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.

I had a great question this weekend at a running forum in Grapevine. One of the runners had lateral knee pain that came and went with no obvious cause. She thought she had ITB (iliotibial band) syndrome (sounded like symptoms her friend told her about) but she had been doing stretching and icing with no avail. What else could she do? Is it possibly from her shoes? Is rest enough?

Let’s talk about ITB syndrome.

The most common cause of lateral knee pain in runners is ITB syndrome, related to repetitive friction of the band sliding over the lateral femoral epicondyle as the knee flexes and extends.

Runners may complain of a sharp or burning pain about 2 cm superior to the lateral joint line (above the outside of your knee); exam may reveal tenderness to palpation there. Swelling and redness are usually not present unless it is severe.

Runners who are predisposed to this injury are typically overtraining. They often have underlying hip abductor muscle weakness; leg-length discrepancies may contribute to ITBS. They also have been found to have either a really high arched foot (cavus foot type) or an extremely flexible flat foot.

Acute phase treatment includes relative rest, ice, and anti-inflammatories. Physical therapy modalities like ultrasound and e-stim can also be helpful to break the inflammation cycle. In cases of severe pain or swelling, corticosteroid injections may be used.

During the subacute phase, stretching of the ITB is emphasized, along with soft-tissue therapy for any myofascial restrictions. Orthotics and shoe gear changes are also often indicated. Many patients actually are running in too heavy or too stabilizing shoes, especially if they have a cavus foot type.

The recovery phase focuses on a series of exercises to improve hip abductor strength and integrate movement patterns.

The final return to running phase is begun with an every-other-day program, starting with easy runs and avoidance of hill training, with a gradual increase in frequency and intensity. Remember: too much, too soon, too fast is what got you hurt in the first place!

Rest alone is usually not enough! This can be a painful chronic injury. Surgery can be considered in refractory cases, but this is rarely indicated.

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.

Wow! What a great panel discussion put on by Saucony in Boston last Thursday night. I love going to Boston during marathon week. It's like Marathon Mecca! The whole city seems to buzz with running excitement. Boston will always be my favorite marathon. 

I had the privilege to be part of the discussion of the evolution of minimalist running and how to transition from stability or motion control shoes to a more minimalist shoe.

The panel consisted of Michael Sandler, who wrote a fabulously crazy but poignant book on Barefoot Running and how it saved him after a severe accident; myself discussing how to strengthen your feet in order to even attempt transition from minimalist shoe gear or barefoot running as well as reminding runners to proceed with caution; Spencer White, head of the Saucony human performance lab, discussing in depth the biomechanical basis for the development of minimalist shoes and how they actually strengthen your feet over time; the legendary coach Dr Jack Daniels, doing coach chalk talk on a white board in order to discuss how to integrate minimalist running as a training tool; and last but not least, Collin Dibble, the owner of Marathon Sports in Boston discussing how to fit runners into the correct minimalist shoe and how retailers have a responsibility to caution and educate consumers on how to slowly integrate these shoes. Whew! What a panel! A fabulous educational experience for all present. I could listen to Dr Jack Daniels telling stories for hours. 

After the panel spoke individually for 10-15 minutes each, then it was time for Q&A. Great questions from the audience showed they were actually paying attention. Even Amby Burfoot from Runners World asked a biomechanics question!

Then it was time to separate into small groups and talk with the runners’ one on one. I was happy to see that I drew a small crowd that wanted to discuss everything from how can I strengthen this muscle or that area to how can I transition safely or can I even think about doing this? Great discussion with a local pedorthist who will probably send me hate mail because I told him he was crazy to be running in a graphite orthotics. A few local podiatrists were also in attendance and I was surprised but delighted that they actually agreed with me that everyone does not need to be in orthotics permanently if their biomechanics can be rehabbed instead of permanently braced. We had a lively discussion about this highly controversial subject in our industry.

Let's briefly discuss this alternative thinking. A runners does too much, too soon, too fast and ends up with let's say plantar fasciitis. Traditional thinking is PF is most likely caused by abnormal pronation. Treatment is to put him in a more stable shoe with orthotics to brace his foot, start stretching, anti-inflammatories, rest and lots of ice. Now what? He's better in 6-8 weeks. Now he wants to start running again. Traditional thought is that his underlying biomechanics predisposed him to have the injury so we should leave him in the stiffer shoes with orthotics. What if he really doesn't have a significantly jacked up foot? Maybe just a slightly over pronating foot? Do we have an alternative to offer him? Yes! Now the hard work starts. Lots of strengthening exercises for the medial and plantar foot and lower leg musculature coupled with balance and proprioceptive training followed by lots and lots of stretching. Then slowly wean him off his orthotics and stability shoes over a period of 3-4 months and transition to a more minimalist shoe gear.

Easy? No! Worth it? Yes, if he wants to find his inner gazelle. No, if he really doesn't care about changing the way he runs to be lighter, faster, and in the long run, less pounding. Can everyone do this? No way! Only about 15% of runners will work that hard to change their running style after an injury, so I don't worry about the orthotics labs going out of business.

That's just the tip of the discussion going on in sports medicine today about the trend of minimalism that is sweeping the running world. Hmmm. Sounds like more blogs to come. 

EPAT is the most advanced non-invasive treatment for musculoskeletal pain. Extracorporeal Pulse Activation Treatment is a new way to conquer chronic heel pain. Pressure waves stimulate the metabolism, enhance circulation and accelerate the healing process without surgery. Dmaged tissue of the plantar fascia or Achilles tendon gradually regenerates and eventually heals. Here are the top 16 frequently asked questions about EPAT.

The Top 16 FAQ’s About EPAT Therapy for Heel Pain

9. It makes the ride home so much more comfortable……….and the next morning if you don’t have to go to work 

Ice versus heat? This is a common question a lot of athletes, coming into my Grapevine, Texas office, ask. Most understand that ice immediately after injury is very important. The questions usually revolve around when to use heat.  There are some basic guidelines that every athlete can use to reduce confusion.

Immediately ice the “fall down, go boom injuries.” Ice works well for reducing redness, swelling and internal bleeding in acute injuries.  It also is a great pain reliever. Acute injuries and post surgical pain and swelling usually respond well to 10 to 15 minutes of ice every few hours. This should be done for up to several weeks after an injury or surgery. Ice can be in the form of an ice pack (ice wrapped in a protective towel) or ice massage (massaging with a frozen water bottle or block of ice). 

