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



 

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. 

3 Reasons to x-ray a stress fracture from running.

Dear MyRunningDoc, 

I have been ramping up my mileage as part of my marathon training. My foot has been sore and aching when I run. Someone told me that stress fractures don't normally show up on an x-ray until they start healing. If this is true, is there really any point to getting an x-ray if I think I did get a stress fracture from running too much?  

Adam J.

Houston, TX

Answer:

Great question!  This is a question I often hear from runners in San Francisco and Houston. Most runners are busy and don't wont to waste their time going to a podiatry office getting an x-ray of their foot unless they really think the x-ray will change what they need to do to get the foot to stop aching and  heal. (And of course, get back to running and training). But when you suspect a stress fracture, there are good reasons to get an xray.

3 reasons to get an x-ray of your foot if you think that you have a stress fracture.

The 1st reason to get an xray of your foot is to make sure that the metatarsal has not actually cracked all the way through the bone or broken into pieces. 

The 2nd reason is to confirm that the metatarsal, if it is broken, is still in a good position that will heal correctly. If the bone is moved out of place after it has broken that it will not heal correctly and will result in what doctors call a “malunion.” When the metatarsal bone heals in an abnormal position it will alter the way that forces are distributed across the ball of the foot. An unnatural distribution of forces across the ball of the foot will put other metatarsals at risk of problems later. It can also increase the chances of nerve compression that can lead to a neuroma. 

The 3rd reason to get an xray of your foot when you suspect you have a stress fracture is for peace of mind. Having an x-ray confirms that the bone is not actually broken and will not likely get worse if you are walking on the foot as it heals. A fracture walking boot is made to protect a stress fracture and allow you to walk while the bone heals.  if you have had an xray of the foot and confirmed that the bone is not completely broken, and you suspect that it is just a stress fracture, then you can treat it as such and feel confident you’re not going to make things significantly worse if you walk on the foot while protected in a fracture walking boot.

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.

Is this black toenail fungus or a bruised toenail from running?

I have been training for a trail run and have been running on lots of hills in Marin. I recently noticed that I was getting some dark black discoloration of my toenail. I am worried that this might be black toenail fungus infecting the toenail. How can I tell whether the toe is bruised or if I really have a toenail fungus infection? Also, what if anything should I do to treat the black toenail if it is infected?

Thanks,
David, Mill Valley, CA


Black toenails are likely one of the most common injuries I see in runners in Houston and San Francisco. There can be a couple of causes of black toenails from running.

Differences between a bruised toenail and a fungal toenail:
A bruised toenail hurts because 1) there is bruise 2) there is blood under the toenail increasing pressure between the toenail and underlying nail bed. This causes pain in the toenail when you press on it or bump the toenail on the inside of your shoes. Fungal toenails are not usually tender unless the toenail infection has been present long enough to make the fungal nail really thick.  The increased thickness can cause some tenderness, but it doesn't happen quickly.

A bruise comes on quickly, but a toenail fungus infection appears gradually. Bruising will appear within a day or two of your long run, race or whatever injury to the toenail. If you kick a coffee table once with your toe, the toenail may develop a bruise and turn black. If you bump the toe inside your running shoe repeatedly while running down hill (or because the running shoes are too tight) you can also get a bruised black toenail from the cumulative trauma. This can happen overnight.  You wake up and the toenail is black.

The changes in the toenail caused by toenail fungus happen very slowly. The color of the toenail will not change quickly.  The increased thickness, yellow discoloration, white crumbly appearance and dark color of a fungal toenail infection happens so slowly that it is almost hard to notice.

You can learn more about black toenails and toenail fungus treatment here by reading about an example of a black toenail in Houston that actually is just a toenail bruise. You can also read about from runners, blisters and black toenails here.  Learn how a bruised toenail can lead to a toenail fungus infection.

Dr. Christopher Segler, Doctor of Podiatric Medicine is Board Certified, American Board of Podiatric Medicine. He is a 10-time Ironman finisher and marathon runner. He lectures frequently to other podiatrist and foot specialists at medical conferences on the treatment of complicated running injuries and running biomechanics. He is licensed to practice podiatry in Texas, California, and Hawaii. He travels back and forth between Houston and San Francisco to see injured runners who have running injuries that need the fastest treatment based on a runner's goals and running doc perspective. If you live in San Francisco or Marin and have a running injury question call 415-308-0833 to speak to him. If you are in Houston and have a question about a running injury, call him directly at 713-489-7674. 

Popping, Clicking Ankle Pain. What, Why and How!

Hi My Running Doc!

My daughter has sprained her ankles a number of times. She keeps turning her ankles and they swell up. She also seems to have this popping and clicking sound from the ankle when she walks and it's really bothering her.

     Questions:

          Why does that happen?

          How do we fix it?

          What's the surgery that she needs 
          to cure the snapping and pain?

Thanks!

