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 .

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

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

QUESTION:

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

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

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

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

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

Anyway, thanks for your time!

Gretchen
San Francisco


MY RUNNING DOC's ANSWER:

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

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

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

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

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

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

Thanks for the question!

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

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

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.

McGlone's Kona Return after Achilles Injury Today on NBC

A minor ache in the back of the leg down near the heel may just seem like a minor annoyance at first. But if ignored for too long, Achilles tendonitis can keep you from running and cycling for months.

This is precisely what happened to Ironman 70.3 Champion Samantha McGlone. In 2007, the fiercely competitive former Olympian showed up in Kona and finished second in the Ironman World Championships, just minutes behind Chrissie Wellington. But a year later, she found herself sitting on the sidelines recovering from an Achilles tendon injury. Reportedly she spent about 6 months with no running or cycling at all. She struggled with the problem for nearly a year and a half.

Runners and triathletes are particularly susceptible to Achilles tendon problems. In part, this is because they are so determined to set goals and stay on track with training. But whether you are a marathon runner, an age-group triathlete, or someone chasing an Ironman World Championship, it can be hard to back off just because you have a little pain in the back of the heel.

Achilles tendonitis is really nothing more than inflammation within the Achilles tendon. Usually, the pain and swelling is in an area just above the tendon's attachment to the heel bone. This is an area known to be prone to injury due to decrease blood flow to this part of the tendon.

Inflammation in the Achilles' tendon is usually short lived. However, if you continue to run with Achilles pain, the tendonitis turns into tendonosis. This is what happened to McGlone.

Tendonosis is a degenerative condition where chonic inflammation essentially breaks down the collagen in the Achilles fibers. It gets mushy and weak. Many times surgery is required to clean out the tendon. Physical therapy can help speed healing. But, as Maglone learned, it won't just go away on its own. You have to see a sports medicine focused foot and ankle surgeon to get better.

Fortunately Sam is back in action. And today on NBC, we can all watch her chasing an Ironman World Championship in Kona, Hawaii. Although her recovery has been longer than the Queen K Highway on a hot windy day, she will surely show her fire and determination as she takes on the challenge on the Big Island.



Dr. Christopher Segler is a multiple Ironman Finisher and award winning foot and ankle surgeon. He lives and trains in the San Francisco Bay Area. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, visit http://www.MyRunningDoc.com or http://www.AnkleCenter.com .