Marathon Blister. Should I pop it?

Question:
Hi MyRunningDoc!


I have been reading your site. This blister formed on my heel yesterday. It is huge and painful. I am running in the Avenue of the Giants Marathon on May 5, 2013 and really can't take a break from marathon training. Should I pop it?

Thanks!
W.H., San Francisco CA

Answer:
Thank you for your inquiry! That is certainly a Giant of a marathon blister. I can see how that would hurt and put a damper on your final marathon training.

There is always an advantage and a disadvantage to draining in any blister on the foot that pops up during training.

With a blister that large and a marathon that close, it is unlikely that you would be able to run the marathon without significant pain. In fact the blister is so big it would probably pop during the marathon anyway.

With most small blisters, it is typically better to let them go away on their own. If you do not drain a small blister and can keep it from getting rubbed when you are running, the fluid will gradually recede and the blister will re-adhere. It will eventually peel away revealing healthy skin underneath. It is also the least likely to get infected because you don't open the blister allowing bacteria to get inside the skin.  This actually will heal the fastest and is the safest approach.

Things get tricky when a running blister on the foot gets big.

When you have a big running blister that causes a great deal of discomfort when you run, it actually hurts because the fluid is getting pushed and compressed.  If you step on a water balloon, the balloon will squish outward under your foot. The balloon will push out and stretch as far as it can unless it pops.

So when you run on a blister like this one pictured here, the blister fluid actually pushes and continues to separate the layers of skin at the edge of the blister. This of course causes more irritation and more fluid accumulation, making the blister even bigger as you continue to run.  The only way to stop this process is to stop irritating the blister on the foot. One way to do this of course is to stop running.

If you can pad the blister and keep the pressure off of it you might be able to continue training without the blister getting any bigger.  That would be hard to do given the location of this blister on the inside of the foot and heel. It will be almost impossible to remove all the pressure from the heel inside the running shoe.

If you pop the blister, it will hurt more for the first day or two.  You can decrease the amount of discomfort by using moleskin or another type of blister cover that will stop the friction from rubbing the overlying skin. It may also be helpful to put some padding around the blister in order to decrease irritation.

If you decide to pop your blister, it is always best to drain the blister by making a small hole at the bottom edge of the blister down toward the bottom of the foot so that the fluid will continue to drain downward and out of the blister as it re-accumulates. Typically some more blister fluid will accumulate inside the blister for several days after you pop it.

The skin on the top of the blister is not what is painful. It is the skin underneath. Some people start to drain the blister and realize this and then trim off the entire top of the blister. If you are to do that in this case, it would leave an open sore about the size of a half dollar. This would of course leave an enormous raw spot that would be very painful whenever you run during training. You foot would be killing you during the marathon.

In these types of cases it is often better to simply drain the blister and leave the top of the blister intact to function as a biologic dressing. This will take slightly longer to heal than if you don't drain the blister.  However this assumes that you are of course going to continue to run, train and complete the marathon that you have planned.

It would be best to be evaluated in person or by a podiatrist or arrange a remote consultation with a running injury expert in order to get more detail, before making your final decision.  You can also learn more about blisters from running by clicking here.

Dr. Christopher Segler, DPM a marathon runner, podiatrist and 10-time Ironman Triathlon finisher who is is Board Certified, American Board of Podiatric Medicine.  He believes the best podiatry practice combines cutting edge technology with the old-school convenience of house calls. He makes podiatry house calls for runners in San Francisco, CA and Houston ,TX. He also does remote consults for runners who live outside of the United States. If you have a question, you can reach him directly at 415-308-0833. You can learn more about running injuries at www.DocOnTheRun.com 

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. 

SF Tri Run Clinic: Foot Issues

Thanks to everyone from the SF Tri Club who joined us Monday evening for the Run Clinic. This was the second clinic in a series designed by Dino and Katie (our fearless Run Coordinators).

The point of the clinic was to discuss some of the keys to training that might help one avoid injury, particularly those running injuries that can wreck a triathlon season. We talked about running shoe selection, common training errors and barefoot running biomechanics.

There were many great questions from our Peeps. I will be posting those questions here, with answers, for all those who could not make to the Presidio Sports Basement for the clinic.

In fact, here's one now...

Question: What ARE the most common preventable running injuries?

Answer: The most common injuries I see in San Francisco runners and triathletes (that are preventable) are:
1. Stress Fractures
2. Achilles Tendinitis
3. Plantar Plate Injuries
4. Peroneal Tendintis
5. Sesamoiditis

See you out in the water, on the track, or on the road!

