Dr Marybeth Crane talks about chronic heel pain and the difference between plantar fasciitis (acute) and plantar fasciosis (chronic). Have a listen.....
Podiatrists have been prescribing compression socks for years to treat things like chronic edema, lymphedema, varicose veins, and to prevent deep venous thrombosis; but recently they have started showing up on perfectly healthy runners. Yes, sometimes compression socks are used to treat shin splints, but do they make you faster? Can you run longer in compression socks? Many runners and triathletes swear by wearing compression they feel faster and recover better. Do they really work? Is there any scientific evidence that they really work? Or is this just more running lore?
In 2007, one study showed no increase in endurance or speed, but they were shown to stimulate blood flow, helping legs recover faster from a hard run. OK, so they help recovery, but can they make me faster? That early study didn’t think so, but that’s why we kept looking.
Most theories about how compression socks improve running performance focus on the physiological and biomechanical support of the lower legs. It is assumed that compression socks may enhance venous return to the heart through a more efficient calf muscle pump, leading to increased endurance capacity. And there is the notion that because muscles are kept more compact, balance and proprioception are improved and muscle fatigue is minimized. Sounds reasonable, but again, what does the research show?
It wasn’t until 2009 that a German study clearly showed that they enhance performance during hard runs. And research done in South Africa and New Zealand both show that knee-highs also improve recovery by boosting blood flow in the extremities. In fact, even compression socks (not your Grandma’s TED hose) have been shown to increase resting arterial circulation by 30% and 40% under physical strain. Many compression sock companies even tout that they have studies that shoe an increase in running efficiency by 5%, which can equate to taking 12 minutes off a four-hour marathon. Crazy? Maybe not? Yet they still aren't for everyone.
One German study conducted on super-fit elite athletes (not most of us in the back of the pack) reported no performance payoffs from compression. According to the study, the socks work better when they're squeezing more performance out of non-elites (you and me).
Lots more studies to come, but if donning some hot pink knee socks will take 12 minutes off my marathon time, bring them on!
Confessions of Myrundoc: Do as I Say, Not as I Do.....
Time to come clean. Yes, I too can fall victim to a running injury. And yes, of course it's a foot related issue. Turns out the old adage is true that doctors are the worst patients, just like plumbers often have leaky pipes at home :) in fact, I think doctors are the worst patients only trumped by pilots. Yes, it's a control issue!
Because I'm the local authority on running injuries I of course started to treat my injury when it was in its mild form....Not! No, I did like most of my patients and ignored it until my foot hurt so bad the day after a race that I could barely out my heel on the ground. Yes, I suffer from the dreaded and incredibly common plantar fasciitis in my left foot. Why? A combination of the perfect storm.
I would like to blame it on the White Rock Marathon, you all remember that glorious day.....45 degrees, pouring rain....but if I'm honest, it started way before that. I ran the DRC Half in November with bronchitis (also a brilliant move) then barely trained the rest of that month as I was getting over my upper respiratory infection. Couple that with an incredibly busy November and December in the office and the OR; you get poor training schedule, exhausted body and depressed immune system. Oh yeah, I also ran the White Rock Half marathon in the pouring rain and had to run the Bold in the Cold Half marathon because my running club was putting it on and the medal was cool.
Long story short, what started as a little tightness at the Phoenix Turkey Trot over Thanksgiving (oh yeah, ran that too, then climbed Camelback Mountain the next day), became a swollen, sore foot by the first weekend in January.
So what do I do? I stopped running. This wasn't really a choice since I could barely put my foot on the ground the day after Bold in the Cold. I started icing, taking Advil and lots of stretching. I looked at my shoes and realized I had five pairs I was working on and all of them were dead. My orthotics were 3 years old and needed replacing. I started wearing nothing but a brand new pair of running shoes to work and clogs on the OR. I even let my partner give me a steroid injection. And I got in the pool and on the elliptical and bike so I didn't gain a million pounds!!
A month went by and I was somewhat better. Maybe 50% but still couldn't run. I was now starting to get annoyed and my staff wanted me to get back to running so I would stop being cranky! Onto EPAT....why have technology if you aren't going to use it? What is EPAT. Yes, I had the EPAT procedure performed the first week in February and yes, it hurts like hell but way worth it. I was about 70% better after the first treatment and 80% after the second. I still did the night splint (incredibly annoying but effective for the first thing in the morning owie), had gotten a brand spanking new pair of custom orthotics and still wearing nothing but running shoes, clogs and a two inch heel when necessary.
I went for my first run in 6 weeks yesterday in Napa Valley, CA. I was in wine country for a conference and my foot was feeling so much better. I did 4 miles of walk run and did pretty well. Tight but not painful! I'm going to have my third EPAT this week and I think that should do it. Maybe I will let the staff video it so you can all join in.
What did I learn? Listen to my own advice. Do as I say, not as I do. If I had started stretching, icing and looked closely at my shoes and orthotics at Thanksgiving; this whole saga probably could have been avoided. Stubbornness and the fact that when I close my eyes I'm 19, did not help me recover.
Thank God for technology! The EPAT certainly saved the day for me. I'm sure two months of physical therapy would've had the same result, but time was short and technology available! Bring on the triathlon season! First race St. Pat's Sprint Tri in Keller on March 10th!
Got Heel Pain? Give me a call!
Thanks For Watching....stay tuned for more!
It’s one week after the cold, wet rain permeated the White Rock Marathon. Lots of people, including my mother, have asked me if I caught pneumonia from running “The Rock”?
So, does running in the rain make you sick? This is one of those questions that seems to be doomed to getting inconclusive answers forever. Especially when it comes to the opinion of Mom!
People usually do get sick more when the weather is rainy. That's because they stay indoors more, and indoors is where cold and flu viruses spread because of increased contact between individuals. On a sunny warm day, everybody goes outdoors, where there is (obviously) more space, better ventilation, and less physical contact with large numbers of other individuals.
Catching an infectious disease such as the common cold requires direct exposure to the pathogen (virus). Exposure comes in the form of close contact with an infected individual. Going into cold and rainy weather will not make you sick unless you also get colonized by the pathogen while you're out there.
There have been reports that cold temperature itself reduces the effectiveness of our immune system, but even that's not sufficient alone - you'd still need exposure to the virus.