Ice can also be helpful in reducing swelling in a chronic injury like runner’s knee or plantar fasciitis. Icing immediately after activity can prevent further inflammation of an already annoyed area and help in recovery.

So where does heat come in? Heat can be used in several different ways. Contrast baths with ice/heat/ice can be helpful in chronic injuries. Especially those joints or tendons that still have just a little inflammation or edema. Heat should never be used alone in these cases. Moist heat is best for chronic stiffness and old injuries with scar tissue. It can also help in the rehabilitation process. For example, when plantar fasciitis becomes plantar fasciosis after four to six months (which is a chronic degeneration of the plantar fascia), deep heat therapy with ultrasound or moist heat packs can help increase range of motion of the area and increase the effectiveness of physical therapy. Heat actually temporarily increases inflammation in an area, but this is often helpful in kick starting the healing process.  Heat can also be used to calm muscle spasms and relax a tight muscle. 

Heat causes an increase in circulation to an area, so it should never be used in acute injuries or chronic injuries with a lot of swelling. It can actually make an injury worse if there is still a little internal bleeding going on. A great way to heat a joint or tendon is to use a reusable heating pack or an electric heating pad for about 20 minutes before stretching, massage or other therapy. Heating an old injury before exercise can also be helpful in warming up the area to ready it for increased activity.

The simple rule of thumb is that ice is used for acute, swollen injuries and heat is used for stiff, chronic injuries. This subject is debated continuously, but I hope this discussion clears up the mystery of ice versus heat!

Run Happy!

Plantar Fibromatosis. Wow, that's a mouthful! What is it? A lump in your arch that is firm and doesn't move. They usually start out as a very small pea sized nodule that increases in size over time. Most people don't even notice them until they get big enough to be annoying in your shoes or when walking barefoot. They can happen to anyone, but are most commonly seen in middle-aged to older patients and are much more common in men than woman. It is also more common in the Caucasian population than other ethnicities.

Most people come into the office complaining of a painful lump in their arch and are very concerned it is cancer. It is actually just an exuberant growth in the plantar fascia (a.k.a. the ligament that holds up your arch) or extra fibrous tissue. We really don't know why they occur, but it is thought that some kind of trauma plays a role in the formation of the nodules. I often see them in pilots and runners who have constant repetitive trauma to this area. Family history is also a factor. As many as 50% of patient with plantar fibromas also have nodules in the palm of their hands known as Dupuytren's contractures. There has been some correlation with medications like beta-blockers and anti-seizure medications. One study even linked an excessive amount of vitamin C with fibrous disorders. Patients with a history of chronic liver problems, diabetes, seizures and alcohol abuse seem to have a higher rate of plantar fibromas.

Treatments vary, but fall into three categories:
1. Do nothing: the nodules are annoying but usually self-limiting. They do not grow indefinitely, so if you can put them down as life's minor annoyance, most patients choose to just leave them alone.
2. Conservative or Non-invasive: Vigorous stretching, accommodative orthotics, physical therapy, and topical transderamal Verapamil.
3. Surgery: injections with a corticosteroid can be helpful to decrease the inflammation around the nodule, but if they are large and painful; most go on to surgical excision.

What should you do? A personal question, that only you with the help of your doctor can answer. In my opinion, if the nodule is small, leave it alone. If it is increasing in size, then it should be addressed.  If the nodule is of moderate size, with no intrasubstance calcifications on x-ray, and is annoying; a three to six month trial of transdermal verapamil coupled with an accommodative orthotic and physical therapy can be helpful. If it meets these criteria and is a little soft, then a steroid injection may also help decrease the size. If the lesion is large, painful, or has intrasubstance calcifications on x-ray; then excision is most likely your best option. Simple excision is not enough with these lesions, removal of not only the lesion, but a large margin is necessary to decrease recurrence rates.

If you have a painful lump in your arch, seek the advice of your podiatrist. Help is only a phone call or mouse-click away!

Great question! I hear this question at least several times a month from my active, athletic patients. Of course, my first response is always, “Are you able to run now?” This is not sarcasm, but a true fact finding mission. If you are unable to run before your surgery, due to the pain in your bunions, then if you can run afterwards - I am a hero! The same goes for the opposite. If you are running pain free before surgery, and really only want your bunions fixed due to the fact you think your feet are ugly, if you can’t run afterwards - you really don’t like me very much!

Let’s talk about this a little more in depth. A bunion is the result of undue stress on the big toe joint, which causes a protuberance of bone or tissue around that joint.  Bunions can be very painful, inhibit normal walking, and make it difficult to fit into some shoes. Contrary to popular belief, bunions are aggravated, not caused, by tight shoes. They usually are due to inherited faulty foot mechanics which put abnormal pressure on the front of the foot.  Pain is the primary reason patients seek medical attention for bunions. A majority of bunion surgeries are performed on women because they wear tight-fitting, high-heeled shoes that worsen the underlying foot problem and cause abnormal stress to the joint.

There’s good news for anyone considering bunion surgery. A survey in 2003 by the American College of Foot and Ankle Surgeons (ACFAS) had surgery performed by a foot and ankle surgeon to correct bunions within the past 6 to 24 months found more than 90 percent of patients who had the procedure say they experienced significant pain relief, increased their physical activity, and would recommend it to others.

Many runners who can benefit from the surgery avoid it and continue to endure pain because they have heard that surgery doesn’t work and is excessively painful. Their biggest fear is that they may not be able to ever run again! The truth, as evidenced by the survey results, is that advanced surgical techniques have allowed us to effectively correct bunion deformities with excellent outcomes in terms of pain relief and improved quality of life.

Ninety-six percent of the survey respondents identified pain relief as a desired outcome of the surgery, and 86 percent also said they hoped to improve their walking and increase their physical activity following surgery. On a scale of 1 to 10 with 10 representing “much pain,” the survey respondents averaged a score of 7 when assessing their pain before surgery, and the average score dropped to 2 when they assessed their pain six months after the operation.  Ninety-two percent said they were able to increase their physical activities -- walking, golf, tennis, exercise -- and 90 percent said they would recommend bunion surgery to others. 

That being said, in most cases, we can treat the pain caused by bunions conservatively. In fact, we feel strongly that surgery should be a last resort. We surprise many bunion patients with our ability to help them avoid surgery when they have been told previously they have no choice but surgery. A custom foot orthotic to off weight the bunion in your shoes is often very helpful. Many patients run for years pain free in orthotics before they decide to have surgery. If you have tried all conservative treatment, however, and bunion pain is causing pain or limiting your activity, surgery as you can see, can be a very effective option.

