Foot Pain

This is going to be long so I hope that it is helpful. Many treatments are offered without knowing what the problem is. Treating the right problem with the right treatment is both a science and an art. Many long time runners know more about handling running injuries than most physicians. The folks at the local running shoe store have usually seen it all and can be a great source. They, along with sports physicians, sports chiropractors, and physical therapists are good resources to help handle your problem. The most important thing to know is whether or not you have a condition that is dangerous.

Pain along the outside of the foot comes from 3 main sources:

The first and most dangerous problem is stress fracture. Stress fractures often come on slowly so they don’t feel like a fracture. Since these are micro fractures they are sometimes not painful until you put the bone under excessive stress, such as running. The pain often intensifies as you run, becoming more and more painful until the bone breaks. The outside of the foot is the most common place for this to occur, along the mid shaft of the 5th metatarsal. Try this test: Find the long bone along the outside of the foot and try to bend it by holding on the the ends and pushing up from the center of it with your thumb. If you feel pain in the mid shaft of the bone then you are probably in trouble and you’ll need to rest it for the next 6 weeks. Keep exercising with a stress fracture, and you run the real risk of a broken bone and all of the troubles that ensue, including a cast and possible surgical pin. If you have pain while hopping on the foot, especially on the first hop, you may have a stress fracture.

The second is tendonitis at the insertion of the Peroneus tendon. This is the tendon that begins as muscle and narrows into a tendon along the outside of the calf and wraps around the back of the ankle bone known as the lateral maleolus. This tendon is attached to the outside of the foot at the wide point near the mid foot. The right foot often suffers from pain at this location because it is usually the foot on the low side of the road. This can be further complicated by a short right leg, thereby placing more stress on the outside of the foot. If you have this problem then there are several things that you can do to mitigate the problem but it will probably not go away anytime soon. You can usually run with peroneus tendonitis though if you make some changes to the stresses on the outside of the foot.

Take a look at your shoes and see if the wear pattern on the sole of the shoes are more oriented to the outside of the forefoot. If it is, then you are over supinating, meaning you are running on the outside of the foot. Supinators get about half of the normal life out of their shoes and have to replace them much more frequently.

Speed is the third major cause of forefoot stress because it causes you to run on your toes. If you add hills to speed you are putting maximum stress on the front of your foot. If this is the cause of your problem, then the fix is simple: Stop running fast up the hills. In fact, stop running fast altogether until the problem goes away. This is what we call rest, which is relative, meaning give the afflicted part some rest from the stresses that caused the problem.

The treatments are as follows:

Anti-inflamatories can be a help. There are a few approaches to anti-inflamatories. Use over the counter medicines called N.S.A.I.D. which mean, non steroid anti inflamatories. Advil, Ibuprofen, Motrin are all pretty much the same. I wouldn’t recommend taking these for extended periods of time, since they can have some deleterious effects on you kidneys and may cause gastric problems. Many runners use Naproxyn or Aleve which can be taken every 12 hours instead of every 6 hours. The idea is that since you have to take less of it, you pose less of a threat to you stomach. The gel caps seem to be easier to digest and are easier on your digestive system. (I welcome Dr. Lerner’s comments here) Since the affected area is close to the surface, you may derive benefit from a topical anti inflammatory such as Aspercreme. Applying folk remedies like Vaporub, Ben Gay, China Gel, etc. are of limited value. they feel good but have no medicinal value. in other words, they cause no physiological effect and contrary to popular opinion, do nothing to speed healing. I use them though, just because they feel good.

Ultrasound works very well for this problem. The effect of a single treatment can be dramatic for this problem because the tendon is close to the surface and accessible to the therapy. This therapy should be done in a PT clinic or chiropractic office since the application requires a license. Don’t have very many of these treatments though. If this treatment is going to work, you will know within 2 or 3 visits. Usually 3 weeks of ultrasound is sufficient.

Epsom Salt soaks do a great job at reducing swelling and inflammation. Fill a bucket with enough very warm water to submerge the affected area and then pour in Epsom salts until they will no longer dissolve. This is called a super saturated solution and will draw out any swelling. Do this for 20 minutes every day.

Ice is the most powerful anti inflammatory i know of. Use a good gel ice pack that has been kept in the refridgerator. If your ice pack has been in the freezer it may cause tissue damage. Make sure that you have a sock or some other fabric between the ice pack and your foot. A 10 minute treat time is sufficient, since the affected area is close to the surface. Another ice option is a frozen water bottle.