"Cold and rainy weather causes virus infections to spread more rapidly than usual" - Fact, due to people staying indoors more and getting exposed
Wash your hands, stay away from people who are sick, and feel free to run and play in the rain, just like we did last Sunday at the White Rock Marathon. Run Happy....and remember to jump in puddles after the 6th mile when your feet are already soaked!
Do NSAIDs Impair Fracture Healing?
There has been a theory that comes from looking at animal studies that NSAIDs like ibuprofen or Naproxen inhibit bone healing and may cause delayed unions or non-unions in fracture patients. Some doctors even go so far to say that you shouldn’t use NSAIDs in postoperative orthopedic case; but what is the truth?
A recent article in the Journal of Family Practice by Yates, Shah and Blackwell, showed NO, ALTHOUGH THE EVIDENCE VARIES. Nonsteroidal anti-inflammatory drugs (NSAIDs) don’t appear to impair clinical fracture healing. Even though animal studies show delayed healing and nonunion with NSAID use, evidence in humans doesn’t merit avoiding NSAIDs in patients with fractures who need the drugs’ analgesic and anti-inflammatory benefits.
NSAIDs are commonly prescribed to control pain in patients with fractures. Laboratory studies have found that their antiprostaglandin properties delay callus formation and subsequent healing.1 However, human studies evaluating the effects of NSAIDs on fracture healing have found variable results.
The majority of physicians agree and recommend using NSAIDs temporarily along with other measures—such as rest, ice, and a steady return to the aggravating exercise—to relieve the pain of stress fractures until the patient is pain-free.
For more info on this retrospective study, click here.
If you are a frequent visitor to Foot and Ankle Associates of North Texas in Grapevine, TX, you probably already know about orthotics. Maybe you have even purchased orthotics. A foot orthotic is an insole placed into the shoe that helps control foot position.
There are two main types of orthotics: Functional and accommodative. These can be prefabricated; like Lyncos that are popular at Healthy Steps or custom; which the doctor fabricates unique for your feet. A functional orthotic controls foot movement and helps a person walk in a way that best supports joints and muscles. An accommodative orthotic helps distribute foot pressure evenly over the bottom of the foot. Most patients use a functional orthotic and usually these are custom for long term usage. A functional orthotic can be useful for many problems and are used to balance the biomechanics of your feet. Think of them as an in-shoe tire realignment for your feet. Accommodative orthotics are very useful to distribute stress in the elderly, diabetic and arthritic populations.
In the foot care aisle at your local drug store or grocery store, you may have seen readymade orthotics for sale. Does it really matter whether you buy store bought orthotics or custom orthotics from your podiatrist? Well, some people may be able to get away with wearing store bought orthotics for a period of time. We often even start our treatment plans with these type of prefabricated devices, so we can get you on the road to better foot health right away; but most patients do need custom for long term control of their foot type. When you think about the long term health of your feet, custom orthotics are the way to go! Store bought orthotics are made to fit many foot problems for a large variety of people; one size fits all usually means one size doesn’t truly fit anyone! To be truly effective, an orthotic must be fitted for YOUR particular needs. Wearing an ill fitted orthotic is not only a waste of time, but it can also make your foot problems worse. Over time these problems can lead to leg, knee, hip, and even back problems. Store bought orthotics tend to not offer long lasting comfort. If you find yourself buying store bought orthotics every few months because of foot pain, it may be time to schedule an appointment to see one of the doctors at FAANT. Your podiatrist will produce orthotics that fit only YOUR feet. The materials used will be those that are best suited for your walking and running needs.
Everyone deserves special treatment! With a real custom orthotic that is exactly what you have. Yes, custom orthotics can be costly, but so can surgery from walking incorrectly over the years. I’m always amazed that some insurance companies will not cover orthotics, but will pay for surgery! Doesn’t make any sense!! Think of the orthotics as an investment and an investment in your health is one of the best choices you can make for yourself.
Love the Shout out in the Dallas Morning News!
Thanks to the shout out from my friend and running peep Spareribs LaMothe in the Dallas Morning News Running Blog this morning. He made a few great points about injury management in his blog. The two best were to seek professional help early in the injury course. The faster you obtain a correct diagnosis, the sooner you will get better! The second point was to find a doctor who runs! As a sports medicine podiatrist who endulges in border-line crazy endurance sports, I speak your language and have a network of other doctors and therapists that are all on the same page!
If your doctor thinks that "LSD" is still a drug and not an acronym for "Long Slow Distance", maybe you need another doctor for your running injury!
Thanks again Spareribs! See you around Lake Grapevine!
Be patient! Keep exercising to get better. Patellofemoral pain can be hard to treat, and your knees won't get better overnight, some people are lucky and get better quickly but it might take six weeks or even longer for your knee to get better. Very few people need surgery to relieve their knee caps instability. Remember, you'll be less likely to get this pain again if you continue to strengthen and avoid “too much, too soon, too fast syndrome!”. Even though the cause of patellofemoral pain syndrome remain uncertain, the good news is that most patients do well with conservative treatment, particularly if they maintain a disciplined approach.
Over my 30+ years of distance running, I've had many black toenails. In fact, I suffered one at Ironman Texas last weekend! A few of my friends, who also participated, stopped by the office this week for black toenail treatment. The following is my advice in trying to avoid and treating this common problem.
Almost everyone who runs will eventually get a black toenail. Getting your first one is a sign that you are now part of the endurance club. Its kinds like cycling. There are two types of cyclists; those that have fallen and those that will fall. While most runners blame a shoe that is too small, this is often not the main cause. Mine was from the well-meaning volunteers who soaked my running shoes trying to cool off the triathletes with their hose! Squish, squish, squish for 26.2 miles equals blisters and black toenails!
If a toe is under pressure from the shoe or a sock that is too tight or too thick, the sustained pressure, step after step, produces an impact or a friction problem between the toenail and the tissue surrounding it. When the tissue gets damaged, fluid accumulates. This is called a subungual hematoma. The red or black color is the result of a few blood capillaries that become broken in the process. The more fluid that accumulates, the more pain. The extra fluid, colored by some blood, accumulates below the toenail. When the pressure gets too great, the existing toenail will be separated from the nail bed.