If the pain in your bunions has caused you to decrease or eliminate running from your life, contact our office for alternatives. Do not let the pain in your bunions change your life!

Run Happy!

Craziness! Earlier this week I was fortunate to carve out a 4 hour block of time for a long cycling workout. Being new to the sport of triathlon, 50 miles was the longest bike ride of my life! It was a really long, hot ride! The funny part was the only part of my body that hurt during and after the ride were my feet! Why is it that my feet hurt instead of my butt or legs? Turns out, I am not alone. Foot pain is much more common in cyclists than most of us realize. Biking is much gentler on my body than running, but your feet do take a pounding!

Let’s investigate foot pain in cyclists just a little. I experienced a burning pain in my forefoot after about 40 miles that did not go away until about 2 hours after I got off my bicycle. Why did this happen? In my case, I sized my cycling shoes too small for the training plan. My shoes fit well when I started, but as soon as my feet started to get hot; they swelled and literally got squished by the stiffness of the shoes. At 40 miles, the nerves in between my toes were pinched and all my toes went to sleep then started to burn like they were on fire! This is commonly called metatarsalgia, traumatic neuritis or parasthesias.

Foot pain like I experienced is actually not uncommon in cyclists. This can be caused by improper placement of clips, poorly sized shoes and certain foot deformities that require more support in the shoes. Luckily, most foot pain can be solved by bigger shoes, metatarsal padding, different socks or custom foot orthotics. Burning pain can be a sign of a Morton’s neuroma, an early stress fracture or lumbar radiculopathy (a pinched nerve in your back), so if your burning does not go away with simple solutions, quickly seek the advise of your podiatrist or sports medicine physician.

Other foot related problems seen in cyclist are plantar fasciitis and Achilles tendonitis, which in the early stages are usually solved by raising your saddle or turning it slightly askew. Often, we wait too long to address an injury because we think it will miraculously solve itself. Long standing foot pain often requires more aggressive treatments with custom orthotics, physical therapy, injections or even surgery in severe cases.

Thankfully my foot pain completely resolved with slightly bigger shoes, a thinner sock and a small metatarsal pad. My upcoming long rides on the way to a half-Ironman triathlon in the fall should be much more comfortable and pain free!

Cycle on....and keep tri-ing!

Houston Rocket's Yao Ming's career may be over due to a non-healing foot fracture. He was sidelined during the playoffs on May 8th with a hairline fracture of his navicular. As of today, this has not healed properly. The nature of his non-union and his prognosis is being kept quiet by the team physicians, but it is evident that there is a problem. Most stress fractures heal completely in 6 to 8 weeks. This is not the 7 foot 6 inch center's first fracture. He has been out portions of the last three seasons with stress fractures in his leg and foot. Perhaps his lanky frame just can' handle the stress of the NBA? Why is it that some fractures don't heal?

Looking at his present injury, stress fractures of the navicular (the cornerstone of your arch) are often slow to heal due to three factors, blood supply to the bone itself, underestimating the extent of the initial fracture so delaying aggressive treatment and too much abnormal stress on the healing bone. Other medical issues can delay bone healing like lack of Vitamin D, poor calcium uptake and many other systemic problems like diabetes, hypothyroidism and peripheral vascular disease. Many of these fractures are actually missed due to lack of specific x-ray findings. Many fractures are actually misdiagnosed for months. Plain film x-rays are often read as normal so the fracture is missed until symptoms increase. Early symptoms can be diffuse and non-specific so the index of suspicion is also low. A bone scan, MRI or CT scan can identify the specific fracture. CT scan is often the most helpful in identifying the extent of the fracture and guiding treatment. For a non-displaced stress fracture, cast immobilization is the first line therapy. Studies have shown that non-weight bearing immobilization in a cast for at least 6 weeks is usually around 80-86% successful. For those that do not heal this way, surgical fixation of the fracture can be helpful and a bone graft may be needed for long standing non-unions. New technologies like electronic and ultrasonic bone stimulators and injectable platelet rich plasma can help even the most stubborn fractures.

Follow up care for a navicular fracture often includes physical therapy and custom foot orthotics. Abnormal biomechanics of the foot often are one of the causes of these fractures, so biomechanical control is crucial to distribute the abnormal stress so an athlete can return to sports and have a lower risk of recurrence.

Yao Ming has had multiple stress fractures during his career increasing the likelihood of traumatic arthritis from avascular necrosis (not enough blood supply to heal so the bone crumbles) in his foot causing him to retire. The next few months will tell the tale for this multi-million dollar All Star. Can he heal his fracture and return to sport? The Rocket's fans are praying for divine intervention to cure their dominant center. 

It happened again today in my office. A woman came in asking for bunion surgery. She had put up with the pain in her big toe for years and finally had had enough. Many years ago her family physician told her to wait until she couldn’t stand the pain in her foot before discussing surgery with a podiatrist. Like many physicians, she assumed any pain in the great toe accompanied by a bump was a “bunion” or Hallux Abducto Valgus. Unfortunately in this case, she was wrong. The patient actually has Hallux Limitis also known as osteoarthritis of the great toe joint. If she had sought treatment many years ago, her joint may have been salvaged. Now her joint was so destroyed that she needed a joint replacement or fusion. Not what she wanted to hear! In her mind, she came in the office asking for a simple bunionectomy and left needing a joint replacement. She regretted not seeking the advice of a podiatrist earlier.

So what’s the difference between Hallux valgus and Hallux limitis?

Hallux valgus is a crooked big toe joint. Over a period of years, the great toe becomes much friendlier with the second toe and drifts toward and eventually under or over the second toe. At the same time, the first metatarsal (long bone connected to the great toe) drifts towards the center of your body making the distinctive bump. This starts out as a minor annoyance, but then quickly becomes a shoe problem with rubbing on the bump. Most people seek the attention of a podiatrist when the bump is rubbing in their shoe and becomes painful. If the deformity is allowed to progress, the great toe joint can actually start to dislocate and you will start to experience joint pain and degeneration.

Hallux limitis is wear and tear arthritis or osteoarthritis of the great toe joint. Many people are predisposed to have this problem by the underlying biomechanical function of their joint. It becomes much worse after an injury or repetitive trauma from things like high heeled shoes, ballet or some sports. The symptoms are different than Hallux valgus. Hallux limitis usually starts with a feeling of stiffness of the joint. It can be accompanied by swelling and redness. This usually progresses to a decrease in range of motion, a distinctive crunching feeling when moving the joint and then a bump that forms usually more toward the top of the joint, not the side like Hallux valgus.

