Filed under: blister care, Foot Care, Footwear, Footwear Products
Heel blisters are quite common – although they shouldn’t be.
Today’s post shows one participant’s feet at the 2014 Amazon Jungle Marathon.
If you look closely at this picture, you’ll see two heel blisters, both on the outside of the runner’s feet. The right foot blister is large but is not blood-filled. The blister on the left heel, however, is very large and filled with a large amount of blood.
It’s easy to think these are normal blisters – but their size makes they abnormal.
In my experience, heel blisters are caused by the constant shear when either 1) the heel is moving up and down inside the shoes’ heel, or 2) by the constant movement at the place where the shoe’s insole touches the inside of the shoe. Over the years, the majority of heel blisters have been the latter. One of the characteristics of this “insole/shoe junction” blister is that they often are flat across the bottom. The blister starts at the point where the insole’s edge at the side of the heel touches the inside of the shoe. That’s what makes the flat line at the bottom. Then the blister forms upward as the fluid forms and it grows. Given enough time and movement, you’ll get blood inside.
These are relatively simple to patch. The skin must be cleaned with alcohol wipes, and then the blister can be lanced and drained. Depending on the size of the blister, you’ll need to apply some type of blister patch. The bottom line is that you need to have something over the blister to protect the skin and prevent the top layer of skin from tearing off. For these, I would use strips of kinesiology tape (my preference is either StrengthTape or RockTape H2O) with antibiotic ointment over the blister to keep the tape from sticking to the skin. The larger the blister, the harder these are to patch but it can be done.
You are better off to prevent these blisters in the first place.
Start with the fit. Make sure your shoes hold your heels in place with just a little movement.
Check your shoes and insoles for rough and/or thick edges at the inside and outside of each heel. Side blisters are much more common than the back of the heel. If the insole has a large thick edge, replace them. If the shoe’s fabric is worn into a hole, you are due for new shoes. Under the fabric is generally a plastic edge of the shoe’s heel counter – the plastic that curves around the heel from side to side.
Engo Blister Prevention Patches are perfect for to help prevent these types of blisters. These patches are super slick. Either the small or large oval can be applied to the inside of the shoe and cover the offending edge of the insole/shoe junction. Clean the inside of the shoe and insole first. I work the patch with my fingers to form a curve to fit with area I need to cover. Then remove the backing and apply the center of the patch first and then push the top and bottom of the patch into place. Rub it a bit to assure adherence.
Filed under: blister care, Foot Care, Foot Care Products, Sports
I have often mentioned the website BlisterPrevention.com.au as a great source of information on blister care. Rebecca Rushton, manages the website and is on top of developments in the prevention and care of blisters. She’s a podiatrist in Australia – and a friend.
Through research and looking at the mechanism of how blisters form, Rebecca has changed some old theories of what causes blisters. Heat, moisture, and friction were always considered the three contributors of blisters. Further consideration has found that shear is a major factor. Shear and friction combine to cause blister formation.
I want to quote a blog post by Rebecca about Healing Foot Blisters Faster to help you understand more about friction and shear.
“You know friction is responsible for friction blisters. But I bet you think friction is rubbing. It isn’t. Friction is about grip. High friction means two surfaces grip together. Low friction means they don’t … they’re slippery.
“Here’s how friction is responsible for foot blisters … There is high friction in your shoe. There just is. This means your skin grips your sock; and your sock grips your shoe. All three surfaces grip together so your foot doesn’t slide around in your shoe.
But with every step you take, your bones are moving around under the skin. And while the skin is stuck and the bones are moving back and forth. Everything in between is pulled and stretched. This pulling and stretching is what causes blisters.
We call it shear. And it needs high friction to get anywhere near blister-causing.”
With this opening, Rebecca starts to explain the effect of shear and friction on blister formation. She talks about cutting friction levels, especially when a blister develops, and gives examples of six friction reducers. Some of these are better than others.
