATF 2011 XC Grand Prix. More recently I completed a half and full marathon part of the PA/USATF road racing Grand Prix and was part of the "A" scoring team. A great feeling ! I think we will take 3rd place in the Grand Prix this season, the best the club has done in years ... Thanks Doc !"

- Patrick M., San Francisco, CA

Dr. Christopher Segler is a runner, triathlete and 6-time Ironman finisher. His practice focuses on rapid recovery of running injuries. He offers a range of services to help runners get back to running as quickly possible. He provides PRP injections for Achilles tendonitis and ESWT therapy for heel pain in San Francisco, Marin and Palo Alto. He also frequently provides second opinions for runners through remote consultations via web conferencing for complicated injuries world-wide. The best treatment is fast treatment! If you have a question about running injuries, you can reach Dr. Segler directly at 415-308-0833.