Hallux valgus and Hallux limitis can occur together in a more complex foot deformity. Usually the bunion deformity has progressed and then is injured by repetitive trauma or a distinctive injury. This starts the progression of the arthritis change. Bottom line: don’t ignore pain in your great toe joint. Treatment of Hallux limitis early can save you from needed a fusion or joint replacement!

Why is treatment of Hallux limitis so important in the early stages?

Once you have destroyed the cartilage in your joint, there is nothing a physician or surgeon can do to make more cartilage. Research is underway trying to replace or regrow cartilage, but we are many years from a solution. Hallux limitis in the early stages can be controlled with a functional shoe orthotic to control the biomechanics. A clean up procedure known as a cheilectomy can help remove all the debris from the joint and get rid of much of the crunching. This will slow down the progression. Some patients can really benefit from a surgical procedure to realign and shorten the metatarsal to give the joint better biomechanics and more joint space. Unaddressed Hallux limitis leads to complete joint destruction and the need for a fusion or joint replacement.

The flip side to this story is that patients with Hallux valgus or your tradition bunion can often delay treatment until they start to have pain. Bunions in the early stages are a cosmetic concern, but the joint is usually not damaged until the later stages. It is important to address Hallux valgus when it starts to hurt so the joint is not permanently injured, but a bump, in the absence, of pain can wait.

The take home message is to have your great toe pain examined by a podiatrist. A full examination including functional biomechanics and x-rays can determine whether your pain is from Hallux valgus, Hallux limitis or a combination. Only then can you make an informed decision on treatments for your foot deformity and pain. Waiting until you can’t stand it anymore is a recipe for unhappy outcomes! If you have great toe pain with or without a bump, don’t delay.

See your podiatrist today so you can keep running happy!

“I have been running since I was 13yrs old and I am 42 now. Friday I was diagnosed with osteoarthritis after 6 weeks of no running but cross training on the elliptical. The doctor thought it was tendonitis but after not getting better he decided a MRI would be appropriate. The MRI confirmed it was osteoarthritis. I am starting physical therapy on Monday 3x a week.

My question: Is it possible for a runner who has osteoarthritis to be able to run again. I feel like my world has been rocked and shaken. Running is HEAVEN for me and nothing compares. It is my total stress reliever and if I do nothing else in a day if I've run my day is totally complete. I am the mother of 3 great kids and I guess I should be thankful I can do the cross training now because I get cranky when I don't get to do something. I just feel like this means my running career is over. My mileage before getting injured was about 25 a week.

Please let me know your thoughts. I have searched the internet for help on other runners who are going through what I am and have osteoarthritis of the foot with no luck so far. Thank you so much for taking my comment. I'm praying for a miracle. I know it's not life threatening but it's my mental state I'm concerned about.”

Answer:

Let me start my answer with a story. I have a runner in his late 30’s as a patient who had the unfortunate luck to be blown up in the Desert Storm conflict while he was serving in the Marines. He has severe arthritis in both feet from his injuries. He has had at least 5 foot surgeries including a fusion of his subtalar joint in one foot. He ran the 2008 Marine Corps Marathon in less than 41/2 hours. If he can run a marathon on feet that are that bad, I am confident that you can get back to some kind of running.

The name of the game is accommodation. You will need a great pair of orthotics made by a podiatrist that knows what they are doing and specializes in biomechanics. They can fabricate a device that will transfer the stress from the arthritic area to a strong, healthier part of your foot. That coupled with physical therapy, core strengthening exercises and a good pair of running shoes will get you back on the road! For more information on living with arthritis click here!

Run Happy! And pain 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 :)

Toes can be a runner's weakest link. For some, it's the knees, for others, the back. And for many, the toes, or at least one of them, can be the problem that tortures an otherwise trouble-free runner. Any runner can get into toe trouble with the right (or wrong) conditions. From blisters, corns, and calluses to stress fractures and ingrowns, those cute little toes can become a big headache.

Toenails alone can be the source of a long list of troubles. Chief among the potential problems is the ingrown toenail--with or without infection. Other, not too pretty problems, are nail thickening due to fungal infections, black toenails due to repeated trauma, and of course other irritations, inflammations and infections. Here are just a few common causes of troubled toenails.

Ingrown Nails

You may be familiar with the warning, "Don't cut the nails too short." Trimming too short can cause the leading edge of the nail to grow forward and cause pressure on the soft tissue at the toe tip. Although this can happen, by far the more common cause of ingrown toenail, and the pain that goes with it, is the curvature of the nail into the tissue on both the medial (inner) and the lateral (next to the other toes) sides of the nail. You can get the picture by looking head-on at your thumbnail. From this vantage point, it looks as if the nail were clipped onto the top of the thumb. Toenails follow a similar curve.

Using local antibiotics like bacitracin and antifungal creams may help, but it's hard to reverse an ingrown, infected nail without an office surgical procedure using local anesthesia. See your podiatrist! Never try to cut the nail "to relieve pressure" yourself. This is a recipe for disaster. It will heal faster and better with a smaller chance of recurrence if you see a podiatrist for treatment. Ingrown toenails do not lend themselves well to bathroom surgery.

Runner's Nail

Long distance runners and ballerinas both may be known for their athletic prowess and war-worn, beat up feet. Thickened toenails are so common among long distance runners, the condition has been dubbed, "Runner's Nail." The thickening and changes in color are caused by repetitive pressure of the shoe on the nail. The resulting thickening makes the nail even more vulnerable to additional problems since it is raised closer to the top of the shoe. These can be treated with a urea compound to soften the nail.

Fungal Toenails

A fungus (like the one that causes athlete's foot) can infect the nail and also cause thickening and discoloration of the toenail. This problem is distinguished from the Runner's Nail by infection. The fungus invades the nail when there is an injury or trauma, which may be so subtle you don't even know it is there. Once infected, a fungal nail is very difficult to treat. There is new laser therapy that works, but prevention is a much better bet. If you notice changes in your toenails, see a podiatrist for diagnosis and treatment.

Black Toenails

Although you can get a black toenail from a sudden, painful trauma that causes bleeding under the nail, for runners it is more likely a chronic, repetitive trauma to the nail caused by short shoes, running downhill, or wearing loose shoes. This repeated micro-trauma causes only a light amount of bleeding and minimal pressure buildup, so little or no pain is felt. In many cases, you only realize this is happening when you notice your toe is discolored. But don't ignore it. The nail can gradually become thicker, and more problems develop.