Dr. Christopher Segler is an SFTRi Club member, 10-time Ironman Finisher and Sports Medicine Podiatrist. He is Board Certified, American Board of Podiatric Medicine. His practice caters to active runners and triathletes in San Francisco, Berkeley, and Mill Valley. If you have a question about a running injury, you can call him directly at 415-308-0833.

Should I drain a liquid nitrogen wart blister?

Question:

I got a blister when I recently tried the liquid nitrogen treatment to freeze a wart on my foot. It is tender and so I stopped running. Should I try to drain the blister so I can run?

Answer:

The idea with treating a wart with liquid nitrogen is in fact to cause a blister. The way this treatment works is that when liquid nitrogen freezes the skin fluid collects between the dermis and the underlying subcutaneous layer of the skin creating the blister. The blister separates the skin layers. Here is how it cures a wart...

The wart is a thick callus covering an encapsulated collection of viral wart particles, which is within then the living layer of skin called the dermis. By creating a blister beneath the dermis (under the wart) the wart essentially gets lifted off of the underlying skin as the blister swells up.

The fluid within the blister will resorb over the next several days. As the blister heals and flattens out, it forms a scab-like structure that doesn’t fully re-adhere to the tissue underneath. Eventually the dried up skin of the blister peels off, and the wart goes with it. If all goes according to plan, you are left with new healthy skin underneath. 

There are many different blistering agents that can be used to cure plantar warts. Here are three of the most common wart treatments that work by blistering:

Liquid Nitrogen - creates a blister with a carefully placed frostbite-type injury. 

Bleomyocin - is a chemical blistering agent injected directly into the wart.

Canthacur - is a topical chemical blistering agent applied to the surface of the wart.

As every runner knows, blisters on the feet can be irritating enough to force one to limit their run mileage or stop running altogether. So it is not surprising that a runner may consider popping a painful blister to lessen the discomfort, promote healing and get back to running. 

This may be a reasonable strategy with friction blisters sustained during a marathon or other long run. But not so with warts treatment blisters.

The problem with warts is that they are caused by a viral infection of the skin. If you poke a needle through the blister (and through the wart containing all of those viral particles) you just might seed the surrounding healthy, non-infected skin with the wart virus. In this way, by attempting to drain the blister under the wart, you may actually infect other areas of the foot and cause a new wart to start growing nearby. 

Then, after the original wart (and its associated treatment blister) have gone away, you may have a brand new nasty little wart rearing its ugly head. Then you have to repeat this process all over again.

Another issue is that the fluid inside the blister is sterile. As soon as you poke a hole the blister fluid can drain out, but bacteria can also get in. So when you pop a blister the risk of bacterial infection goes up. 

If you have a wart that is being treated by a podiatrist, and the blister is large enough to interfere with your activities, you should follow-up with the treating physician. After all the doctor is being paid to treat the wart, so let the doctor finish what he started. Let your podiatrist decide whether or not to drain the blister, and do the draining if needed. That is the safest way to remedy the blister AND make sure that there isn’t any risk of causing a bigger problem long-term.

Heal fast and get back to running! 

Dr. Christopher Segler is a podiatrist who focuses on the rapid treatment of running injuries. He is a runner himself and 10-time Ironman Triathlon finisher. You can learn more about warts, blisters and running injuries at AnkleCenter.com and DocOnTheRun.com  If you have a question about a running injury, you can reach him directly at 415-308-0833.

Marathon Blisters Related to Pronation?

QUESTION:

Hi Doc,

I have just finished a marathon qualifier for an ultra coming up here in South Africa. I have always been pretty neutral footed, but with the tendency to pronate slightly. I have always had the odd blister after a very long run, but lately they seem to be worse and I am wondering if I am beginning to pronate more (can this happen over time?). I have taken a photo of some blisters that occur after a marathon. I don't like to get rid of them, I sorta let them callous for the season so its not so sore :-). Should I try pronation shoes? What are your thoughts? I use Nike Pegasus +28's. Really hope you can shed some light on this for me :-) 

Many thanks

ANSWER:

Blisters that pop up anywhere on the foot during/after a marathon are always the result of excessive pressure and friction. With excess friction the underlying layers of the skin begin to separate. Fluid accumulates and collects between the dermis and epidermis creating the fluid filled bubble that runners know as a blister. In the pictures here we can see that one blister has clear fluid and the other is dark. The dark blister implies that this is a collection of blood. This kind of blister is of course often referred to as a "blood blister." 

