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.
Back in the early 80’s I bought my first pair of running shoes. I went for New Balance, and they coast an amazing $45.00. There were the big names at that point: Adidas, Asics, Brooks, Nike, New Balance, Puma, and Reebok.
That was then. This is now. Shoe companies galore.
- Hoka One One
- New Balance
- Newton Running
- Pearl Izumi
- Topo Athletic
- Under Amour
- Vibram FiveFingers
Twenty nine shoe companies! I faint that amazing and overwhelming. There may be more I missed.
Then of course, each of these companies have different versions of shoes, typically road and trail. Then different types of control and support features. Then “regular” shoes versus minimalist shoes. And zero-drop shoes.
I went to one online website of a well-known company that sells many different shoes and some of the shoes manufactures had 16 or 18 different shoes models to choose from.
Companies that were known for their hiking boots and shoes now make running road and trail shoes. An underwear company makes shoes. It’s a hot market and everyone want a piece of the pie.
What’s a runner to do when they need new shoes? In my mind, there are three answers:
- First, visit your friendly neighborhood running store. And no, I don’t mean Big 5. I mean a running store with people who actually run, know shoes, and can make recommendation based on your form and gait, foot strike, shoe history, and even injury history.
- Secondly, use the services of a reputable online running shoe company. They typically offer call-in support to help you select the right shoes or a chat pop-up box to ask a sale person questions to determine the right shoes. Some even have online shoe buying guides.
- Thirdly, take a chance and just buy or order a pair of shoes on your own.
I recommend the options in the order presented. The running shoe marketplace is too crowded to make an intelligent choice any other way.
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.
Several weeks ago I was interviewed by Gabriella Boston, a reporter for The Washington Post. She emailed me asking whether I was available and when could we talk. When she called we talked for about an hour. She asked all kinds of questions about foot care based on my experiences for runners.
The article came out on the 17th and is worth reading. The title is How Runners Can Keep Their Feet Happy. Sections include, run training, proper footwear, cross training, and foot care. Gabriella interviewed two podiatrists, a physical therapist, and me. Fixing Your Feet is also mentioned in the article. Click on the link in the paragraph above to read the full article. My bet is that you’ll learn something new.
I’ve been on vacation much of the past two weeks and given my time away, have turned to a good friend, Alene Nitzky, an experienced and well qualified ultra runner who wrote an article published at the Coloradoan website. You have heard me go on and on about the importance of god foot care. Here’s another slant, from an ultra runner who has run Badwater and many other ultras.
Runners spend all kinds of money on entry fees, clothing, travel to races, nutritional supplements and race foods. They spend all kinds of time on training, body work, stretching, weight training or cross training.
They worry about their weight, hydration, nutrition, sleep, and preparing for race-day conditions. And most of all, they obsess about finding the right shoe.
But in all this obsession, the two things they forget are the most essential tools they have to carry them from start to finish and go into those expensive running shoes.
Your feet are your base of support. They are the vehicle that carries you forward and through the distance. You can’t run without them. So why do so many runners neglect them?
You can do all the right training and preparation, wear the right shoes and gear, but if your feet fail you, it can ruin months of hard work.
The problem is lack of foot care. Blisters are just a symptom of the problem. Friction and moisture are the two culprits in creating blisters. Improper hydration plays an important role, too.
Blisters are caused by layers of skin and fabric or debris trapped inside the shoe or sock, combined with friction from running motion. Creases in socks, rough edges inside shoes, and dirt contribute to these rough spots. Calluses that are allowed to develop on feet and are not removed can lead to deep, painful blisters. Rough or jagged toenails can catch on socks, causing the fabric to bunch and rub against the toes.
The role of hydration, especially too little sodium relative to fluid intake, also contributes to blistering. Fluid travels out of the blood vessels into the tissues and separates layers of skin, making shoes tight and contributing to more friction. Check your hands while running. If your hands are swollen, your feet are swollen, too. Popular sports drinks often don’t have enough sodium to replace what is lost during long, hot weather events.
Regular pedicures are helpful. If you don’t want nail polish and all the extras, you can do much of it yourself. Softening and removing calluses over time reduces the likelihood of blisters under these trouble spots. Soften rough, dry spots with lotion when you’re not out running. Keep your toenails trimmed and filed. Underneath the ball of the foot, most people don’t realize they have callouses, and these are a common trouble spot.