Really, most of the pressure that results in this "toenail injury" is produced by the regular action of the foot coming forward, thousands of times every mile. Each time your foot swings forward, a little extra blood is pushed into the toe region due to the force of the foot coming forward. If you increase your distance regularly and very gradually, your toes will adjust to each new maximum distance and only complain when you extend farther. In a marathon training program, almost everyone gets at least one black toenail. Running faster too soon and too long will increase the chance of this injury.
Hot weather also improves your odds of getting one. When it's warm, your feet swell more than they would on cold days. Because there is more pressure, and more fluid, there are more black nails generated during the summer months. This is especially true when it is humid!
How do I prevent black toenails?
You'll reduce the chance of a black nail if you ensure that you have enough room in your toe area when you fit your shoes. At least half an inch is needed, when you're standing in the prospective shoes (in the sitting position, the toes aren't all the way forward). If you've had a history of black toenails and summer is approaching (or here), you may want more toe room. When you add more room at the end, ensure that the arch of the shoe matches up with your arch. Also, run in the shoe before you buy it to make sure that the shoe isn’t too big and that your foot doesn't slide forward as you're running, which can aggravate the toe more than a tight toe box.
Do all black toenails need to be treated?
Leave black toenails alone and allow them to grow out if they are not painful. About 70 percent of the black toe problems are best treated by ignoring them. The damaged part of the nail is gradually pushed out, and the foot slowly returns to normal. If they are painful, red, or swollen; time to see your podiatrist.
Can I just stick a needle in it to drain it?
Do not attempt bathroom surgery! Many runners will heat up a needle and drain the fluid under their nail. Often this introduces bacteria and now you have a painfully infected toe! Take any sign of infection seriously. If it continues to hurt or the pain increases, this is a bad sign. Toe infections can lead to cellulitis (blood poisoning), gangrene, and worse, especially if you have diabetes. See your podiatrist first, not last!
Will I lose my toenail?
Yes. It will take a few weeks or months, but as the toenail continues to grow, eventually it shoves out the damaged, blackened toenail. The black toenail is raised off of the toenail bed, and underneath it is often the healthy remainder of your toenail. Your black toenail will gradually loosen from the sides and you will be able to trim it away.
When will my toes be pretty again?
If pretty toes are important to you, you can paint the black toenail or even the thin new toenail, or the bare skin. You can also stop by Healthy Steps and have a prosthetic nail put on by our licensed medial nail technician. Most people won't notice the difference if you use a darker shade of polish. Full replacement of your toenail takes about 3 to 6 months, and the new toenail will often be a bit wavy, thin in some areas and thicker in others. After 8 to 10 months your toenail should be back to normal (unless you get a side infection of fungus….another topic).
Black toenails are part of distance running, but take them seriously or they can stop you in your tracks!
I normally do not comment on football in my blog, but I have been asked this question so many times this week that it is comment worthy. For the record, even though I have allegiance to the New England Patriots and the Cowboys, I have always been a Brett Farve fan. He is the epitome of the endurance athlete as a football player, just like Cal Ripken was an example of the ever present endurance baseball player. (Yes, I love Cal too!) That aside, I think Brett is crazy to play tomorrow!
Why? First, he has two fractures in his foot and ankle. A stress fracture in his ankle and an avulsion fracture of his calcaneus (the heel bone). His ankle is already a disaster in which he has had at least 5 surgeries that we know of and has significant degenerative arthritis! Why make it worse? The season is a disaster and the Vikings are losing confidence in him. If he can’t move tomorrow, he is either going to get seriously hurt or get pulled by the coach. Why not sit voluntarily?
On the flip side, he probably needs an ankle replacement already. He could numb up his ankle, play, then risk crushing whatever cartilage was left. Stupid! And a bad example to younger football players. Face it: the season should be over and he should call it a career. (Which he should’ve done at the end of last season anyway!
Brett, don’t play. You risk hurting yourself more or at the very least looking more stupid that your antics have been in the last two years!
How long does it take to recover from a marathon? How long does it take to recover from an Ironman triathlon? How much racing is bad for my body? These are all good questions posed in my office on a regular basis. The problem is that the answer is always, "It depends". Everyone recovers at a different rate. Age, experience and current fitness level are large variables in the equation. I know a marathon runner in town who ran 100 marathons in a less than 10 years; and of course, we have all heard of Dane Rauschenberg who ran 52 marathons in one year for charity and then wrote a book about it! The flip side is that I know runners who can only do one marathon a year without getting hurt and most triathletes only train for one Ironman a year.
So what is the magic formula? How much is too much? I think the first thing to think about is what is your goal? If you are just talking about finishing the marathons and not really having a time crunch, then feel free to do up to six a year but realize that having more than two quality runs in a year is very difficult. The Ironman distance should not be attempted more than 2 or 3 times a year regardless of time goals! Now, for those of us who are addicted to the watch, "racing" a marathon is something that should not be done more than twice a year. "Racing" an Ironman triathlon should only be attempted one a year.
Why is this true? Well, simple math. It takes a minimum of 4 months to train effectively for a marathon and 6 months for an Ironman. Then you need at least one day for every mile you ran and three to five days for every hour your triathlon took. That means a month of recovery before you start to train again after a marathon and at least 6 weeks after a 12 hour Ironman. Last time I checked, there were only 12 months in a year; hence, the common recommendation of racing no more than 2 quality marathons or one quality Ironman triathlon a year.
Why do some people recover faster? Age. My feeling is that youth is wasted on the young. I remember being able to run a marathon and get up and go to work the next day. Now I have to take at least one day off and often take two! Experience does help. Your body has been there before, so it knows it will live. Veterans often have a post-race routine down that helps them recover. (Often this includes the anesthesia known as beer!) If your fitness level is high and your nutritional status is good, you will recover faster.
What can you do to hasten recovery? Walk a cool down after the race. Do not sit down immediately even though your legs are begging you to! Take a 15 to 20 minute walk and stretch gently. An ice bath is best, but very few people I know are that tough. A cool bath followed by stretching before you go to bed is helpful. A large amount of carbohydrates and water also helps. Hence the beer phenomenon! A massage a few days after the race will help you recover. More than anything, do not start training again until you are fully recovered. Many injuries occur due to too much, too soon, too fast and too fatigued syndrome!
