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. 

How Custom Cycling Orthotics Decrease Knee Pain Caused by Forefoot Varus

Knee pain is one of the most common complaints among cyclists. If your knee is aching when you finish the climb over Mt. Tam or a long ride out through Marin, it may be because the foot is slightly out of alignment.

In the simplest of terms, your foot is "locked" in place to the pedal by the cleats. if your forefoot is tilted lightly in relation to the rearfoot (a condition called "forefoot varus" or "forefoot valgus") then your leg may tilt slightly when you pedal.

This tilting of the knee can cause the knee cap (or "patella") to track out of alignment. When the knee cap tracks incorrectly, the cartilage on the inside of the knee cap can become irritated and inflamed. This type of knee pain when biking is called "patellofemoral syndrome."

This short video describes bicycle pedaling biomechanics as it relates to knee pain and conditions such as forefoot varus that can be easily corrected with custom cycling orthotics.

Dr. Christopher Segler is a sports medicine podiatrist, cyclists, and 6-time Ironman triathlon finisher. His practice focuses on cyclists, runners, and triathletes in San Francisco, Marin, and the East Bay. He is currently training for Ironman France. If you have a question about pain while cycling, you can call him directly at 415-308-0833. Learn more about house calls for athletes at www.DocOnThRun.com and learn more about foot and ankle pain at www.AnkleCenter.com .

Will orthotics help heel pain when running?

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

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

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

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

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

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

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

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


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

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San Francisco Podiatrist Explains Why Athlete's Foot is Common in Bay Area Runners and Cyclists

Athlete's foot is a fungus infection of the skin that often occurs in runners, cyclists and other athletes. It just so happens that the San Francisco Bay Area has a climate that can make it easier for you do develop a case of itching, burning, peeling feet that characterizes the condition.

In order for any fungus to grow best, it needs a habitat that is dark, warm and moist. As it turns out, shoes are perfect for this. You put on your running shoes and head out for a run through Golden Gate Park. Your feet sweat (even if it is fifty degrees), and the heat from your feet turns the shoe into a little incubator for the nasty stuff to grow. If it is like many days in San Francisco, you may even get some rain or light drizzle further soaking your shoes. Then you get home and toss your shoes in the closet until you get ready to go for a run the next day.

The problem is that very few closets have heat or air conditioning vents in them. For this reason, the shoes just won't dry out. They stay damp. And damp running shoes equals fungus.

Cyclists have a similar problem. Head out on the road to Nicassio or anywhere else in Marin county on the weekend and you will see hundreds of cyclist out for a ride. Most of them are wearing shoe covers to help keep their feet warm and dry. But these shoe covers don't breathe very well. As a result, all of that moisture gets trapped inside the cycling shoes. Once the ride is over, many cyclists will toss there shoes in the garage right next to their bike. Sitting in a cool and damp garage keeps the inside of those cycling shoes damp as well.

Sooner or later, the fungal spores in the shoes will cause an athlete's foot infection. Often this is just nothing more than mild peeling of the skin on the bottoms of the feet (see picture above). But some people get severe itching, redness and burning of the feet. Once in a while a secondary infection (caused by bacteria) can start an even bigger problem.

So what to do?

First off, it is very easy to prevent athlete's foot by simply drying your running shoes and cycling shoes out. Bring them inside. I usually leave mine near of a heating vent for a couple of hours after I go running or biking. This ensures that the insides of the shoes will stay dry. Dry shoes don't support fungus very well. If you wear cycling shoe covers, take them off after every bike ride to help them dry out.

If you do get athlete's foot, over-the-counter (OTC) anti-fungal treatment creams will usually cure the problem in about 4 weeks. All you have to do is follow the directions on the tube. Make sure you use the cream for about a week after the problem seems to have gone away. Otherwise you might still have some fungus in the skin that can flare back up in only a couple of weeks after you stop applying the anti-fungal medicine.

Keep in mind that if you get athlete's foot, you will have been shedding fungal spores in your shoes. You need to decontaminate them by spraying lysol in your shoes and letting them dry out thoroughly afterward. If the athlete's foot doesn't improve after you treat it yourself with OTC medications, see the best podiatrist you can find.

Dr. Christopher Segler is a runner and Ironman triathlete who practices Podiatry in San Francisco. He offers house calls to busy athlete's through www.DocOnTheRun.com. You can learn more about common causes of foot pain at www. AnkleCenter.com, San Francisco's best podiatry treatment information site.