Moisture is another problem, even in our dry climate. If you are running trails with stream crossings or crossing snow banks at high altitude, you are also at risk for developing blisters. But even without water crossings, your feet sweat, and moisture in socks and shoes can become a problem.
Keeping your feet as dry as possible helps. If you have a dry pair of shoes and socks to change into after the stream crossings are behind you, that will help.
Use a good sock that wicks moisture away. There are many different brands at specialty running stores. Keep your shoes and socks clean. If you’re running a road marathon, don’t race in shoes or socks you wore on trails. The dirt will stay inside and cause friction.
A foot kit should be part of every runner’s supplies. You can learn how to give yourself a pedicure, how to stock a foot kit and tips for avoiding blisters and other foot problems by doing some research.
Band-Aids are fine for knees and hands, or even on feet that aren’t being used, but they are not meant for use on feet while running. They don’t hold up to friction, moisture and shearing. The Band-Aid will soon bunch up and crease, and any dirt in your shoes and socks will stick to them, causing more friction.
Two excellent resources for learning how to take care of your feet are John Vonhof’s book, Fixing Your Feet, 5th Edition, Wilderness Press, 2011, and website fixingyourfeet.com. You can also get a free subscription to his fixing your feet blog with helpful tips.
I encourage you to check out Alene’s websites. She’s a great person with a big heart.
Filed under: blister care, Foot Care, Footcare, Health, Sports
Last weekend I worked the finish line at the Ohlone 50KM Trail Run in San Francisco’s East Bay hills. This is a tough trail, very exposed to the day’s sun, and every step is either up or down. Some people say, and I believe that if you finish Ohlone, you have a great chance of finishing Western States.
One runner who I admire and consider a close friend is Catra Corbet. She has proven herself as the “owner” of this trail. Many years she will run an Ohlone 100 or more just because she loves the trail so much. This year, Catra did 200 miles on the trail!
In talking to Catra after she completed the 200 miles, she mentioned that she had no blisters. I remember years ago taking a picture of her taping her toes. She used to tape every toe. I have a photo of her with a heel blister too. Now though, Catra runs blister free. What’s the difference?
I believe Catra’s success with blister free feet came through the miles of running she puts on her feet. She doesn’t run short runs, she doesn’t run a couple of times a week – she runs a lot. Many of you know Catra, or have heard of her – and know how much she runs. She also has found the right shoes for her feet – Hokas. She also wears Drymax socks – a favorite of mine.
But it’s not just Catra. I have worked medical and provided foot care at hundreds of ultramarathons, adventure races, walks, and multi-day races and have seen the same thing.
At the Western States 100 at 55.7 miles, for example, the top 20 to 30 runners come through Michigan Bluff without needing any type of foot care. There may be one of two that get some type of foot care from their crew down the road, but if so, is generally pretty minor. Most often, if anything, they just change socks or shoes.
As the race progresses and more runners come through, we begin to see runners needing help with foot care. The farther back the runners are, the more foot care they need. Not every runner, but many of them. And many of them have multiple issues. Not just one blister, but quite a few. The more problems that have, the more complex the repair, and the longer it takes to complete the fix. This becomes a huge issue if they are trying to stay ahead of the cutoffs at each aid station. I remember a runner several years ago that we patched up. At the next aid station, she need more care and wanted to get out of the aid station quickly to avoid the cutoff. That meant not doing a quality patch job –and she came back to the aid station after going a bit down the road. She knew her race was over.
So the point here is that you need to put lots of miles on your feet in order to train them for long conditions. You can run 10 miles a day, day after day, and then try and do a 50 miler, and odds are – you will have problems. You have 10-15 mile feet – not 50 mile feet.
This applies to walking, running, adventure racing, hiking, – any activity where you use your feet.
It all boils down to how many miles you are putting on your feet.
We all can’t be the top runners. Many runners don’t have unlimited time to train. So what can the rest of us do? Make sure you get some long runs, especially closer to your race. Make sure you have the best possible fit in your shoes. Make sure you wear quality socks. Reduce your calluses. Learn proper toenail care. Change your socks and shoes as necessary for the conditions of your run or race.