So how much is too much? Again, the answer is always, "It depends." Listen to your body. Really listen and stop being stubborn or stupid! If you start training and you are exhausted, you are doing too much. If you are spending too much time in my office and less on your bike, you are doing too much. The answer is really simple stupid. Listen to your body and it will tell you how much is too much.
Bottom line: Let your body fully recover from your races and quality times will be recorded. Race only one to two marathons or one Ironman triathlon a year. As for other distances, keep in mind that you need one day for every mile of a running race and at least 3 days for every hour you raced in triathlon. Anything shorter, you better take off your watch and go for the finish instead of the time and prepare yourself to spend some quality time with your local sports medicine physician!
Run Happy! And Recover Well!
Did you know that there are more than 250,000 Achilles tendon injuries in the United States each year? Of these injuries, almost 25% require some kind of medical intervention to heal. A fully ruptured tendon requires surgery. Most other injuries can be treated conservatively and will resolve without surgery.
The most poorly understood Achilles tendon injury is actually not an injury of the tendon, but an inflammation of the bursa sac that separates the tendon insertion on the heel bone from the back of your ankle. The fluid in the bursa actually allows the tendon to move smoothly over the bone. When the bursa sac becomes irritated from frequent or abnormal movement, it becomes inflamed and bursitis can set in.
Achilles bursitis, also known as retrocalcaneal bursitis, is a common overuse injury in runners, hockey players, football player and many other athletes. Improper shoe gear and too much, too soon, too fast syndrome are usually the cause of this pain in the heel. It can also be seen in non-athletes who wear poor shoe gear or low cut shoes. Often it is seen in people with rigid, high arched feet.
Bursitis is a painful swelling that occurs in the back of the heel just deep to the Achilles tendon insertion on the heel bone. This inflammation makes it painful to squat, lunge or run uphill. Many shoes press on this area and make the pain worse. Even running on uneven or soft surfaces can increase the inflammation.
First line therapy for Achilles bursitis is rest, ice, heel lifts or heel cups and gentle stretching. Many patients require physical therapy and functional foot orthotics for complete relief of symptoms. Severe cases my even require a period of non-weight bearing casting or bracing prior to physical therapy in order to decrease the inflammation of the bursa. Chronic cases may even require more invasive therapy with extra corporeal shock wave therapy or injection of platelet rich plasma to jump start the healing process. Surgery is rarely needed unless bursitis is ignored for a significant period of time.
Long standing Achilles bursitis can cause significant difficulty in ankle movement and often a spur will form within the insertion of the tendon. Left untreated, this can eventually cause a rupture of the Achilles tendon at the insertion and lead to life long disability. If you are experiencing painful swelling in the back of your ankle, seek the help of your podiatrist early, so you can get back to running quickly and avoid any long term effects of this chronic inflammatory syndrome.
So Run Happy! And Injury Free!
A stress fracture is a tiny crack in the bone caused by overuse. Most stress fractures occur on your metatarsal bones in your foot but they can occur in any part of the body. Stress fractures develop over a long period of time and are often initially unnoticed. Your bones naturally break down bone and rebuild bone on a continual basis. If too much force in repeatedly applied to the bone, then the breaking down of bone will exceeds the rebuilding of bone. The bone is insufficiently repairing itself. This is called bone fatigue. Over time the bone becomes weaker and eventually cracks. The fracture is very small and is often unapparent on x-rays.
Physical activity is always encouraged, but working out too hard too fast puts your body at risk for injury. When starting to work out or changing your workout routine, make sure you give your body time to adjust to the new stresses. It takes time for your muscles and bones gain the strength necessary to absorb the impact of running, jumping, and jarring. When your muscles fatigue, they no longer distribute the forces along the entire bone and the bone has to carry an increase of load. This will lead to fractures. Sometimes even changing the surface you run on can lead to injuries. If you are used to running on the grass or a softer surface, changing to cement or concrete surfaces will force your body to absorb more of the impact. You may not notice the bone fatigue initially but over time, you may develop a small crack in the bone or stress fracture.
Stress fracture pain is usually experienced with increased activity. Therefore, one may notice the pain to get worse the more they work out. The pain also occurs earlier in the workout as the fracture progresses. Initially the pain will subside with rest, but as the fracture increases in size the pain will become more constant. The pain may also be elicited by palpating the area over the fracture. Sometime a doctor may use a tuning fork to elicit the pain. The fork causes vibrations in your bone, and if a fracture is present it will cause pain. If no fracture is present, the tuning fork will not cause pain. Your podiatric physician will also take x-rays to rule out any other complications. The stress fracture will often be unapparent on a x-ray because the crack is so small. Therefore, the physician may need to order an MRI or bone scan to further assess the injury.
The best treatment for a stress fracture is rest. Chen Lu, a professional figure skater, missed the Olympics due to a stress fracture, Scott Neidemayer missed his Hockey All Star Game, and Yao Ming had to sit out a large portion of the season to nurse his stress fracture. Whether you are a professional athlete or have sport hobbies, you need to rest if you have a stress fracture. The only way to fully recover and prevent the injury is to slow down and allow your body to heal. Changing your workout to less impact sports and slowly increasing your body’s demands is highly recommended. Athletic shoes lose their shock absorptive properties and should be replaced at least every 6 months. NSAIDS can be taken to reduce the pain but should not be taken for long periods of time. If you are experience any foot pain that is continually getting worse, you should see a podiatric physician to assess the injury.
This is a guest blog by Dr Peter Wishnie.....Run Happy! And with less stress :)
Cowtown Marathon kicked my butt! I'll admit it. I have again been humbled. It happens to all of us from time to time. I thought I was in good enough shape even though I had been lazy in my training lately. Too many things to do, not enough time. I was taught again to respect the distance. Yesterday's Cowtown Marathon in Fort Worth, TX was typical of the marathons I have run in the last two years: Freezing (25 degree wind chill factor), 30 mph wind in your face half the time, and added killer, rolling hills to the mix. I have not had good race karma. I thought White Rock Marathon in December was bad, but this was much worse and very hilly. For the record, I HATE COWTOWN! The last time I had run this race was in 1999. My peeps talked me into running it again because the Austin Marathon weekend timing didn't fit the schedule and this was closer to home. Never again....But truly it was not all the race's fault. It was poorly organized with random water stops and almost no spectators, but that's not why I had a bad day. I've been traveling too much, hadn't run enough (only one 20) and was mentally and physically tired. My absolutely wonderful running peep, Dr Steve Buksh, ran the whole way with me and should get a huge reward for not killing me when I started whining then ultimately crying (yes, that bad of a day). My hamstrings went into a seizure at about mile 16 from all the hills and we walked a good 2 or 3 miles. By 23 miles, I could barely run and looked like an epileptic. Definately not my day...but the lesson learned is to respect the distance. No matter how many times you have run 26.2 miles, it is still a formidable task and not for the weak or unprepared. The marathon humbled me yesterday and I learned my lesson....always respect the distance.