We have always tried to reduce friction in both preventing blisters and when treating blisters. As Rebecca says, and I support, “Otherwise all that stretching (shear) continues at the blister base while it’s trying to heal. Making it hurt more. And taking longer heal.”
So take a moment and click on the Blister Prevention link and read Rebecca’s full blog post. While you are there, I encourage you to subscribe to her email list.
Many of you have participated in a 50-mile race, a 100-mile race, an adventure race, or some other type of multi-day race. Some multi-day races are non-stop while others are stage races. A lot of these races provide medical care at aid stations – and some also provide foot care.
If you have received foot care aid at these aid stations, you have been helped by the generous people I’ll call the “heroes” of foot care.
The picture shown here is from the Amazon Jungle Marathon this past October. Every one of the 15 members of our medical team helped with foot care. No one said they didn’t want to do feet. You can see the working conditions: sand everywhere, water bottles as footrests, a tarp to protect the runners and our knees (that quickly filled with sand), and supplies strewn all over and shared between medics. What you don’t see are the flies and bugs that were constantly in our faces, and the sweat running down our faces from the humidity. Now keep this up for hours, well into the night.
These are the heroes of foot care.
Most races have them. They volunteer their time and even supplies. They often go to races at their own expense. They work often under adverse and uncomfortable conditions. They want to do the best patch job possible. They are dedicated to getting you back into the race. They want you to have a great race experience. In short, they care.
I’ve been at races that have well-organized foot care services and others that have nothing. Some people providing their services are podiatrists, doctors, nurses, paramedics or EMTs, physical therapists, chiropractors, or other medical specialists. Other times they are simple people who have learned foot care techniques on their own or from someone else.
I know you appreciate these foot care people.
So how can you thank them? Let me share a few ideas.
- Simply say thank you.
- Make sure you have done everything possible to have healthy feet going into the race.
- Trim your toenails short and then file them smooth.
- Reduce calluses as much as possible.
- Wear quality shoes and socks.
- Know how to do your own foot care just in case we aren’t there or there’s a line for our services
- And finally, be patient. Good foot care and blister patching takes more than a minute.
We love helping runners and always welcome your appreciation.
Filed under: blister care, Foot Care, Footcare, Health, Sports, Travel
In early October I had the unique opportunity to return to Brazil and provide foot care to runners at the 10th Annual Jungle Marathon Amazon. The race is more than a marathon. It’s three races in one event set in a stage race format. Every day the race camp moves to a new location as the runners go through the jungle and along the beaches of the Amazon River. There’s a seven day, six stage race and a four day race, that both start at the same time. Then on day four, the single day marathon stage starts.
This year’s race was the toughest of any event I have been a part of. There was single track trails hacked through the jungle, red dirt roads with loose dirt, swamps and streams and rivers, humidity, heat, rain, sand that got everywhere, never ending wet feet and water-logged shoes, bugs and spiders and snakes, jaguar sightings, a lot of bee stings, either cold food or food heated with hot water, jungle and beach camps, carrying all your gear in a backpack, and nine nights in a hammock. Runner’s feet took a beating and as the days progressed, it was harder for them to recover. The cumulative affect of having your feet wet for the majority of every day, became a struggle for many runners. Maceration was a serious problem for everyone, and blisters affected all runners to varying degrees.
After the race ended, I was able to take a a few minutes and interview Amy Gasson, the second place women in the seven day race. Amy was a joy to know and smiled every day with a great positive attitude. Here’s the link to listen to the audio interview. It’s 17 minutes long.
Considering the interview was recorded with a handheld digital recorder, in the lobby of our hotel with all it’s normal background noises, the sound quality is remarkable. There’s a lot we can learn from what Amy shares. She did her homework and prepared well – both physically and her feet. Here’s a photo of Amy and me at the finish line.
Thanks Amy for letting me get to know you at the Jungle Marathon Amazon.