Over the years, I have talked to too many runners who think blisters are naturally a part of running and racing. They don’t have to be. Make smart choices and put miles on your feet, and your feet can be blister free.
The other day I was looking around the website for the Western States 100 and came across the picture below. It’s pretty brutal. The feet have been pounded to death and been wet – probably the majority of the race. I see torn blisters; blisters on the heels, bottom of the heel, ball of the foot, the crease by the toes, side of the big toes and the toes; and macerated skin. I have no idea if the runner finished the race or was helped off the trail, but my guess is that he gutted it out to the finish line. Click on the image for a larger picture.
My point in showing you this photo is to remind you, as strongly as possible, that there is only so much that I or any other medical person can do to repair your feet and get you to the finish line. You are the one person responsible for your feet, not your crew or anyone on the medical staff. Here are 15 questions you have to answer about your feet:
- What are the best shoes?
- Will you have additional shoes in a drop bag – the same kind, what size, and where?
- What are the best socks – one pair, two pair, double layer, Injinji toe socks, and what brand?
- Will you change socks – where and when, the same socks?
- Will you wear gaiters?
- Do you need lubricant – what kind, where on your feet, how much, and when to reapply?
- Have you trimmed your toenail and filed them short and smooth?
- Have you reduced your calluses?
- What is your plan for managing your feet during the race?
- If you get blisters, what will you do?
- How will you manage the inevitable water in your shoes and socks?
- Do you have a foot care kit?
- Do you and/or your crew know how to use the materials in the kit?
- If you go to medical for foot care, can you describe what you want them to do?
- Have you put the training miles on your feet necessary to run 100 miles?
These are not hard questions – but each is important – and together they make up your plan for your feet. The runner whose feet are pictured above made some wrong choices about his feet. As did many other runners. It happens every year and at races across the country. It’s not just a Western States issue.
The best time to ask these questions is in the months before the race. Then develop a plan. Just like you make up drop bags, find a crew, plan your food, a plan for night running – you need a plan for your feet. I emphasize “You.”
I cannot stress this enough. The medical staff at races cannot fix every big and little problem each runner has. At most races there are too many runners per medical or podiatrity people. And not enough supplies. And not enough time to get everyone patched up to continue on and make the cutoffs. Yes, we are there to help you and we do the best we can.
At Western States there are eight aid stations with medical staff. Each station usually has someone who is in charge of feet. These people have varying degrees of skill and supplies. Did the person above seek help at any of the eight aid stations? I wish I knew. If he did, what did they do?
Of course, looking at the feet above, you might be asking, “What could have prevented this?” or “How do we fix this?” Those are questions for a different post on a different day.
I’ll give you a hint though; the first question is answered in the pages of Fixing Your Feet. And if you have an old edition, you are shorting yourself because these are new information, new techniques, and new products in every edition.
The second question is harder. I have some ideas that other might not think of. This runner will struggle for many days as his feet heal. I pray that he’ll wonder what he did wrong and what he could have done better – and then seek out answers so his next race has a different outcome.
Note: I wish I could credit the photo to a photographer. If I find out, I’ll add a comment to this post.
Filed under: blister care, Books, Foot Care, Foot Care Products, Footwear, Health, Sports
A few weeks ago I was interviewed by Scott Warr and Don Freeman from Trail Runner Nation. I was honored they asked me and we had fun doing the interview. The subject? What else but feet!
You can listen to the interview on their website, download the MP3 file, or better yet, subscribe to their podcast series through iTunes. Here’s the link to their webpage: FEET – Injury Prevention and Treatment with John Vonhof.
Here’s what they wrote on their website:
One of your most important tools as a runner is your feet. You need to take care of them or your training/race may be foiled. John Vonhof literally wrote the book on how to take care of your feet: Fixing Your Feet. This book is now in the FIFTH edition! John joins The Nation to discuss the basic principles of foot care:
- How you can have healthy & happy feet
- Blister prevention and treatment
- What to keep in a foot care kit
- Taping your feet
The interview is 62 minutes in length, but my interview starts about five minutes in. Enjoy the interview and then subscribe to Trail Runner Nation’s podcast.