Now we can talk about delayed onset muscle soreness tomorrow when I can barely walk :)
Run Happy ....and respect the marathon or she will beat you into submission!
Inspiration From Newbies!
This morning I got to spend a few minutes with a new group of hopeful marathon runners who had joined the local Team-in-Training Program raising money to fight Leukemia and Lymphoma. It was 35 degrees and I had to drag my 2 year old with me because of life's bad timing :) I was not in the greatest of moods when I got there, to say the least.
My bad mood cloud almost instantaneously lifted and my mood changes 180 degrees! What amazed me is that you could almost palpate the hope and joy in this group. A cold Saturday morning at 7am and they are laughing, joking and supporting each other in this endevour. These types of moments always reinforce the realization that it is the journey, the miles on the pavement, the friends and peeps we run who support us, laugh and cry with us, that make marathoning such an uplifting pursuit....a growth experience for all...not the race itself, but the journey to get there.
I applaud everyone who got up this morning, laced their running shoes and headed out the door to run with their peeps.....
Happy Valentine's Day! Here's to the love of the run.......
Alert the Media! A below knee cast was seen to provide better and faster results than a removable walking cast or ace bandage in severe ankle sprains! Duh! You can't take off a cast and it forces you to be compliant. Most of our patients want to be compliant but life gets in the way. Ten days in a cast rapidly improves short term outcomes......what will they report next? That physical therapy imporves long-term outcomes? Who funds these studies? Can I get some of their money to prove common sense? Just kidding......
For complete article: click here
Primary source: The Lancet
Lamb SE, et al "Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomized controlled trial" Lancet 2009; 373: 575-581.
Additional source: The Lancet
Hertel J "Immobilization for acute severe ankle sprain" Lancet 2009; 373: 524-526.
Severe ankle sprains healed significantly more quickly with a below-knee cast or air-cell brace compared with a Bledsoe boot or a tubular compression bandage, investigators here reported.
The 10-day below-knee cast and the Aircast resulted in 8% to 9% improvement in the quality of 90-day recovery compared with a tubular compression bandage, Sarah Lamb, D.Phil., of the University of Warwick, and colleagues reported in the Feb. 14 issue of The Lancet.
The degree of improvement with the Bledsoe boot did not differ significantly from that of the tubular compression bandage, which was the least effective device.
The quality of recovery at nine months did not differ among the four devices.
"Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery," the authors said. "This was achieved best by the application of a below-knee cast. The Aircast brace was a suitable alternative to below-knee casts."
"Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device," they added. "Tubular compression bandage, which is currently the most commonly used of all the supports investigated, was, consistently, the worst treatment."
Severe ankle injuries (grade II-III) can cause significant incapacitation and require three to nine months for recovery in most affected individuals, the authors noted. Systematic reviews have revealed lack of high-quality evidence to aid clinical decision-making related to management of severe ankle injuries.
For more information on the treatment of ankle sprains, click here.
Run Happy! And try not to fall down go boom!
A very smart person once said that a goal not written down is just a mere wish. I passionately believe this is true and have proven the power behind written goals in many aspects of my personal and professional life. In fact, this year I was planning on running the Sacramento Marathon, but fell in a pothole and broke my foot just a few months before the race! The fact that my foot was broken did not deter me from trying to reach my goal (Yes, I am that stubborn). I cross-trained; swimming and biking for hours, trying to keep my cardio fitness intact, just so I could indeed run this planned marathon. It was the week before the race when my husband interjected just a little common sense (please don’t tell him I said he was right) and he asked me why I was so hell bent on running Sacramento? There were so many other races on the schedule and I had only recovered from my stress fracture 3 weeks prior and done a long run of only 16 miles. I really did not have any good reasons to tell him except for the fact that I had written it down as a goal almost 6 months prior and I was determined to reach that goal. Common sense intervened (maybe I’m not that stubborn after all) and instead I did my first triathlon, all that biking and swimming was good tri training, then I picked a marathon 2 months later that I could run after adequate training. Goals are a powerful thing. Running goals can take on a life of their own and guide our training.
I challenge all of you to do a goal writing exercise to determine where running fits in your life. Think about lifetime goals; perhaps qualifying for Boston or just to finish an entire marathon; then break down your goals into smaller segments. Try to ascertain how you will reach that lifetime goal by achieving smaller goals; write down your 5 year goals, your 3 year goals, your 1 year goals, and finally your immediate goals. It is hard to run a marathon without starting a running program, perhaps training for your first 5K can be your quarterly goal, then a 10 or 15K for 1 year goal, then build up to the marathon or a faster marathon from their. Again, looking at lifetime goals by themselves is often overwhelming; but broken down into smaller increments become very doable!
Look at your goals then start a reasonable plan to meet them! Not only are you more likely to meet your goals if you write them down, but you are also less likely to get injured if you follow a plan.
Run Happy! And reach For Your Goals!
There are general rules for injury prevention that must be followed to avoid loss of training due to injury. Consistency and gradual incremental increases in overall athletic stressors are the key to any successful training program.
Causes of injury
Probably the main cause in distance running is the volume of training, especially if there is insufficient rest between sessions. This is the classic “too much, too soon, too fast” syndrome. Research has indicated that there is no link between speed and injury in distance runners, unless of course an appropriate warm-up routine has not been followed. Don't overdo it! The amount of training you actually carry out plays a key role in determining your real injury risk. Studies have shown, for example, that your best direct injury predictor may be the amount of training you completed last month. For example if May is a heavy training period, watch out in June! This relationship may seem strange at first, but it simply reflects the fact that vigorous training produces tired muscles which may not be able to stand up to further training stresses. Fatigued muscles also do a poor job of protecting their associated connective tissues, increasing the risk of damage to bones, cartilage, tendons, and ligaments.