This post is an editorial about foot care at races – and more importantly, the lack of it.
Last week I returned from my second trip to Brazil to help provide foot care at the Amazon Jungle Marathon. I plan to write a post about the race later, so I won’t go into detail here – but this is the toughest race I have seen. Over the years I have worked many multi-day multi-sport adventure races and multi-day running races. Most of these are six or seven day events. Adventure races are races where the clock doesn’t stop until the team gets to the finish. Running races are typically stage races where each day is a specific mileage and camp changes every day.
Please continue reading – even if you don’t do multi-day races – because this blog post applies to those doing 24-hour races, 100 mile races, and athletes in general.
These types of races always have a list of mandatory gear. The list is composed of mostly safety items with a mix of medications and first aid stuff. Some of the first aid items can also be used for foot care. The photo shows an example of a first aid mandatory gear list. Here’s the rub though. Most athletes want to minimize, as much as possible, the amount and the weight of the stuff they have to carry. If the list calls for tape, they’ll carry a ½ inch wide very small roll, as few as possible blister patches, 2 or 3 alcohol wipes, 2 Band-Aids – you get the picture. They don’t have the right stuff because the lists are very general and don’t specify exact brands or types of supplies. They don’t have enough because they are not the average athlete and will need more. They only carry what they are required to carry and miss what they need for their feet. And many of these athletes don’t know how to use what they carry.
I have worked many multi-day races and have seen athletes finish a day’s stage and come to medical for every little thing. The medical staff should not have to manage all your foot care. You can manage the small pea-size blister on your toe. If you have hot spots, you can tape over them and check your shoes for seams. There is usually not enough medical staff to care for 100% of each runner’s needs. In addition, the supply of medical equipment is limited and can easily be over taxed by runners wanting everything done for them.
One runner in the Jungle Marathon came to see the medical team every day, telling us what he wanted down to the color of the tape and showing us all the spots on his feet he wanted fixed. We would have had to spend an hour just on him, with a lot of supplies, when he had a medical kit but wanted us to do it for him.
I am becoming more and more convinced that mandatory gear lists should be material specific. The width, length and type of tape should be listed. The number and type of blister patches. Scissors rather then a needle. Specific powder and amount. A specific number and type of tape adherent. And do on. The mandatory gear list needs to be reviewed with the medical director. This applies to runners in any race 50 miles or longer too. While the majority of runners don’t typically carry foot care supplies in a 100-mile run, their crews need to have the supplies.
I also am convinced that runners need to know how to patch their feet. Running a 100-mile race with no knowledge of how to care for one’s feet if and when problems develop is asking for trouble and putting undue burdens on the medical teams. You cannot assume that all medical personnel know how to patch feet – and have the best supplies for doing so.
Earlier this year I worked a multi-day event that had only basic medical supplies at the aid stations. There was virtually nothing that could effectively be used for foot care. The participants were not promised foot care, only first aid and medical personnel. In fact the pre-race materials did not mention foot care. Many aid stations did not allow crew access. The result was runners who were generally not carrying a foot care kit, had no crew access at many aid stations to help with their feet, and no medical personnel trained in or equipped to do foot care – a disaster waiting to happen. I had my complete foot care kit and worked on many runners’ feet. I know several other aid stations happened to have medical people who knew how to do basic foot care. But we each used our own supplies. I can honestly say that without the few of us on the course, the finishing rate would have been less than 30% because the race organizers did not think through the possible problems and build in solutions. Their disclaimer to me was that they had not promised foot care and runners were on their own.
In my opinion, putting on a race of any length requires race organizers to put runner safety as their first concern. Runners pay their money and expect a certain amount of good organization and common sense in return. In what has become a catch-22 situation, many runners genuinely expect there to be medical personnel able to manage emergencies as well as manage their feet. They think “first aid” and “medical personnel” means foot care. In reality, many races make no provision for foot care and take an “Oh well – that’s life” attitude. In fairness to medical personnel, I know anyone doing medical at an aid station will try and help any runner needing it. However they may not have the supplies and / or the training.