Thanks Scott and Don for giving me the opportunity to share a bit of my passion for feet on your podcast.
How specialized can shoes become? Last year I watched many runners at the Jungle Marathon Amazon struggle with waterlogged shoes. The race went through rivers and swamps, dirt roads, sand on beaches and in the jungle, and through all kinds of rocks, roots, and other jungle junk. I remember one racer whose waterlogged Hoka’s seemed to each weigh three pounds after a day going through water, sand, and jungle. I saw shoes after shoes that were filled with sand and dirt, and were also waterlogged. This makes one’s race harder as you have to lift that weight with every step.
I have run races where my shoes were wet from stream or river crossings, or rain, or from puddles. Now Reebok has introduced their All-Terrain Series shoe as a solution to the problem with water. The shoes were designed to help runners in the Spartan Race Series of obstacle courses.
The Rebook All-Terrain Series Shoe
The Reebok All-Terrain Series shoe is a new shoe made for the popular obstacle races popping up worldwide – but I think they’ll be valuable in any race or event where water is a problem and traction is important. It’s named after the ever-popular Spartan Race Series and was designed and engineered in cooperation with the Reebok Spartan Race community. An important feature is the mesh H2O Drain ports that drain water quickly through the upper and midsole. The Super model has four drain holes on each side. The Sprint model has small drain holes all over the mesh upper.
The shoe has an outsole with square indented lugs and mid-foot teeth offering superior traction to shed mud. There are even lugs on the front toe of the shoe. The shoe is lightweight and breathable, with a rubberized tongue that will not absorb water and has holes to help expel water. Under the foot is a RockGuard plate to provide protection from rocks and other hard or sharp objects. The upper is made of DuraGrip for durability and ION Mask-fabric to repel mud and water. The shoe’s colors are vivid and bright.
There are two models, an All-Terrain Super and an All-Terrain Sprint. The Super is made for longer distance races and is engineered with more cushioning and stability. The Sprint is made for shorter distance races with a light-weight midsole and a low drop.
This is a serious shoe for obstacle course racers or events were water is a problem. It’s a shoe that can handle any abuse a Spartan Race can give it so you are unstoppable on any course – provided your legs and body don’t quit. I read reviews of Spartan racers who had tested the shoe and all swore by the H2O Drain ports. Having spent a week last October in the Amazon, I saw what wet shoes do to a runner’s feet. I think these would be great in the Amazon or any event with lots of water.
The Reebok All-Terrain Super retails for $119.98 while the Sprint is $109.98. Reebok says they should be in stores the end of April. They are also available through the Reebok website. I’m told they run a bit small so it is recommended to go up a half size. Reebok also offers the option to design your own shoe with a variety of colors for the upper, midsole, laces, tongue, and more. Here’s the link to check out the Reebok All-Terrain Series shoes.
Of course, remember to try any shoe for a while before committing to wear it in a race or long distance run/hike. Make sure the fit works on your feet. Make sure any shoes you buy for a specific event will hold up through whatever it throws at your feet.
The Spartan Race Series
The Spartan Race Series is an international obstacle racing series with three levels of courses: a 3-mile Sprint, an 8-mile Super and a 10-12 mile Beast. You will run, jump and crawl your way over a dozen or more obstacles. Courses are uniquely designed to test your mental and emotional fitness and push you past your limits. Race as an individual, as a part of a team or both!
Choose your Spartan Race here. There are races in many states, as well as Canada, England, France, and 11 other countries. Spartan has offered a discount to my readers interested in trying a Spartan Race. You can get 15% off any Spartan Race in the continental U.S.
If the idea of an obstacle race interests you, Spartan offers a free eBook, You’ll Know at the Finish Line: The Spartan Guide to the Sport of Obstacle Racing.
A FREE SPARTAN RACE ENTRY: If you are interested in a free entry into a 2014 Spartan Race in the continental U.S., write a comment to this blog post and tell me your thoughts on the All-Terrain shoe and why you deserve a free entry. The deadline is midnight Saturday, April 26, 2014. I will pick randomly pick one response on Sunday, April 27 and send that person the code for a free race.