You can try using a foam roller along the side of you calf. This will only help if that particular area is painful though. If there is no pain there then you will not derive any benefit.

If you are wearing orthotics of any kind, this would be a good time to scrutinize them since many of these appliances are made with the assumption that almost everyone over pronates (rolls the foot excessively inward) during the gait cycle. This often results in improper biomechanics, loading huge stresses on the outside of the foot. Shoes that have too much pronation control can cause the same effect. Take a look at your shoes and see if there is a lot of plastic or other cushioning material along the instep area. If the shoe is nearly straight along the inside of the arch then you may have “Motion control shoes” and need to switch to another type of shoe. Other shoes that control motion known as “Stability shoes” can cause the same problem. In general, runners with high arches should not use either of these type of shoes. The best way to tell if your shoes are the right type is to go to a running specialty store. You can tell if it’s a running shoe store if all of the people who work there are runners, track coaches, winners of running events or well known runners. They are generally skinny runners with stringy muscular legs. They will know what type of foot you have and what type of shoe will work best. Fitting running shoes is not an exact science and it is possible to get it wrong. However, a good running store should be able to get it right at least nine out of ten times. The key to this is the return policy. Quality running shoe stores will always have very liberal return policies.

There are exercises that can help to strengthen the the muscles that attach to the tendon. Standing on a step and doing calf raises and slowly lowering can be helpful in developing strength and flexibility. The stretches that we use on Saturday mornings are a good way to stretch the outside of the foot. Start with the toes in contact with the floor and slowing rotate the foot in large circles. Do this for 20 seconds every hour of the day to develop flexibility.

There are some don’ts to consider. Do not get a cortisone injection in this area. Not only is it painful but it can weaken your tendon. Do not get orthotics as a first treatment. They often worsen the problem or caused it in the first place. Don’t get off the shelf orthotics either. I often recommend the off the shelf orthotics but this is one condition where they are only going to prolong or worsen the problem. Only in rare cases do they help.

There is another problem that can cause pain along the outside of the foot. If you have contact pressure along the outside of the shoe it can rub along the wide bony area of the foot, causing an irritation. The best way to handle this is by locating the laces nearest to the affected area and simple re-lacing the shoe to skip that area. Sometimes the shoes are fine during short runs but as your foot swells on the long runs there is more pressure and the area can get irritated. Sometimes it is just the fit and you need new shoes. The most troublesome shoes are new or very worn ones. Be wary of either. In general. runners are going to need 2 or 3 pairs of running shoes per year if you a Marathoner, less if you run less mileage. I always keep 2 pairs of shoes, new ones and worn ones. That way I always have a god pair to race on without having to run on brand new shoes. Besides that, I love the smell of a new pair of running shoes.

I hope this helps. Leave your questions or comments below.

Steve Smith D.C.

IT Band Syndrome

If you have been a runner for any length of time at all, then you have no doubt heard of “Illiotibial band” or “IT band” syndrome. If you haven’t had it yet, then you probably know someone who has. Of the five most common running injuries, Illiotibial band syndrome ranks number one. This problem is often seen in marathon training programs that take you from the couch to the finish line in just 5 months. Unfortunately, the problem tends to show up late in the training after the runner has done the first 14 or 16 miler. The problem is most often first noticed on the short recovery run following a high miler. This is often baffling, since the runner did well on the big run and can’t connect the problem with the cause. The recommendation for rest is never well-received and bedevils a training schedule that has even longer distances in the coming weeks. Rest has the dual outcome of helping the problem and causing a training gradient that is too steep. If you miss the next long run, say a 16 miler, then you’ll be going from the 14 miler that caused you the problem, to an 18 miler that will surely leave you in a sorry condition.

Having laid out the training problems associated with IT band syndrome; let’s take a look at the symptoms, causes and solutions.

Here’s what it feels like:

• The pain is on the outside of the knee, at the bony area just above the joint and usually feels like a deep burning ache while running.
• The pain is worse when going down hills or stairs. Downhill pain may persist after the run.
• The pain usually stops, shortly after the run.
• Subsequent runs result in an earlier onset of pain, which may also be more intense.

What is the cause?