Many injuries occur due to weak muscles or muscle imbalance. Assessment of muscle strength and balance and regular sports massage can be an integral part of a sports injury preventative strategy.
Resistance strength training can make muscles less susceptible to damage. This can be achieved in the gym or at home in your living room with a few dumbbells and a core ball.
It is important that any exercises are specific to your sport. In distance runners, adding hill training to your strength program can be a valuable tool for injury avoidance if carried out properly. Core stability exercises are an extremely useful tool in preventing muscle imbalance, especially in woman.
Remember that to achieve your running goals, you need months and years of successful running free of injury and illness. Pay attention to your body and all of these tips to ensure that you’ll continue to pound the pavement injury free for years to come!
Dr Crane advises the new training program at Luke's last Thursday night. A good time was had by all, but if you missed it we have provided the highlights. The video is broken into two parts because YouTube will only allow 10 minute videos and it is 18 minutes before the Q&A!
We are unique individuals, and one formula will not be right for everyone. It takes time to figure out what works best for us, but the important thing is that you learn from experience, and enjoy the process of becoming a better, stronger runner.
Run Happy! And Injury Free!
The jury is still out when it comes to stretching in the running community. I have been running for almost 30 years with multiple coaches on numerous competitive levels, all of them told us to stretch daily to get faster and avoid injury. Yet many incredibly competitive runners never stretch and never seem to get injured. Is there any proof that this common recommendation is actually valid? What do the studies say about stretching? Does it really prevent injury? Will it make me faster? Again, the experts really don’t agree on much! In most arguments between stretchers and non-stretchers, it inevitably comes down to "stretching helps prevent injuries" and "stretching is a leading cause of injuries in runners".
The motion of running, repeated over many years, strengthens and shortens several posterior muscles. The most affected are the calves, the hamstrings and the lower back muscles. These muscles play a primary role in lifting the feet and moving the runner forward. Exercise physiologists blame shortened muscles for a reduced range of motion, decreased athletic performance and increased risk of injury. To add insult to injury, the aging process contributes to further loss of joint and muscle flexibility.
The majority of runners and coaches believe stretching improves performance and reduces the risk of injury. In the meantime, experts disagree on the benefits and dangers of stretching. While many experts credit stretching with numerous benefits, improper stretching remains the second leading cause of running injuries! So, if we believe in stretching; what is the most effective method?
First and Foremost; the warm up and cool down should never be optional in your running routine. Cold muscles are at the highest risk for injury; by warming up and increasing the temperature of your muscles they will be more flexible and have an increased speed of motion. Warming up can loosen your muscles and soft tissue as much as 20 percent. The cool down allows blood to continue flowing through your muscles, working its way more slowly from a high level of exertion to its normal resting condition. Build stretching into your regular schedule, both before and after your daily run; after warm up and as part of your cool down. Take the time, it’s worth it!
Bottom line: Most experts agree that stretching reduces muscle soreness after running and results in better athletic performance. Gentle stretching after a race or intense workout can also promote healing and lactic acid removal from the muscles. Stretching is most effective when performed several times each week; a minimum of one stretching session per week is sufficient to maintain flexibility. Most coaches and runners believe in stretching before and after every workout. The experts never agree on much, but the majority seems to feel that stretching is beneficial to runners if done properly. So follow the precautions outlines and always warm up prior to stretching. Your body will thank you and who knows, you may even get a little faster!
Run Happy! And warm up and stretch before!
So we all know that to prevent blisters, you need to minimize friction. This begins with shoe selection. Shoes should fit comfortably, with about a thumb's width between your longest toe and the end of the shoe. Remember that this is often your second toe, not your great toe! Narrow shoes can cause blisters on the great toe and little toe. A shallow toe box can lead to blisters on the tops of the toes, while loose shoes can create blisters on the tips of the toes. Shoes that are too big can cause sliding of your foot which can blister the soles as well as the tips of your toes.
Always try on shoes in the afternoon or evening, because feet tend to swell during the day. Walk or run around the store before buying them and then wear the shoes around the house for 1 to 2 hours to identify any areas of discomfort. It often helps to break in shoes by wearing them for 1 to 2 hours on the first day and gradually increasing use each day.
Socks can decrease friction between the feet and shoes. Coolmaxx or synthetic moisture wicking socks or even special double-layered socks can minimize shearing forces. These can wick moisture away from the skin more effectively than wool or cotton can, further decreasing the likelihood of blisters. You can also carry extra pairs of socks to change into if your socks become too damp on a long run.
Another preventive measure is to use padded insoles or moleskin to decrease friction in a specific area. Drying agents can also help. Foot powders and spray antiperspirants are inexpensive ways to decrease moisture. For severe sweating, there are prescription antiperspirants you can get from your physician that provide even more effective drying.
A study of West Point cadets revealed a more than 50% decrease in blisters in those cadets that used spray antiperspirant before running, but many experienced some skin irritation; so test the antiperspirant on a patch of your foot before trying this on the run.
A thin layer of petroleum jelly or Body-Glide can also be applied to the feet to decrease friction. Conditioning the skin by gradually increasing activity tends to lead to formation of protective calluses rather than blisters.
Blisters are a fact of life in distance runners. Almost one in three marathon runners experience blisters at some point in their training.
So how should a blister be treated?
1. If the blister is small and not painful, leave it alone! Place a small band-aid or piece of moleskin over it to protect it and treat the cause so it will not become bigger.
3. Once your blister has been drained, you should treat it as an open wound. Dress it daily with a bandage. Keep it dry and clean for a couple days and if you engage in the activity that caused it in the first place before it heals, take care to provide extra padding and secure the area to prevent any rubbing that may irritate the wound. Change the dressing anytime it becomes moist or soiled and keep an eye out for infection.
When should I see a doctor for a blister?
If you experience increased redness, swelling, pain, or green or yellow discharge you should take it to your physician immediately to make sure it's not becoming infected.
Bottom line: blisters are a common annoyance for many runners. These tips should help you conquer this pesky problem before it slows down your run.
Run Happy! And hopefully blister free!