Eliminate the cause of the irritation, and a new nail will gradually form. It takes six to nine months for a new nail to form, so be patient. If the nail thickens, you can file it down. If there is pressure and pain under the toenail, see a doctor. Drainage from a blackened nail can be a sign of melanoma and should not be ignored.

Why did that toe turn on you?

Trauma, either acute or chronic can contribute to all of these toenail troubles. Trauma--like stubbing a toe--can cause changes in the growth pattern of the nail and eventually it can cause thickening, discoloration, or infection. More often, excess pressure and repetitive trauma is caused by the mechanics of the foot inside the shoe.

Trauma can come from shoes that are too small or shoes that don't grab the midfoot firmly. If the shoe is too small, every step causes the toes to press against the front of the shoe. Tight shoes restrict blood supply to the toes, increasing the risk of infection. If the shoe doesn't grip the midfoot adequately, each time the shoe hits the ground and stops abruptly due to friction, the foot will slide forward unless it is firmly held in place inside the shoe. Momentum forces the foot forward inside the shoe until the toes collide with the front portion of the shoe.

It is important to prevent this sliding or pistoning of the foot inside the shoe. If the shoe comes up high enough on the front of the foot, it can help prevent the foot from sliding forward by holding it at the ankle. Most running shoes, however, don't come up high enough to be effective. In most cases, the lacing across the midfoot has to do the job. You can also glue extra tongue padding in the shoe for a tighter grip on the foot. The extra padding allows the laces to be tighter without pain. Both the padding and tight lacing stop the foot from sliding forward in the shoe.

The best way to prevent most of these problems is to get the right fit. Find a running shoe store where the employees are professionals who understand runners' needs and the differences in the shoes the sophisticated industry is producing. Shop late in the day or after a good run to allow for the natural swelling of the foot. Don't rely on street shoe size or assume that the size is the same from one shoe to the next. Try on both shoes, lace them firmly, and run. A good running shoe store will let you run up and down the block. Get a promise that you can return the shoes after several days of wear inside at home. Don't ever expect running shoes to "break in." They need to fit well from day one.

As you can see, toenail troubles are often from self inflicted trauma or trauma from shoes. If your toenail are looking funny or painful, see your podiatrist for answers to your toenail troubles.

Let's take a closer look. Your heel swings from side to side as your foot moves. When the heel swings correctly, your foot can flatten and regain its arch as you walk. (normal pronation with resupination) But if your heel swings too much, your foot may flatten more than it should. (overpronation) Over time, such excess movement causes many foot problems. And yes, some people do walk normally, but not many.

When the heel hits the ground, its outer edge touches first. Soft tissues (muscles, tendons and ligaments) relax. Your foot is able to flatten, adapt to uneven surfaces, and absorb the shock of touchdown. During midstance, your heel is below the anklebone, and the front and back of your foot are aligned. Your foot easily bears your weight. As the heel lifts, it swings slightly to the inside. Muscles, tendons, and ligaments tighten. Your foot regains its arch, allowing your toes to push your weight off the ground.

Too Much Movement Causes Strain!

When your foot flattens too much (overpronation), some bones are forced to support too much weight. The muscles pull harder on these areas, making it more difficult for tendons and ligaments to hold bones and joints in place. Over time, you may develop swelling or pain on the bottom of your foot or near the heel. When your foot flattens too much, the ankle and heel do not align during midstance. The foot strains under your body's weight. This aggrevates the growth plates and makes kids have foot pain.

Abnormal biomechanics causes overpronation. This is easily controlled with a custom orthotic. That is why most biomechanical foot pain and deformities are treated conservatively with custom orthotics. Change the biomechanics, decrease the stress and take care of the pain from the strain.

Custom orthotics with vigorous stretching can make your child walk as close to normally as possible. Some kids still run a little funny due to the growth process, but at least when aligned they don't strain and won't complain of pain!

So soccer moms, if your child runs funny and is complaining of foot, ankle, knee, leg or back pain....it definately can be their feet.

Let's check them out before the season becomes a wash!

The Debate Continues....On and On....

They are at it again. The debate that has been going on since the late 1970’s when custom orhtotics became the mainstay of treatment for plantar fasciitis. “Millions in Potential Health Care Savings: Prefab Orthotics Found More Effective” was a press release today from a company that...guess what?…makes an off-the-shelf arch support! Are you kidding me???

Now don’t get me wrong, I think there is a place for prefabricated arch supports in our treatment plans and not everyone needs a custom orthotic; but to say that prefab is BETTER than custom is ludicrous! Let's use common sense! They sited a poor study done in California on patients with plantar fasciitis and then backed it up with a totally flawed study from 1996! That’s all they have??? What about the millions of patients that have been helped by custom orthotics across the country? Several thousands right here in the Dallas/Fort Worth area!

Just another ploy to get patients to potentially waste their money on off-the-shelf inserts prior to visiting their podiatrist! A copay is much cheaper and I am so sick and tired of seeing peolpe waste hundreds of dollars on things they find on-line. Then spend months in physical therapy or even need surgery to try to conquer their plantar fasciitis; when they could have gotten better much faster IF the first thing they did was call the podiatrist!

I’m done venting, but for more information on why custom orthotics work check out my patient information pages.

There is always one in every crowd that answers, “Run slower.” Ha Ha!!

DOMS is a regular visitor in most distance runners’ lives. This does not have to be debilitating, but prevention is your best defense against this nagging pain. We have discussed some of the treatment options and suggested methods for prevention.

Above all, remember that certain muscle pain or soreness can be a sign of injury. If your muscle soreness does not get better within a week consult your doctor.

Run Happy! And try to avoid muscle soreness!!

Question is, why do cramps happen and how can you prevent them? They have never occurred during his extensive training, so why in the middle of a race? 

Muscle cramping usually occurs due to a depletion of "The Big 4": sodium, potassium, magnesium, and calcium. Also, if an athlete is dehydrated, even slightly, going into a race, muscle cramps can be common (no matter how spot-on race day hydration is). Cramping can occur due to the depletion of one or a combination of these four minerals. One area that I would first examine is your everyday fueling. I realize that conventional thinking says that if an athlete cramps up during a race, then it must have been something nutritionally that went awry during the race. This may be the case, but actually the answer usually lies in one’s everyday nutrition and hydration. 