A blood blister insinuates more pressure or increased trauma, not just friction.

The location of the blister is important and helps a podiatrist figure out the cause. These blisters and calluses forming at the inside of the big toe joint. The medical term for this location is the "medial and plantar-medial aspect of the first metatarsophalangeal joint." 

All runners know the basic causes of blisters.  To be clear we will review:

1. Running shoes that are loose. The feet slide around with every foot strike and push off while running. The result of 26.2 miles of this is excessive friction producing blisters. 

2. Running shoes that are too tight. The feet are compressed against the inside of the shoes, increasing the risk of excess friction (with increased pressure) at parts of the shoe that move (such as the tips of the toes or ball of the foot where the break in the shoe occurs).  

3. Wet feet. Think twice about running through those garden hoses on the marathon course. Moisture in the skin can weaken the structure between the layers of skin, making blisters form with less friction that usually required. 

4. Starting and Stopping too much. If you are running with a walk/run approach, all of the starting and stopping actually takes more force (and produces more friction) than running at an even pace. This can increase your risk of blisters.  

There are other certain circumstances that can contribute to blister formation at the medial big toe joint. 

1. Pronation. As the foot pronates, the foot rolls inward, unlocking the joints in the mid-foot. The first metatarsal bone gets pushed up by the ground and the running shoe effectively twists right around the inside of the big toe joint. This of course creates excess friction and stimulated the formation of blisters during longs runs such as marathons. 

2. Bunions. Same forces at work as in excess pronation, with the added pressure at the bunion stick out and presses against the inside of the shoe. 

Solutions:

1. Blister-prevention socks that have 2 layers that can glide past each other. In effect, you beat up the socks instead of the skin.

2. Custom orthotics or over-the-counter inserts that support the foot, stabilize the subtalar joint and decrease pronation. If properly fitted and constructed, inserts can slow the pronation that contributes to the problem. 

3. Motions control running shoes. Stability running shoes decrease pronation with aggressive medial posting on a stable platform.  They are heavier, and stiffer. Beware-if you have high arches they can increase your risk of shin splints and stress fractures. 

4. Build mileage gradually. This gives the skin a chance to toughen up and form protective calluses without blistering.  

When in doubt. See a local podiatrist for a complete evaluation, running shoe analysis and gait exam to assess your running biomechanics. 

Dr. Christopher Segler, DPM a marathon runner, podiatrist and 10-time Ironman Triathlon finisher who is is Board Certified, American Board of Podiatric Medicine.  He believes the best podiatry practice combines cutting edge technology with the old-school convenience of house calls. He makes podiatry house calls for runners in San Francisco, Palo Alto, Sausalito, Pacifica, and Corte Madera. He also does remote consults for runners who live outside of the United States. If you have a question, you can reach him directly at 415-308-0833. You can learn more about running injuries at www.DocOnTheRun.com 

Today's View From the Run

Running in the San Francisco Bay Area is just amazing. Millions of people, but if you get off the main road, there is almost no one. Today at Crystal Springs, just a handful of runners and a placid dear enjoying the perfect weather. 

I love running. And I love California! 

Barefoot Running: Good Idea or Bad?

This weekend Dr. Segler was invited to speak at the International Foot & Ankle Foundation (IFAF) conference in South Lake Tahoe, CA. The group of attendees includes podiatrists, sport medicine specialists and foot surgeons from all over the United States.

The IFAF is a premier nonprofit educational organization established in 1979 dedicated to providing the highest level of continuing medical education programs in exciting venues around the world and providing increased revenue to help support continuing education, research, the Swedish Podiatric Surgical Residency Program, the Franciscan Foot and Ankle Institute and the NW Podiatric Surgical Biomechanics Research Laboratory in Seattle, Washington. Dr. Segler has become one of the featured speakers at IFAF events around the country.

On Friday Feb 1, 2013 he was lecturing on "Barefoot Running: Good Idea or Bad." The talk centered on his experience with elite triathletes, serious marathon runners and recreational runners with whom he has worked in the San Francisco Bay area. Dr. Segler explained that the key to understanding the trend is to appreciate the goals of runners embarking upon a minimalist path, while appreciating the potential biomechanical limitations and training pitfalls that can lead to running injury. He endorses natural running form as a cross-training tool for many runners and triathletes.