S.B., Berkeley, CA

Answer: Ankle sprains are the most common musculoskeletal injury. In fact, there is no sports injury that shows up in the emergency department more often in a twisted ankle. Fortunately ankle sprains heal just fine most of the time. But in some cases there can be a significant injury to the ankle that prevents them from healing properly and causes problems down the road.

There are 3 primary potential causes of popping and clicking in the ankle that might be associated with persistent ankle sprains and chronic ankle instability.

1. Torn Peroneal Retinaculum

2. Lateral Process Fracture of the Talus Bone

3. Osteochondral Lesion of the Talar Dome

One common cause of popping and clicking in the ankle is from dislocating or subluxing peroneal tendons. The peroneal tendons run down the back to leg behind the fibula. They turn around the end of the fibula as they curve down toward the outside of the foot. 

There is a thin band of tissue called the peroneal retinaculum that holds the peroneal tendons in place behind the fibula. In some cases involving ankle sprains, the peroneal tendons actually fire so hard to try to keep the foot under the leg when you roll the ankle that the perineal retinaculum actually gets torn off of the fibula bone. Because it is torn, the peroneal tendons are not held firmly in place behind the fibula.

When this occurs, the peroneal tendons are free to slide forward over the leading edge of the fibula bone. As the tendons snap back and forth across the fibula, they cause a popping and clicking sound and/or sensation as you walk. When this occurs it is not always painful but it certainly can be painful. It is more worrisome if it is painful simply because this might signify a tear or a split in one of the peroneal tendons.

If one of the peroneal tendons is torn or split it might need a platelet rich plasma injection (also known as a PRP injection) to help stimulate healing. If the torn peroneal tendon cannot heal on its own, it might require surgery to sew it back together. In any event pain in this area should not be ignored.

Another cause of popping and clicking in the ankle can be a misdiagnosed or undiagnosed lateral process fracture of the talus bone. The talus bone is the bone that connects the top of the foot to the bottom of the ankle. Lateral process fractures are sometimes referred to as snowboarders fractures.

We used to think that lateral process fractures were a rare occurrence. However Dr. Segler led a team of investigators through the largest study ever completed on lateral process fractures of the talus. He and his team won an award from the American College of Foot and Ankle Surgeons for this research. What his team found was that these fractures are about 10 times more common than previously thought. They just get missed all the time.Is

Lateral process fractures are frequently misdiagnosed as ankle sprains. Yet a broken bone does not generally heal the same way as a torn ligament. If not treated correctly, the broken bone can develop into a nonunion where the bone actually never heals. When this occurs, there can be continued pain and swelling in the ankle. Sometimes there can be a popping and clicking sensation as well.

The third potential cause of popping and clicking in the ankle after an ankle sprain is an osteochondral lesion of the talus. An osteochondral fracture is a crack in the bone underneath the cartilage. Basically what happens is the ankle rolls and the talus bone can tilt so far that the corner of the talar dome smacks into the tibia bone or fibular bone. If the talus has a hard enough impact as it twists, it can crack the bone and damage the cartilage. 

Sometimes the cartilage and the fractured piece of bone (known as an osteochondral fragment) can become loose. If not treated correctly this may not heal. If the cartilage is loose and has a flap of tissue that flips back and forth it can cause a clicking or popping sensation. This is often associated with swelling and pain in the ankle.

If there is popping and clicking from the ankle, but no history of a serious ankle sprain, the shape of the fibula can potentially lead to subluxing peroneal tendons. The retinaculum might actually still be intact but because there is not a very deep groove in the back of the fibula the peroneal tendon still slide back and forth causing a popping and clicking sensation at the side of the ankle. This can cause peroneal tendinitis.

If this is the case, it is possible to perform surgery to deepen the groove at the back of the fibula in order to help the peroneal tendons stay in place. This will stop the popping and clicking and prevent chronic irritation of the tendon that can lead to tears in the peroneal tendons.

Another related issue with chronic ankle instability and persistently weak ankles is that the ankles can get sprained over and over. If you often find yourself rolling your ankles when walking on uneven surfaces or running on trails, the first step would be physical therapy or a home rehabilitation self-treatment program to try to strengthen the ankles and restore stability.

In some cases of chronic ankle instability the ankles are so weak that the ligaments on the outside of the ankle need to be surgically repaired or rebuilt. 

In any case, if you have popping and clicking, especially associated with pain and swelling of the ankle, it shouldn't be ignored. Get it checked out right away.

Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. His practice is limited to  runners, triathletes and active young adults who want to stay active. He travels often to accommodate patients with complicated injuries in San Francisco, Houston, and Hawaii. He also provides remote consultations via Skype for injured expat patients living abroad who need expert advice, but cannot readily access a true foot and ankle expert while overseas. If you have a question about a complicated foot or ankle injury that just isn't getting better, you can reach him directly at 415-308-0833. 

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. 

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