The first thing I would suggest is to monitor your hydration levels before and after training (especially long training days). This can easily be done with a body fat scale that also measures body water percentage. Take this reading each night before bed for 7 days straight so you can determine an average body water percentage; then, after training sessions, re-measure your water percentage. You will probably notice a reduction in your water percentage, as this is normal. Your goal now is to refuel and rehydrate in order to get this water percentage back to its ‘normal’ level. Another easy way to monitor your hydration level is to pay close attention to your urine color. The goal is to keep your urine color in a range from clear to a very light yellow. If one’s urine color is a darker yellow, this can be a sign of dehydration (be aware, that if you take a multiple vitamin, the B-vitamins will turn your urine color yellow, and this is normal; not a sign of dehydration). Following a long training run or race…get your urine clear and keep it clear throughout the day, as this will ensure proper hydration. 

In regards to the Big 4, try to consume a fluid replacement drink that contains all four of these minerals, and be sure to consume this fluid replacement drink during training and racing. Also, be sure to use your “sodium capsule” of choice during training, and not just on race day (you may already be doing this). If you find yourself avoiding sodium in your daily nutrition, try to lightly salt your foods with sea salt. Also, drinking vegetable juice is a great source of sodium and potassium (be sure to check with your physician that there are no blood pressure issues that would contraindicate the use of additional sodium). 

So, in summary, my advice to Tim would make everyday hydration and fueling your focus as this will get you to the start line in a state of optimal hydration. This should help avert any nasty cramps in your next race! 

Run Happy! And cramp free! 

I was returning this morning from Ft. Lauderdale and going through security with a few hundred other sun-kissed travelers when it hit me that most people were actually BAREFOOT going through the security line. I had my trusty socks on, but the majority of people were barefoot on carpeting that probably saw at least several thousand stinky sweaty feet a day. Disgusting! Don’t people realize that walking barefoot in an airport even for a short period of time puts their health at risk? I guess not. 

Let’s talk about this. You would never walk barefoot in an airport bathroom, right? No. That would be completely gross to most Americans. Yet, the bathroom floor probably is cleaner than the carpeting in the security line. The bathroom floor gets cleaned several times a day with disinfectant. The carpeting in security might get vacuumed once or twice a day, but most likely gets actually cleaned very sporadically and only when something gets spilled. I can’t confirm this because the TSA agent working the security line had no idea when or even if the carpeting was ever cleaned!

What’s at risk? Let’s make the assumption that you are a very healthy person with no chronic diseases that would hamper your immune system. What could you possibly pick up from a dirty carpet? Let’s just talk about the really common things because the list could actually be quite lengthy!

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!

HEEL PAIN (PLANTAR FASCIITIS)

This syndrome is most commonly caused by several factors, including, but not limited to:
-Tight calf muscles
-Increase in body weight
-Sudden change in the amount of intensity of exercise
-Improper or worn out shoes
-Abnormal foot biomechanics (excessive pronation or supination)
Due to any of the above factors, the plantar fascia (the ligament that holds up your arch) is pulled or strained so that a portion of this very strong ligament starts to tear or fray like a rope at its weakest point (where it attaches to you heel bone). This tearing causes microscopic internal bleeding in this area. Your body reacts by causing inflammation, which in turn causes irritation to the nerves, bursae and muscles in this area. As the inflammation occurs, the body tries to heal itself by depositing calcium in the area of the tear. This creates the “spur”. Not everyone will have a visible spur on x-ray, especially in the early stages. The spur is not the cause of the pain! It is just a tangible sign that extensive tearing has occurred. The tearing and straining is the cause of the pain and then the nerve becomes inflamed which makes the pain more sharp and long-lasting. The straining must be stopped, along with the inflammation, in order to resolve this problem.

Diagnosis of plantar fasciitis is made with a physical examination including a biomechanical exam. X-ray are recommended to rule out a stress fracture or tumor in the area. Shoe gear is also evaluated. (Don't forget to bring your running shoes to your appointment!)

Treatment initially includes all of the items listed below. If any of these treatments increases your pain, please call or contact the office. It has been estimated that 85% of heel pain can be eliminated by non-surgical treatements; but these take time and effort on the part of the patient and doctor. BE PATIENT! Your heel pain did not appear overnight, and it will take a while to totally eliminate the pain.

Conservative therapy can include:

1. Ice (at least 15 minutes twice a day);

2. Stretching (your doctor will give you calf and arch stretching);

3. Anti-inflammatories (either orally or in an injection); and

4. Arch supports/Taping/or orthotics.

Remember that treating the biomechanics of your feet treats the underlying cause where the other treatments are only treating the symptoms! Some people need physical therapy, night splints, and casting for relief. Conservative treatment often takes 4-6 months to eliminate plantar fasciitis.

Surgical treatment is the last alternative, after conservative therapy has been exhausted. Extracorporal shock wave therapy (ESWT) is a relatively non-invasive surgery that is quite effective, but deemed experimental by many insurance companies. If you are interested in more information about ESWT, click on the word underlined above.

There are two common surgical approaches to heel pain: the traditional approach (removes the spur) and the endoscopic approach (lengthens the ligament to reduce the strain and therefore reduce your pain). If your pain is not eliminated by conservative treatment after 4-6 months, we will discuss which approach is best for you.

Remember, the earlier you seek medical help for heel pain, the faster it will go away! If you have pain more than 5-7 days in a row in the same spot, call or contact our office for an appointment.

Need help with stretching? Go to our video  Donnie and Dr Crane amatuer video heping you stretch your way to pain relief on YouTube! You are not allowed to make fun of our amatuer photography!

Run Happy! And treat your heel pain early for the fastest results!

What is patellofemoral pain?

Patellofemoral pain a.k.a. chondramalacia patella is the most common running-related knee problem. If you have this condition, you feel pain under and around your kneecap and often swelling of the area under the knee cap may occur. The pain can get worse when you are running or when you sit for a long time. Pain can also be associated with a “crunching” sensation when the knee is put through range of motion. You can have pain in only one knee, or you can have pain in both knees. It usually starts as a minor knee pain after running that progresses to pain when you get up in the morning, pain during or after exercise then pain all the time. Prompt intervention can decrease the period of disability form this injury.