Dr. Segler was asked, “Do you feel that you are helping other physicians here at the conference by sharing your experience in treating runners and helping them address the unique biomechanics of running injuries?”

Dr. Segler replied, “Well, I certainly do feel honored that the IFAF has invited to me speak about my experience, but I personally really feel that I am the one learning and gaining the most at these events. When invited to share the stage with a panel of experts like this it forces me to pay very close attention to my work and my knowledge base. I actually have textbooks in my office written by the IFAF faculty who are also lecturing here. These are the people I have admired since I was in medical school. The expectations are high and those expectations force an attention to detail that requires learning.”

Dr. Christoper Segler is a 10-time Ironman Triathlon finisher who combines his personal experience as a runner and triathlete with his nationally recognized expertise as a running injury specialist in order to help injured runners return to running as quickly as possible. He practices podiatric sports medicine in San Francisco. Being passionate about running and the benefits it brings to athletes, he believes that all injured runners should think it is a reasonable goal to return to running. He believes that it is the physician's job to determine the patient specific goal of the patient and help achieve that goal not just find a different activity. He believes that running injuries are not a sign that running should be abandoned as an activity, but that there is a problem that has simply not been identified and adequately addressed. you can learn more about running injuries and even view the PDF of the lecture Dr. Segler gave at Lake Tahoe by visiting www.DocOnTheRun.com

What is The Best Way to Tape a Plantar Plate Sprain In the Ball of the Foot?

The plantar plate is a small ligament that reinforces the bottom of the joint capsule at the ball of the foot. When you sprain this ligament, the ball of the foot can be sore and ache when you walk. One of the best ways to decrease the stress to an injured plantar plate ligament is to tape the foot so that the ligament it stabilized and can heal. This video will show you how to tape the ball of the foot when the plantar plate is sprained or injured.

The first thing you need to do is get the correct type of tape. The very best tape is called Tensoplast (or Elastoplast). It is good because it stretches when you walk. With Tensoplast tape, the toe can flex slightly without getting irritated. You should order one roll of tape that is one inch wide by five yards in length.

Now that you have the right tape, you will cut a piece of tape to the correct length using your hand as a reference. The correct amount will reach from the tip of your finger the base of your palm. Next you will cut that piece of tape into two equal size pieces. Just cut the piece of tape lengthwise splitting it right down the middle. Take one of the two pieces and place it back on the roll to save it for later use. Now you are ready to tape the toe to help the plantar plate heal.

Take the piece of tape and center it on the top of the second toe. You should place the tape between the foot and the last knuckle in the toe. The tape should be right at the base of the toe. Wrap one strand around the toe, pull down slightly to create some tension in the tape and stick the tape across the ball of the foot so that it is in place on the bottom of the foot under the little toe joint.

Now take the other strand and it wrap it around the toe in the opposite direction, pulling down slightly to create some tension in the tape. This strand will cross over the other as you stick the tape across the ball of the foot so that it is in place on the bottom of the foot under the big toe joint.

If placed correctly and looking at the bottom of the foot, the tape will look somewhat like a breast cancer awareness ribbon. With the tape in this position, the pressure on the tape when you walk will keep it secure. There should be just enough tension in the tape that the second toe is pulled downward slightly lower than the third toe. This will decrease the tension on the plantar plate at the bottom of the second toe joint and help it heal.

You should keep the tape on 24 hours a day to protect the plantar plate as the sprain heals. Change the tape if the adhesive wears out and isn’t sticking to the the bottom of the foot. If your skin becomes irritated, discontinue use. Don’t tape the toe if you have an allergy to tape or adhesives. Heal fast, and get back to running!

This instructional video was created by Dr. Christopher Segler who a 10-time Ironman Triathlon finisher. He is also an internationally recognized expert on running injuries and healing foot injuries while running. He is often invited to lecture on the rapid treatment of complicated running injuries to foot surgeons, podiatrists and sports medicine physicians at medical conferences. He practices sports medicine podiatry in San francisco, CA, but also offers remote consultations world-wide. To learn more about the causes and treatment of capsulitis and plantar plate injuries, visit the ball of the foot information page at www.AnkleCenter.com. if you would like to learn about how to get the fastest treatment possible for a plantar plate injury, you can learn more at www.DocOnTheRun.com.

Disclaimer: This video is intended to provide general information about sports medicine injuries and self-teatment options. This of course is not (nor is it meant to be) a sufficient substitute for a medical evaluation by a local physician or medical doctor.

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