The Jungle Marathon had multiple doctors and paramedics, a fully stocked medical cache of basic and emergency supplies including medicines and narcotics, bandages and foot care supplies galore, and a complete set of medical protocols. Each checkpoint was manned by at least two medical personnel with a complete medical kit. Western States has great medical care at the major aid stations. So does Badwater.
In the end, every race lives and dies based on runner perceptions and what they share with their friends. Give them a bad experience; bad or non-existent medical care and / or foot care, and the word will spread.
Filed under: blister care, Foot Care, Footcare, Footwear, Health, toenails
Here are a few foot care tips I wrote to help runners at the Amazon Jungle Marathon. I’ll be there in a few weeks to help with foot care on the medical team. The tips are valuable for anyone doing a 24 hour race, a multi-day event, an adventure race, or a long backpack. Remember, your feet will carry you day to day only if you take care of them.
Start with good toenail care. Trim your nails short and then use a file over the front edge to remove any rough edges. File the tip of the nail so when you run your fingertip over the tip of the toe and over the nail, you don’t feel any rough edges. You can also file the top of the nail if it’s thick. Coming to the race with bad toenails will ensure toe blisters and black toenails.
Make sure your shoes fit well. Have enough room in the toe box for your toes to wiggle. Your feet may swell over the race and you don’t want shoes that are too tight. Some shoes, like Hokas, retain water and become heavy over the days, as they are wet so much of the time. Wet and waterlogged shoes are heavy.
Get good socks. Don’t show up with cotton socks. Socks made with Coolmax or wool are good choices. Injinji toe socks are great. Have several pair and wash then after each day’s stage or have one pair per day. Also don’t show up with old socks or ones with holes in them.
Do whatever you can to reduce any calluses. Getting a blister under a callus can be painful and it’s very hard to find the pocket of fluid for draining. After showering, use a callus file or pumice stone to shave the callused skin from your feet. Then apply some callus cream. This is something that should be done several times a week. Calluses are the result of friction and pressure between your shoes and feet. Make sure your shoes will drain water.
Shoes that hold water inside will increase the maceration effect of your feet being wet to long, leading to wrinkled and soften skin that can fold over, crease, and split open. Check this by filling your shoes with water and seeing whether it will drain out. You can heat a nail (at least 1/8 inch round) or an awl and make several holes at the inside and outside arch, and the heel of your shoes. Learn how your feet respond to being wet for long periods. Do some long walk or runs three to six hours long with wet feet. Try several products like Desitin or similar cream for baby bottoms that works to control moisture on the skin. Google “baby bottom cream” to see many options.
Do not skimp corners on your foot care kit you need to carry in your pack. Have several yards of a good quality tape, several needles to drain blisters, and learn how to drain and patch blisters. The medical team will try and help with your foot care needs, but we can become overwhelmed by the number of people wanting help. Part of your responsibility as a runner is to know how to do good foot care.
Carry a good pair of camp shoes to wear in the camp after each day’s stage. You don’t want to walk around barefoot and doing so will destroy the taping or blister patching done by you or the medical team. Lightweight Crocs, flip-flops, or sandals are easy to strap to your pack. Change into these after running to allow your skin time to heal from the moisture.
Today’s blog post is a little bit by me and a lot by Rebecca Rushton. Rebecca is a friend and podiatrist from Australia. I admire her work regarding blister formation and prevention. I follow her website and whatever she writes.
Having worked many events over the past years, I have seen hundreds of toe blisters. These may be at the tip of your toes, between your toes, or under your toes. They are very common, especially in ultras, adventure racing, and multi-day stage races. Understanding the causes of toe blisters, and ways to prevent them is important, not just for you but for your crew too.