The exact cause of patellofemoral pain is hard to define. It has been described as having something to do with the way your kneecap (called the "patella") moves on the groove of your thigh bone (called the "femur"). Contributing factors include overuse and overload of the knee joint (too much, too soon, too fast syndrome), biomechanical problems and muscular imbalance or weakness. Often it is associated with an extremely flexible foot type and over-pronation (rolling in of your foot). It is more common in women than men and this is due to the “Q angle” of woman’s hips putting more stress on the knee. Weakness of the vastus medialis or the inner thigh muscle has also been implicated as a cause.

What can I do to help my knee mend and relieve the pain ?

Take a break from running and any other activities that can cause a lot of pounding on your legs. Practice relative rest activities like swimming, biking, or the elliptical trainer which supports your body weight and puts less stress on your knees. As your knees feel better, you can slowly go back to running. It is important to do this slowly, and increase the amount of time you run by only about 10-20% a week. 

Physical therapy is the mainstay of treatment. It is imperative to work on the muscle imbalances that led to injury as well as stretching your hamstrings and strengthening your quadriceps. Strengthening is very important because your quad muscles control the movement of your kneecap and this is the most recognized cause of this syndrome.

Talk to your podiatrist about your running shoes and orthotics; it would help to bring your shoes in for the doctor to see, proper running shoes can really help knee pain. Orthotics are often needed to decrease excessive foot motion that causes stress on the knee. Even just a simple arch support insert can be helpful. Although custom orthotics are considerably more expensive than off-the-shelf devices, they last much longer and provide more support or correction. For hard core runners, the durability is important. Many people wear out a store purchased device in just a few months when a custom device can last for 2 to 3 years. In some cases, however, an over-the-counter device can be just as effective, particularly when combined with a stretching and exercise program.

Ice your knees for 10 to 20 minutes after activities, this can ease the pain and speed up healing. To keep your hands free, use an elastic wrap to hold the ice pack in place. An anti-inflammatory medicine like ibuprofen may also help, however this should not be used to “get through” your workouts.

Will I ever be able to run again?

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.

Run Happy! And free of knee pain!

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!

Run Happy!

55 million Americans experience one or more foot problems every year! Many fail to seek medical advice early and develop more complicated foot conditions that can be severe and difficult to treat. One of the most common foot problems is heel pain. It is estimated that 15% of the adult population complains of heel pain, which includes one million runners who experience heel pain (plantar fasciitis) every year. The American College of Foot and Ankle Surgeons has stated that heel pain has reached epidemic proportions in weekend athletes. This common condition is typically ignored, especially by athletes. People tend to seek treatment only after the problem becomes severe and disabling or when they just can’t run. When foot health concerns are ignored, simple conditions can develop into more serious problems affecting the ankles, knees, hips or the back. A simple functional orthotic is the answer for many people experiencing this kind of foot pain.

Orthotics are devices which fit into the shoe to aid the foot and allow it to function more optimally. "Functional orthotics" are usually relatively rigid in shoe braces that are designed to control motion and correct the function of the foot. Individuals with flatfeet, tendonitis, plantar fasciitis, knee, hip and back problems  and certain foot deformities, may benefit from functional orthotics.

Will orthotics help my foot problems? The goal of the functional orthotic is to control the abnormal motion in the foot, improve foot function, decrease the pain in the foot, ankle, knee, hip or back and to add support. The orthotic should make standing, walking, or running more comfortable. The orthotic must be rigid to help control the motion in the foot and add support. If the orthotic is soft, the weight of the body would collapse the device and it would no longer function.

Functional orthotics are a successful treatment for many problems affecting the lower extremity. In a recent article in the Journal of the American Podiatric Medical Association, 75% of patients surveyed had good to excellent results from functional orthotics. This includes 17% who felt the orthotics "cured" their pain. Less than 10% had no relief. The most commonly treated condition in the study was a painful heel. Over 20% of patients surveyed were treated for a painful heel and 20% were treated for a painful arch. Fourteen percent of the individuals were using orthotics for flatfeet. Other conditions treated with orthotics were knee, hip and back pain, foot arthritis, bunions and high arches. Tendonitis was not specifically evaluated.

Individuals with plantar fasciitis (heel and arch pain) who also have flatfeet usually respond best to orthotics. People with high arches may require orthotics as well, but they do not respond as well. Orthotics can help slow the progression of bunions and hammertoes, but they will not prevent this process. Orthotics may help with some pain at a bunion, but they will not "cure" the bunion. When the motion in the foot is contributing to the problem, orthotics are generally recommended.

Podiatrists are the most common prescribers of orthotics, but pedorthotists, orthotists, physical therapists and sometimes chiropractors will also provide orthotics. Remember that the device is only as good as the doctor taking the mold and writing the prescription. Make sure that your practitioner is trained in foot biomechanics and experienced in orthotic therapy.

Orthotics are a staple in the treatment of the majority of foot pain. When utilized for the correct indications, orthotics are highly successful in controlling foot pain and can add pep to your step! Orthotics have helped Plaxico Burress conquer his chronic injuries and they may help you!

Run Happy! And Thank God Football Season is almost here!!!!

What causes ingrown toenails?

Toenails can be slightly deformed due to hereditary reasons (blame Mom and Dad).  It can also occur from trauma, shoe pressure and toenails that are improperly cut; usually too short  Fungus in your toenails can also cause ingrown toenails and tight or pointy-toed shoes can also be to blame. Runners are the worst when it comes to making a disaster out of their toenails! Black toenails, yellow and even brown little mountains are common from trauma and fungus! 

Even in the worst cases of ingrown toenails, most people are back to activity in just a few hours or days depending on pain tolerance and the extent of the infection. Rarely is the infection so severe that hospitalization and IV antibiotics are needed to prevent toe amputation.

Run Happy! And try to avaoid ingrown toenails!

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!

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!

While every shin splint injury has its own specific biomechanical causes, most are rooted in tight calf muscles and relative weakness in the front leg muscles. What's going on is that your tight calves are pulling up on your heel, which in turn pulls the front of your foot down. This puts strain on the muscles in the front of your leg, which unfortunately are not strong enough to resist the pulling. This causes a big pain in the leg! This is very, very common in runners, since running tends to exercise the calf muscles more than those in the front. But fear not, a little rest and a lot of stretching and strengthening will fix you up and possibly make you a better runner, too. 

How do we treat them? Early on in the syndrome, shin splints are treated with ice, relative rest (slow down and get off the hills and uneven surfaces), anti-inflammatory like ibuprofen, stretching, and arch supports. Take a good look at your shoes. These often need to be replaced or upgraded to a better pair for your foot type. (More discussion on that topic in a future article).