San Francisco Podiatrist: Out-Run Your Fat Cells!

An article in the San Francisco Chronice discusses some alarming statistics.

Ten years from now, 80% of men and 70% of women will be obese. In addition, there will be a 98% increase in obesity related diabetes. The problem of couse isn't just that all those fat people will have a tough time fitting in an airplane seat when getting on the plane in San Franciso heading to Hawaii.

The problem is that essentially preventable conditions like heart disease, stroke and diabetic foot amputations will follow those plump Americans like the dust cloud following Pigpen in the Charlie Brown cartoons.

The truth of course is that the bigger the waist size, the shorter the life. Many of the ultimately fatal complications of obesity and diabetes are lifestyle related. A little prevention can go a long way.

Given that I am a podiatrist and runner, I of course am biased toward exercise and preventing the complications that lead to foot amputations. Not just because I like to run, but because people who have diabetic amputations don't live very long.

We know that a "pre-diabetic" (sometimes also referred to as a "borderline diabetic") can often reduce their blood sugar and reduce the chances of developing diabetes just through regular exercise. A diabetic who is taking insuling who begins a walking or moderate running routine can go from taking insulin shots, to just taking some pills to keep the blood sugar under control.

And we all know that exercise is a more reliable way to fight obesity than diets.

So maybe just by adding a 30 minute running routine in Golden Gate Park, along the Embarcadero, or through Marin, San Francisco Bay Area residents could actually outrun the ability of their fat cells to pack on the pounds. San Francisco is easily one of the most scenic and runner friendly cities in the world.

As a Podiatrist who has done lots of diabetic foot sugery, I can honestly say that I would rather meet you on a Saturday morning run in San Francisco than see in the hospital because you need me to amputate a part of your diabetic foot. Every run in San Francisco I go on feels like a success. Every diabetic foot amputation feels like a failure.


Christopher Segler is a Foot Doctor in San Francisco who practices Podiatry. He is also a multiple Ironman Finisher. For more info about foot pain or running injuries see www.DocOnTheRun.com or www.AnkleCenter.com

Can Runners Heal Heel Pain?

What could be worse than a runner with heel pain? Answer: a runner who has heel pain and can't run. In this excerpt from a video interview with Ironman finisher and award winning podiatrist, Dr Christopher Segler discusses heel pain.





Dr. Christopher Segler is an Ironman Triathlon Finisher and award winning foot doctor specializing in elite athletes. His podiatry sports medicine house calls practice is located in San Francisco, Marin, Oakland and Berkeley. You can register for a FREE membership and will receive the monthly newsletter “Finisher’s Circle,” which provides expert advice on increasing your running efficiency and preventing injuries and foot pain by visiting http://www.AnkleCenter.com .

Young Woman Dies in White Rock Marathon

On December 15, 2008 during the Dallas White rock Marathon, a 29-year-old woman collapsed and was pronounced dead, the race director said.

According to the Dallas morning news, Marcus Grunewald, director of the 39-year-old Dallas White Rock Marathon, said that the young newlywed woman’s death was the first in the event since 1986. In that race a 47-year-old man collapsed after suffering a heart attack and died during the marathon.

Witnesses to the event said the woman appeared to be running fine until mile 21, just a few miles from the finish, when she suddenly stumbled. She was helped to a nearby curb and then lost consciousness. "Her body was cold," one witness said. "She was already gone."

The race director told the Dallas Morning News that due to the marathon's 66-degree weather, higher than the race's average, medical aid and water were readily available along the race route. Although heart attack is suspected, the exact cause of death had not been determined. An autopsy was pending.

This tragic event illustrates the importance of checking with your primary care doctor before training for any endurance event. Undiagnosed heart disease or other underlying medical conditions can lead to disaster.

Even if you have been training for months without any episodes or warnings of trouble, distress of running faster during an organized marathon can lead to enough over-load to cause a heart attack.

After running for many miles particularly at your maximum capacity, dehydration can lead to electrolyte changes that can contribute to a heart attack. It is critical to make sure they don’t have any underlying heart disease before considering when these events.


Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His podiatry practice is at Don On the Run Podiatry House Calls in San Francisco, Marin and the East Bay. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting http://www.AnkleCenter.com .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His Bay Area Sports Medicine Podiatry practice offers house calls in San Francisco, Marin and the East Bay. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting http://www.AnkleCenter.com or www.MyRunningDoc.com.