Rebecca’s recent blog post details seven likely causes of toenail blisters. Here’s the link to Toenail Blisters.
- Shoes too small
- Shoes too big
- Nail shapes and deformities
- “Cocked-up” big toe
- Clawed toes
- Downhill terrain
- Long, thick or rough toenails
Make sure you sign up for Rebecca’s emails and you’ll get a free copy of her premium resource The Advanced Guide to Blister Prevention. The sign-up box is in the upper right corner of her web page. While you’re on her website, be sure to check out the rest of her content.
Maceration in a Dry Race
Two weeks ago I worked medical at Badwater. This year’s course had some serious uphills and downhills – but the course was dry. Unless one has feet that sweat heavily, there typically would not be any issues with wet feet.
Yes, this post is going to talk more about maceration. I’ve done a number of posts this year on maceration, but the problem won’t go away, so there must be more to learn.
So here’s how maceration happened in a dry year at Badwater and what you need to learn from it.
It’s very simple – really. Runners pour water over their head to cool themselves. Or well-meaning crews douse their runners with water over their heads, or spray them up and down with some kind of tank sprayer. The water runs down the runner’s clothes and body, down their legs, and ends up in the runner’s shoes. Socks and shoes become saturated.
Sometimes runners will changes socks and shoes during the run, and this helps for a bit, until more water is poured over the runner’s head and down into his or her shoes.
The water buildup leads to softening of the skin and maceration. In the photo you can see three areas of concern. If you click on the image, you’ll open a much larger copy image where you can see the detail even better.
First, the skin has torn at the base of the fourth toe. There may or may not have been a blister with fluid under the skin on the ball of the foot. My guess is it was not a blister, but simply wet softened skin that was stressed and then tore.
Secondly, notice the fold of skin at the bottom of the baby toe. The toe was probably pinched in the shoe toebox, folding under the fourth toe. This puts pressure on the skin of the baby toe, pushing the skin forward into a fold from the tip of the nail to under the toe. When I see these folds, the skin in usually intact and not torn.
Thirdly, notice the fold of skin going down the center of the ball of the foot. This is the most serious of the three problems. The fold is painful. The skin is not torn, but has pulled up and then folded over on itself.
As the skin goes through the maceration process, it first looks like the skin of a prune – shriveled up. The longer the maceration continues, the more chance for the skin to soften. The foot inside the sock, inside the shoe, can be squeezed and as the runner moves through the foot strike, with his whole body weight carried on his feet, pressure is put on the skin leading to creases in the skin. The creases are most common in a line down the length of the foot rather than across its width. Continuing through the maceration process, the creases of softened skin can lead to the skin lifting up and folding over on itself. In the photo you can see the shadow from the fold – it’s significant and can be quite painful.
In this case, all three problems were caused, by the runner’s admission, his pouring water over his head and allowing it to run down is legs into his socks and shoes.
It seems so beneficial to cool yourself off by pouring water over your head and/or by spraying your body and legs – but there are negative side effects.
The hard part for the runner, besides the pain, is that there is no quick fix to remedy the skin folds. It takes time, sometimes days for the skin to return to its normal state.
In an upcoming post I’ll talk about some products to help protect your skin from wet conditions. For now, avoid pouring water over your head. Protect your feet.
Filed under: blister care, Foot Care, Foot Care Products, Footcare, Health, Sports
Last weekend I worked foot care at the Western States 100 Mile Endurance Run. We had a fairly dry winter with not much snow in the high country and I had heard runners talk of the dust on the trail. Based on that, I did not expect to see high number of runner’s having foot trouble because of maceration.
Working Michigan Bluff aid station, at 55.7 miles, I was surprised by the runners coming in with wet feet, and varying degrees of maceration. For some, it was minor skin softening and maybe a few surface creases. Others had more severe maceration, with creases that were deeper over widespread areas on the bottom of their feet. A few were really bad – deep creases and skin folding over on itself. In extreme cases, the folded skin can split open.