After we address your shoes and overpronation or underpronation (your foot rolling in or out excessively when you run), then we move on to the muscle imbalances in your lower leg. Your calf muscles are too strong and tight, while your front leg muscles (anterior compartment) are too weak. This is easy to remedy but won’t happen overnight. Stretching your calf muscles with a simple wall stretch for your Achilles tendon many times a day( how many?) will help. Strengthening the front of your leg can be done by actually putting a small weight (or an athletic sock full of sand) on your foot and lifting it towards your shin. Hold that for a count of ten then relax. Repeat twenty five times. You will be amazed how tired those muscles are!

If your pain persists after two weeks of these simple solutions or is at any time pinpoint or severe in nature, call my office or your sports medicine physician. Stress fractures can creep up on the overzealous new runner and can take 8 to 10 weeks of no running to heal!

Shin splints are common in today's active population. It is important to keep in mind that shin splints, like most running injuries, are basically an overuse injury. Listen to your body and back off when you begin to feel pain.

These are just a few tips to get you on the road to recovery! Run Happy!

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:

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Men’s Cross Trac (sandal with forefoot and ankle strap) $100.00

A few helpful points:

Beveled outsole helps promote natural stride

****Please note****Crocs Orthosport sandals do not accommodate custom or OTC orthotics because in most cases you don't need them!

Summer comfort! Run Happy!!

What it is: Kinoki Detox Foot Pads, $19.99, www.buykinoki.com

What it claims to do: The foot pads collect “harmful toxins” from your body while you sleep, says the manufacturer, by “cleansing and detoxifying your skin’s outer layers,” boosting your energy level and improving your health and wellness.

Unfortunately these don't work.....no miracle detox and feeling of invigoration....perhaps just great marketing......

Decide for yourself...Here's the full story

Bottom Line:  While Kinoki foot pads probably won’t hurt you, they likely won’t help you either. Save your money and put it toward a nice safe pedicure at Healthy Steps!!

Run Happy!

Just do it! I may sound like a commercial, but it is good advice. Today should be the last day you try to use lame excuses to continue being fat, tired and a cardiac risk! Write down you excuses. When you look at them on paper, you realize most are ridiculous and can be overcome. Starting an exercise program can be a monumental challenge, but we are all up to it! I guarantee you will thank me in a few months when you are closer to your ideal self than you thought possible!

Run Happy...and often! It gets easier!

Any kind of sports participation can increase the incidence of osteoarthritis due to increased twisting forces, high impact, muscle weakness or over-development and joint instability which causes abnormal peak pressures and greater stress in certain areas of cartilage which can lead to osteoarthritis. Nevertheless, for normal joints , there is no scientific evidence that simply the action of running, even over a long period of time, causes permanent joint damage or even a predisposition for osteoarthritis.

What is the risk of osteoarthritis in runners? Many studies of long-term runners show no increased incidence of osteoarthritis in these competitive runners. Some studies did show more evidence of osteophytes, but no correlation with joint pain or instability. Confusing the issue for many runners are the numerous incidents of misdiagnosis of repetitive stress injuries like patella-femoral syndrome as arthritis. This is reversible and caused by abnormal tracking of the kneecap, which is treated with physical therapy and orthotics.

Joints are in fact strengthened by activity and damaged by inactivity. Studies have shown that the articular cartilage actually thins and becomes more fragile with inactivity, therefore increasing the risk of arthritis. Joints adapt to the stress of exercise and become stronger and more able to endure the long term stress of running. Remember the doctor saying to increase slowly? This is why. Ligaments and muscles, which support the joints, are strengthened and reinforced by the stresses of the running activity, improving joint mechanics, if the joints are properly aligned.

Here is the truth about foot biomechanics. Proper biomechanics during the strengthening process is essential for joint health. Improper biomechanics can increase the stress on the joints in an abnormal fashion and actually increase the incidence of osteoarthritis and hasten joint damage.

Bottom line? Running does not increase the incidence of osteoarthritis unless the lower extremity biomechanics are faulty. In fact, almost 75% of Americans over the age of 65 experience some symptoms of osteoarthritis. This is not increased in runners. In fact, running may actually help with the symptoms of osteoarthritis.

The benefits associated with long distance running profoundly overshadow the risk of osteoarthritis. In runners, orthotic devices to correct their biomechanics early in their training may actually decrease the stress associated with increased osteoarthritis. If you have joint symptoms, see a sports medicine podiatrist today and have your gait realigned. Your joints will thank you. Remember, your feet are meant to carry you for a lifetime. Don’t let the fear of osteoarthritis rob you of the joy of a lifetime of distance running!

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!

What’s the Deal with Runner’s Knee Pain?

I had an email last week from a relatively new runner asking who they should see for their knee pain. I asked if they twisted, fell, or jammed their knee or if it was just a wear and tear injury? They confided that as they increased their mileage and distance, their knee pain started to increase. New shoes helped, but didn’t fix their nagging pain. Sounds like a biomechanical problem to me! But it could still be a traumatic injury they can’t remember…especially if they were out dancing on tables on a Friday night ... Just kidding!

Seriously, mechanically induced knee pain is extremely common in runners. A good analogy is that if you need a tire realignment on your car, the struts can wear out. In fact, you may have no acute foot and ankle problems at all and they can still be the cause of your symptoms.
The best way to assess a runner’s knee problem is to start with a sports medicine orthopedist who can rule-out a primary knee problem, like a tear in the meniscus (cartilage), ligaments or tendons. If a primary knee problem is ruled-out, but you just keep having this nagging pain; or if your tendonitis keeps recurring in spite of being compliant with physical therapy and rest; it’s time to look elsewhere for the cause.
Your feet affect the function of all their contiguous structures or in English, everything they are connected to. Yes, your feet can even cause back and neck pain!

How? Your feet affect your postural control. Postural control is the ability to maintain the body’s center of mass over the supportive foot, a.k.a. being able to keep your balance. Often, balance or proprioception is lost in patients with chronic foot and ankle instability from an underlying congenital foot type. This leads to lack of postural control which leads to knee, hip and back pain a.k.a. postural symptoms. Many studies have concluded that a functional orthotic reduces postural sway and improves stability, therefore reduces further injury in patients with congenital or acquired foot and ankle instability.

Bottom line, if your knee pain is chronic and you have ruled out a primary knee problem, look to your support structures known as your feet.

…..Run Happy! And be sweet to your feet (and knees too!)