Theories are abundant, as are solutions, leaving the subject open to a lot of opinions and therefore gurus of the realm. Having said that, I will substitute the literature with my own observations of runners who have IT band syndrome.  To understand the problem let’s take a look at how your body moves while running. Running is a one sided activity, only one foot is in contact with the ground at a time. When your foot strikes the ground, you are in essence balancing on one leg while the other half of your body is suspended in space. The muscles that hold you in this position are the gluteals, psoas, abs, and a small muscle on the side of your hip called the tensor fascia latae. If any of these muscles are weak, your hip will drift too far lateral and over stretch the Illiotibial band. This isn’t usually a problem when running short distances, but when you tire on a long run, the muscles fail to hold your form and that’s when the trouble begins. As your knee passes back and forth under the overstretched IT band, the bony prominence plucks it repeatedly and creates pain and inflammation at the attachments.

The second biomechanical factor is that your knee tends to twist just a little bit when you are running. This causes the IT band to pluck over the outside of the knee. The twist occur somewhere between the time the heel strikes and when you push off with the toe.  There are a few variations of how the foot strikes the ground and various schools of thought on exactly how this should occur. I have seen athletes of all styles who are very competitive and injury free.  Observation of sprinters quickly reveals a definite tendency to run on the toes, in order to engage the springy calf muscles. Some of the wackiest looking gait patterns cause no apparent injuries. In general though, if your foot rolls inward too much, it will cause trouble. This is especially so with endurance athletes.

Prevention and treatment:

Exercises that strengthen your gluteal muscles, tensor fascia latae, and core should be your first line of defense. I have found it nearly impossible to explain exercises inside of an article in a comprehensible manner. Drawings and photographs only add to the confusion. Even face to face coaching can be difficult to teach the exercises. I have noticed that teaching the exercises and stretches to those who most need them are the same people who have the most difficult time learning them. I have videotaped the exercises that work the best and you can view them here. These are not the only exercises that work – there are others but I have had great success with these. The 3 point touch is the best all around exercise, followed by the side plank and abdominal strength. The abdominals can be tricky if you have a sensitive back so I have left out some of the more effective methods. If you’re a new runner and I highly recommend that you start these exercises right now- to prevent having problems in the first place.

Cross training on a bike, roller blading, or strength training in the gym almost completely eliminates the risk of having the problem. Start cross training early and you will complete your training without the risk of IT band problems.

If you are an experienced runner who has a recent onset, then think about getting a new pair of shoes. If those shoes you have been wearing have lost their pizzazz and your gait muscles can’t control your feet from excessive roll- in, then your legs will twist too much. Sometimes that is all it takes, new shoes. This is the best case scenario, since almost all runners love new shoes and avoiding pain is a natural survival instinct. If you are new to running and you already have new shoes then a pair of those off the shelf orthotics might help. There is an  80% chance that the store bought orthotics will work, when compared to the custom made, “ExpenseMaster Nine Thousand Deluxe” model made by your local health care professional. Go to the local running shoe place where all the runners go to get them. The guys who work there, are used to seeing all manner of problems and they are generally pretty good at helping you to get the right product. I’ve had great luck with “Superfeet.”

Using a foam roller along the side of your thigh seems to help many runners. The theory is that the IT band is over-tight and needs stretching. I have personally stretched an actual IT band and I can tell you that this anatomy is anything but stretchy. It is a tough band; it is a ligament and like all ligaments isn’t intended to stretch very much. Ligaments are not supposed to stretch much. If they did then you would have no joint stability. I don’t pretend to really know exactly why the foam roller works  – I only know that many runners report feeling better from the use of it. Add this one to your repertoire of treatments and you will increase your odds of getting better.

Use an ice pack over the affected area, Since the IT band is very near the surface, the ice has a more direct and therefore greater effect. 10 or 15 minutes is enough. If the ice pack is very cold then a shorter treatment time is better. I like to use solid ice massage over the area but you can only stand it for a few minutes, 4 to 7 minutes is enough, no longer. Use a styrofoam cup full of water and freeze it. Then peel away about 1/2 inch off the top of the cup. You can use the ice cup several times. It is a little drippy, so you’ll need a towel.

A lot of runners use Advil, Ibuprofen or Aleve. These over the counter meds can really help with the initial inflammatory phase.