My daughter experiences them regularly, early in the season when she is training for summer track. They can take your breath away. My advice is always to “run through them,” but often times it has been known to slow her down to a walk or crawl until the pain subsides.
What is this sharp twinge of pain just below the rib cage usually on the right? It is called a “side stitch” or “exercise related transient abdominal pain” (ETAP); and until recently there was no clear and universally explanation for the cause of this annoying cramp. Although not considered a true sports injury, it has been estimated that 70% of regular runners suffered from a side stitch in the last 12 months, that’s a big pain in the gut!
Some researchers believe that the side stitch is caused by stretching the ligaments that extend from the diaphragm to the internal organs, particularly the liver. The jarring motion of running while breathing in and out tends to stretch these ligaments. Runners tend to exhale every two or four steps, more frequently when trying to get back into shape. Most people exhale as the left foot hits the ground, but some people exhale when the right foot hits the ground. It is this group who seem more prone to get side stitches.
There is greater force on the liver (which is on the right side just below the rib cage) when exhaling while the right foot hits the ground. So, just as the liver is dropping down the diaphragm raises for the exhalation. It is believed this repeated stretching leads to spasms in the diaphragm and this spasm causes your pain. Seems like a good explanation to me, much better than my old coach’s explanation, “because you are an out-of-shape wimp!” Other less accepted theories have included: diaphragmatic ischemia, imbalances of the thoracic spine, and irritation of the parietal peritoneum. Whatever the internal cause, there are some simple veteran runners tips that may help avoid or at least diminish this pain.
How do you stop a Side Stitch?
According to leading experts, to stop a side stitch when running, stop running and place your hand into the right side of your belly and push up, lifting the liver slightly. Inhale and exhale evenly as you push up.
Can you prevent a Side Stitch?
To prevent a side stitch, take even, deep breaths while running. Shallow breathing tends to increase the risk of cramping because the diaphragm is always slightly raised and never lowers far enough to allow the ligaments to relax. When this happens the diaphragm becomes stressed and a spasm or "stitch" is more likely. This is why they happen more often when runners are trying to get back into shape after a layoff.
Ten other tips to alleviate or avoid the pain of a side stitch include:
If you continue to experience pain, seek medical attention. A side stitch that lasts more than a few minutes could be early signs of appendicitis (or just simply annoying constipation). Pain radiating into your shoulder, chest or back may even be heart-related.
For most runners, a side-stitch is just a signal to slow down and relax! In my family, it gives my daughter an excuse to skip the end of a grueling workout! Maybe she is the smarter one?!
Run Happy! And without the mysterious side stitch....
Anne was running the White Rock marathon in Dallas in 2007. It was a cold, wet day, and by mile 18, she had a “cramp” in her hamstring and into her butt. It continued to get worse and worse as it got colder and colder. First she described that her fourth toe went numb, then the entire bottom of her foot. By the time she got to mile 24, she relates being freezing, wet, miserable, and could not feel her left foot or calf! Quit? Never! It’s not even in her vocabulary….Although her running friends that were doing their best to drag her to the finish kept encouraging her, Anne was convinced she had somehow severed her sciatic nerve with the muscle spasm in her butt! What was going on? Piriformis syndrome!
Anne had just experienced a very rude introduction to her piriformis muscle. This muscle arises from the sacrum, passes through the sciatic notch (an opening in the pelvic bone) and attaches to a bony prominence on the side of the thigh bone (greater trochanter). The piriformis muscle acts in outward rotation of the hip. The sciatic nerve exits the spinal cord and passes through the notch in front of the piriformis (in some people the nerve actually passes right through the muscle).
What went wrong that day around White Rock Lake? Anne irritated her piriformis muscle by getting tired (because her pre-race training had been, when she was being honest with herself, less than adequate), which caused her to overpronate, and then she coupled that with running on uneven surfaces and progressively colder temperatures which caused Anne to tighten all of her muscles shivering anyway! As the piriformis became inflamed, it swelled and compressed the sciatic nerve, which caused her foot to become progressively numb.
Most piriformis injuries are caused by overuse or by forced rotation of the hip caused by running on uneven surfaces. You can also irritate your piriformis by falling on your butt and having a direct blow! Pain can usually be elicited early in piriformis syndrome with direct palpation or stretching of the muscle. Anne describes pain enough to jump off the massage table pain when her piriformis was palpated for a month after the marathon!
Why me? Look at your training schedule and you may see an answer. Anne did! Worn out orthotics and not enough miles coupled with an unusually cold day! Other factors come into play like tight hip adductor muscles and excessive pronation. If your adductors are tight, the piriformis has to work harder to abduct the hip before it can help in outward rotation. Also, when your foot excessively pronates (or rolls in) when pushing off, your whole leg rotates inward and the piriformis acts to externally rotate your hip and has to work overtime every time you push off.
Can I keep running with piriformis syndrome? Yes and No. In the early stages, you can run; if you continuously stretch before and after, as well as making sure you warm up the piriformis before running. Decrease your mileage at least 30-50%, slow down and avoid hills and speed work as well as uneven surfaces. If you are finding that the muscle pain is causing you to alter your gait, slow down and start therapy before you end up with another injury. Think of it this way, as the piriformis tightens, the pelvis is actually pulled upward which gives you a functional leg length discrepancy. This can cause major biomechanical injuries to your other foot and leg! In other words, piriformis tightness in the left hip can cause arch or knee pain in the right leg!
What else could it be? The best answer to piriformis syndrome is to get a true diagnosis from a sports medicine physician. Lumbar spine injuries like a herniated disc or degenerative arthritis as well as a pelvic stress fracture can mimic piriformis syndrome. A complete physical exam should highlight the culprit muscle and x-rays or even an MRI may be needed to rule out other possible causes.
Piriformis syndrome is treated with physical therapy, pelvic manipulation, tons of stretching, anti-inflammatories, functional orthotics or shoe inserts to align your gait, deep tissue massage and manipulation, and even the dreaded cortisone shot to the butt in some cases. Very few people need surgical release of the muscle for complete relief of symptoms.
After Anne experienced piriformis syndrome, I bet she will never joke about a pain in the butt again! Be smart! Maintain your core strengthening routine, wear your orhtoics if you pronate excessively, stretch your hip adductors, and strengthen your abductors to ward off the dreaded piriformis syndrome!