While maceration is commonly caused by stream and river crossings, it also happens when runners pour water over their heads and body and it runs down into their shoes. Feet also sweat a lot, some people’s more than others, and this also can lead to maceration.
I also worked the finish line. There I saw even worst cases of maceration.
Severe maceration can manifest itself as a burning sensation, and the feeling of large blisters all over the bottom of their feet. Taking off the runner’s shoes and socks, we found virtually all of these complaints to be degrees of maceration. Two facts are evident. First, as might be expected, the longer a runner is on the course, the worse the feet can become. Secondly, not changing one’s shoes and socks during the race can magnify the effects of maceration.
The photos here are of one runner. My recollection is this runner finished the 100 miles in about 29 hours. She came into the podiatrity area of the medical tent and could barely walk. This is not uncommon. Runners dig deep and finish on adrenalin and then once they stop, the extent of the injuries to their feet hits them.
Photo 1 shows the bottom of the right foot – it’s worst than the left. You can see the white of the skin, and the creases running over much of the foot. The creases extend down to the mid-foot. Notice the white skin flap on the tip of the little toe.
Photo 2 is a close up if the toes. You can see the large skin flap on the little toe. This flap of skin was very white and looked as if the skin on the tip of the toes had been pulled outward and pinched. It was about ¼ inch in length. It runs from the toenail to the bottom of the toe.
Photo 3 shows the side of the forefoot. You can see the large fold of skin of the inside of the ball of the foot. This can be very painful and can split open under pressure.
Unfortunately, there is no quick fix for maceration. Typical treatments include warming the feet, moisture-absorbing powder, dry socks, allowing the feet exposure to air to dry, and time. In talking to this runner, she did not change her shoes nor socks during the 100 miles. I don’t recall the type of shoe, but my guess is that it did not allow water to drain.
There are several ways to manage possible maceration. Several years ago I watched as an adventure racer coated the bottom of his feet with Hipoglos, a European version of zinc oxide. The compound helps control moisture on the skin, whether zinc oxide or Desitin or a similar product. RunGoo, Century Riding Cream, and Blue Steel Sports Anti-Chafe Cream are similar products. I may have another product to announce early next month.
Another helpful tip is to make sure your shoes drain well. Whether that means mesh uppers, mesh or a draining material down to the shoes upper sole, or making drain holes with a heated nail, draining water out of the shoe is important. Then of course, changing your shoes and socks is also important. Most 100’s have aid stations with drop bags and it’s easy to put a pair of shoes in one or two drop bags, or have your crew have them ready.
Maceration can be cruel. It ruins the race for some runners. It’s painful. It can take days to heal fully. But there are ways to minimize its effects. If you are running a 100 or a multi-day race, and there is a chance of water on the course, plan accordingly.
Years ago, back in the late 80’s, I has the good fortune to run the Western States 100 Endurance Run four times. While I never earned the silver buckle, I had respectable times: 26:32, 26:00, and 24:32. The fourth time, I pulled myself at Rucky Chucky. I always did my training in the Ohlone Wilderness, Lake Chabot, and Mt. Diablo.
My third time, when I missed the silver buckle by 32 minutes, I never should have finished. My training for the six months before the race was only 750 miles! I was 250th into Robinson Flat and 100th at the finish line. Between the two, no one passed me and I passed everyone I could. My pacer and I had a great night run, picking people off as we ran. I thought I had a shot at 24 hours, but when I got to Highway 49, I knew I would fall short.
So it is with those memories that I wish everyone at Western States the best of luck for a safe and fun run.
I’ll be doing foot care at Michigan Bluff and then Sunday morning at the finish line. I hope some of you crewing will have the opportunity to stop by medical at Michigan Bluff and say hi. If you are running the race, I hope you can run past with great looking feet.
But if you need help with blisters or any foot related care, I’ll be there.