Continuous running on a slanted road surface is stressful to the knee on the low side. Change direction, switch sides or better yet, find a flat surface. A short leg can have the same effect. Keep the short leg on the high side of the road and you may even equalize the stress. You might be surprised how many runners have a significantly short. A few millimeters is no big deal but anything over about 10 millimeters is probably going to cause trouble.

Poor pelvic alignment has the same effect as a short leg and causes the runner to have an uneven gait. A good chiropractor can easily fix this. Use this simple test to determine if you are out of alignment. Lie on your stomach and with your head turned to the right, then do a straight leg raise on the right, put the leg down then try the left. Repeat the test with the head turned in the opposite direction. The straight leg raise should yield level of equality with the head turned in both directions.

You can try one of those knee straps placed above the knee. I don’t like this approach, since it ignores the cause of the problem but it can be a good band aid treatment until you con strengthen your gluteal muscles. I hear many runners reporting a decrease or complete relief of pain.

By far, the best treatment is rest. Rest is a relative. In many cases you can continue to run but only up to the point that you have pain. pushing beyond that point will probably cause earlier onset and more severe symptoms. Avoid running down hills. Do not shorten your stride as this only increases the number of knee flexion cycles and irritates the knee even more.

Illiotibial band syndrome often resolves spontaneously, leaving the afflicted runner to believe that the treatment he has been using has worked.  Sometimes patients tell me that their treatment regime has worked out very well but I often wonder whether or not it would have gone away without treatment. When you have a tough schedule ahead of you, it is better to err on the side of caution and do all that you can to ameliorate the condition as soon as possible.

The Last Runner

Here’s a little background of the history of the Pasadena Pacers and how we came up with our ideals.

In the early days, we used to all wait for the last runner to come in from all of the long runs. We often made a victory arch and at the very least cheered for all of the runners coming in. Since we all waited for the last runner, there were more people cheering for the slower runners and very few or even no cheerleaders for the fast runners. It came to pass that the last runner was the most important runner. It seemed like that person came to represent for each of us the victory of overcoming adversity in life. We all held the deepest admiration for the last runner, a person to whom we could flow admiration and help. Each week we left with spiritual boost – because of the last runner.

I still remember Her. She lost 67 pounds, quit taking all of her drugs, and went on to run 16 Marathons. She was 60 years old when she started with us. She made tough men turn their faces to avoid being seen suppressing tears. I have no doubt that she was the inspiration for many runners to go the extra mile. If you are a slow poke, you are probably causing the same effect. I can tell you this; I remember Mary well – I have forgotten who the fastest runner was. I believe this will always be the case with the Pacers. The clubs that revere the fastest runners and neglect the accomplishments of the slow folks have different goals. To elevate the spirits of men, while pretending to be just running is my goal. Go fast if you like, if it makes your spirit soar. Slow down once in a while and take a look at the fellow next to you, running or walking a 16 miler together can open the door to the soul. If you are a pre-conditioner, all it takes is running your first 3 minutes together.

My son won the Santa Anita Derby Days event in 1996. He was just 8 years old at the time and the only runner in his age category. We were running the 10K and late in the race were in 2nd to the last place. Sean was exhausted and the last place runner was about to pass us. She was a woman who was probably in her early sixties and was just plodding along. We were closing in on the finish line, about half a mile ahead and She told us to go on ahead of her. She gave a lot of encouragement to my son, told him that he had the heart of a champion and that he would probably do something very great one day. Then I noticed something about the woman. Even though she was probably one of the oldest runners and would finish dead last, she wasn’t even breathing hard. When I asked her if she was tired she told me that she had always maintained this pace. She had run 20 Marathons at that pace and didn’t mind being last. I finished the race with Sean ahead by about 20 yards. I never saw the lady again.

A friend saw the imminent finish of a my 10 year old son and quickly formed a victory arch. There were a lot of runners milling around who sensing a momentous event, rushed to join in. The announcer shouted out his name over the PA. There were a lot of atta-boys and pats on the back afterward.

The greatest champion, the one who achieved the greatest victory that day, was the woman who lifted the spirits of an exhausted boy and took away his defeat in made him a champion. That friend, the one who formed the victory arch, that was Bob Lazzarrini, the fellow who came to the Pacers dinner and spoke about overcoming adversity. He would later become the Pacers president.

It was the last runner who lead us to develop the 4th axiom of the Pacers: “Give and receive praise and admiration to those around you.” One never knows just how far their words will reach into the future. Choose them wisely.

Warmest Regards,

Steve Smith