Run Happy! And hopefully without a pain in the butt!
This week a very good runner from Wichita Falls came in with an Achilles tendon problem. He gave a horrible story of a primary care physician who injected his Achilles bursae TWICE with cortisone. He was looking for better answers and was willing to drive almost 2 hours south to find them.
I was almost apoplectic! Injected his tendon or even around his tendon?! In my world, that’s almost borderline malpractice; but I can’t fault the physician, she obviously didn’t know any better and was trying to treat the patient. Bottom line: Go to a sports medicine physician. We would all tell you the same thing: injecting the Achilles tendon can lead to spontaneous rupture which would basically end his running days. Look at poor Dan Marino…a ruptured Achilles tendon ended his Hall of Fame career!
Let’s talk about Achilles tendon injuries. They are very common especially in runners with high arched feet or very flat feet. Both of these foot types put way too much torque on the tendon and will cause a wear and tear tendonitis that eventually becomes tendonosis without proper treatment.
Tendonitis results from overuse. Long-standing tendonitis becomes tendonosis (degeneration of the tendon) which is much harder to treat. This overuse can happen over a period of time or can happen over a weekend. Those of you who exercise regularly or are in training for an athletic event, as strong as the Achilles tendon is, this work horse could use a break every once in a while! With chronic, long term, sustained use, this tendon becomes strained. It also can become just as strained with whom we fondly refer to as the “weekend warriors”. You know who you are! You are the ones who think it perfectly o.k. to hike the Appalachian Trail or take the steep way down the Grand Canyon over a three day weekend because “it was there”! Marathon runners who decide they can run the Western States 100 without the proper training….you can't hide for long....I will find you....
The simplest form of treatment can involve rest, heel lifts, icing, inserts, night splints, custom orthotics and anti-inflammatories. More complex forms Achilles tendonitis can include immobilization through a boot or cast, physical therapy, and in the most resistant cases, surgery. Active release myofascial release is very helpful. Thank God for David Bloom at Restoration Physical Therapy and Dr. Darryl Laney at Laney Chiropractic in Keller! Most of my long-standing Achilles tendon injuries are successfully treated with aggressive PT and manipulation on top of orthotic control. The longer you have it, the worse it gets. Do not let it get that far. Tendonosis is a chronic degeneration that can lead to splitting of the tendon and long term disability!
Thinking of waiting to see if it works itself out or are trying to work through the pain? Let us help you reconsider. Chronic Achilles tendonitis (tendonosis) results in degeneration and breakdown within the tendon and this, in turn, can lead to a partial tear or full rupture. Now that will put you out for more than a couple months! If you are experiencing a nagging pain or swelling to the Achilles tendon or the back of the heel, call or contact the office to have it evaluated. It is that simple!
Spring is in the air in North Texas. The brief snows are gone and recreational sports are starting their schedules. The soccer, baseball and lacrosse leagues are having their first games; the high-school track team is gearing up for competition, and The Leukemia Society’s Team-in-Training groups are just starting to increase their mileage aiming for an early summer marathon finish. Spring is in the air, and our old friend the ankle sprain is starting to show up more frequently in the office. Basketball and volleyball seasons are always the main producer of this injury; but you would probably be surprised how many ankle sprains occur in outdoor sports like soccer, baseball, lacrosse and of course track and field. Ankle sprains have been reported to be approximately 20% of all sports injuries with more than 25,000 occurring every day in the United States.
Uneven, wet fields coupled with early season fatigue and competitive full-contact intensity equal injuries. The ankle is the joint that compensates for uneven surfaces. 85% of ankle injuries are sprains, which are caused by a failure to compensate for this uneven footing. Jumping, cutting, and pivoting put the ankle at risk. Many athletes put themselves at further risk by not rehabilitating these injuries properly, returning to sport too early, and giving themselves an inadequate adaptive ability to uneven surfaces or sudden twisting. The use of narrow cleats with minimal arch support or the use of running shoes for a court sport can also place an athlete at risk for ankle sprains.
Ankle sprains occur in runners mainly because they are chatting away as they are on a long run and are simply not paying attention. How many runners have you seen fall off the curb or in a pothole while running? Lots…Pay attention to where you are going and you can prevent this type of injury. If you know you are a klutz, run on an even surface, like a track, when you are tired or distracted.
If you have an ankle sprain, you should be evaluated by a sports medicine podiatric foot and ankle surgeon if you have localized pain, swelling and bruising, as well as inability to walk more than 5-7 steps comfortably. Many a foot fracture has been missed in the emergency room when x-rays were taken only of the ankle and not the foot. The fifth metatarsal is often broken with the same mechanism of injury of an ankle sprain, so the foot should be evaluated as well. If severe ligament injury is suspected, an MRI can evaluate the grade of injury. This is really what decides whether surgery is needed for full recovery.
Treatment for ankle sprains really depends on the degree of severity, which can only be determined by your doctor. Initial treatment always includes “R-I-C-E” therapy – Rest, Ice, Compression, and Elevation. Pain and edema is usually controlled with NSAID’s (non-steroidal anti-inflammatories) like ibuprofen. Bracing or casting coupled with non-weightbearing on crutches may be needed in more severe injuries to rest and stabilize the ankle while it heals. Return to pain-free range of motion (ROM) and stability is the goal. Surgery is only recommended in Grade 3 severe injuries in athletes or in those patients who have had multiple ankle sprains and suffer from chronic ankle instability. Long-term ankle instability can often be avoided with an aggressive physical therapy program. Bracing should only be used in the short-term during rehabilitation because long-term bracing actually causes atrophy and decreased ROM.
Physical therapy is needed for all ankle sprains. The goals of physical therapy should be to regain full ROM, strength and proprioception (where your brain thinks your ankle is in space). Regaining strength in the peroneal tendons as well as overall balance training are the keys to successful rehabilitation of an ankle sprain. A maintenance program of ankle strengthening, stretching, and proprioception exercises helps to decrease the risk of future ankle sprains, particularly in individuals with a history of multiple ankle sprains or of chronic instability.
Bottom line: if you happen to fall down and go “Boom”, have your ankle sprain evaluated by a podiatric foot and ankle surgeon. Delaying treatment and rehabilitation can lead to life-long instability.
For more information on ankle sprains, go to our home page and click on "All About Feet".
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