Maceration at Western States

July 7, 2013 by · 1 Comment
Filed under: blister care, Foot Care, Health, Sports 

Last Saturday and Sunday I worked medical at the Western States 100 Mile Endurance Run. I spent Saturday at the Michigan Bluff aid station at mile 55. With the help of Tonya Olson, we patched a bunch of feet. Some had blisters, one needed shoe modification, one had severe heel blisters that had split, and lots of maceration. We saw more maceration than in many past years.

After we closed our aid station at 9:45 pm, I went to Foresthill and talked to George Miller, who was doing foot care there. He had a pretty calm afternoon with nothing unusual.

I found a nice parking space near the finish line at the Auburn High School and spent an uncomfortable few hours trying to get some needed sleep. About 5 am, I headed over to the podiatrity tent and set up my gear. By then, 24 hours into the race, even with about 100 runners in, the tent was quiet.

Around 7 am, things started to pick up. As runners finished, there was a large washtub for them to wash off the dirt. Then they could move to one of the kiddy pools with cold water and ice to soak their feet. Only after that did we see them. As they moved from place to place, Dave, assigned to work finish line podiatrity, and Tonya and I (from Michigan Bluff) looked over their feet and answered any questions. This went on until well after the race ended at 11 am.

This year’s Western States was hot. I’d guess hotter than normal. To my knowledge, there wasn’t that much water on the course. However we saw a large number of runners with severe maceration.

Maceration

Maceration

Here’s a photo of one runner’s foot. This was repeated over and over as we evaluated runners at the finish. Most were convinced that they had large blisters that we needed to lance. In fact, with one or two exceptions, there were no blisters. Just wet, macerated feet with lots of skin folds, creases, and waterlogged skin.

We told the runners that time would heal their feet and to go home or back to their hotel and start a regiment of Epson Salt soaks. The salts help to dry the skin. Powders and airing the feet help too.

Some of the runners had blister with blood inside – some were tinged with pink, indicating blood traces. The decision was made not to lance these blood blisters. When runners have dirty feet and have not showered, and will be walking around in dirty shoes or sandals for a few hours during the awards ceremony, we didn’t want to increase the possibility of infection. In these cases, we gave them the same instruction to do Epson Salt soaks and watch for signs of infection.

A good question is why there was so much maceration. In the heat of the course, often time runners take advantage of every opportunity to keep cool. This includes going through streams, using water soaked sponges at aid stations, pouring water over their heads, and whatever else they can think of. Sometimes well-meaning crew and volunteers squeezed soaked sponges over the heads of runners. The problem is that the water runs down the legs and into the shoes. This helps maceration.

I have seen some runners coat their feet with zinc oxide or SportSlick to help hold moisture at bay. Changing shoes and socks can help, and can be important when maceration has started. Drying the feet and using powder in fresh socks is also important.

Here are four blog posts about maceration and wet feet. Read them to know more about this condition and gain insights about how to manage your feet when wet.

Maceration  – June 23, 2011

Training for Blisters in Wet Conditions – September 15, 2012

Training With Wet Feet – May 5, 2013

A New Kind of Foot Coating – September 25, 2011

Foot Problems at Western States

June 25, 2013 by · Leave a Comment
Filed under: blister care, Foot Care, Health, Sports 

This weekend close to 400 runners will start at Squaw Valley and make the trek over the Sierras towards Auburn – 100 miles away. It’s the Western States 100 Mile Endurance Race. I love the race, having completed it three times in the late 80’s. It’s tough and throws a lot at the runners. Cold, heat, extreme heat, streams running down the trail, rocks, dust and grit, water crossings, long ups and long down through numerous canyons – and for many runners, a second sunrise with renewed heat.

Toe Blister

Toe Blister

I will again be working at the Michigan Bluff aid station doing foot care. Later, I will be at the finish line taking care of feet as people finish. Having worked this race for years, I have a good idea of what foot problems to expect. Here’s what I commonly see and a few tips.

First, here are common problems:

  • Toe blisters. Under the toenail, on the tips of toes, between toes, and under toes.
  • Heel blisters. Either at the rear of the heel or at the sides.
  • Ball of the foot blisters. Either in a certain area or across the whole foot.
  • Side of the foot blisters.
  • Stubbed toes. From hitting rocks or roots.
  • Sprained ankles.
  • Sore feet.

Here are some tips:

  • Cut toenails short and them file them smooth. No rough edges to catch on socks or hit the toebox of your shoes.
  • Reduce your calluses as much as possible. This close to the race, don’t file too much off. Aim to get reduce the thickest rough patches.
  • Use Engo Blister Prevention Patches in problem areas – sides of the heels and ball of the foot. They will greatly reduce friction and shear.
  • Pretape any problem areas.
  • Check your insoles for thick edges at the sides of the heel – always a problem area. Thin these down or change insoles. Most side of the heel blisters are caused by these edges.
  • Don’t use Vaseline as a lubricant. Stick to SportSlick, BodyGlide, or a similar lube.
  • Change socks frequently and clean your feet. Today’s trails shoes often have mesh uppers, which allow sand, dirt, and trail dust inside the shoe, on and into your socks, and on your feet.
  • Know how to manage your feet and patch blisters on your own – or your crew should have these skills. You can’t count on aid station people knowing what you need or want or doing it on your time schedule. There may be other runners in front of you or they may be out of supplies.
  • If you feel something inside your shoe, stop and clean it out. Even a small rock can cause problems.
  • Wear gaiters to keep rocks and trail grit and dust out of the top of your shoes.
  • Build your own quality foot care kit. Stock it with what you need and learn to use everything.

Maybe I’ll see you at Michigan Bluff. I hope it’s just to say Hi as you run through.

Have a great race.

Blood Blisters

July 22, 2012 by · 1 Comment
Filed under: blister care, Foot Care 

In reality, most blisters don’t have blood in them. Repeated heavy pressure (friction) or simply long periods of pressure can turn an ordinary blister into a blood blister.

The fluid will go from clear to light pink, and with continued pressure, to blood red.

The general rule of thumb is not to lance and drain any blood blister. You may have to pad the area to take the pressure off the blood-filled skin. You need to now how to manage a ruptured blood blister.

Here’s why. The problem with blood blisters is that by draining them, the athlete’s circulatory system is opened to possible infection. In a sterile environment or at your home, this may not be an issue. However out on a trail, or somewhere where the athlete may be unable to keep his feet clean, it’s a different story. Where the blister is on the foot can present more problems. A blood blister on the side of the heel is not as problematic as one on the bottom of the foot. The opened blister is exposed to dirt, grime and any bacteria on whatever is touching the skin. Blood blister must be treated as wounds.

Another issue is whether the athlete has he right supplies in his foot care kit to patch the blister. Opening it up and not applying antibiotic ointment and a covering it is a huge mistake.

I tell athletes that normally blood blisters are not lanced because that is the wise thing to say. If everyone thinks they can simply lance them, without fully understanding how to care for them, we’ll have a lot of people with infected feet.

At Badwater last year we had a runner with a very large heel blood blister. She was from Brazil and would be flying home – but she was also a diabetic. Because of her diabetic status, we declined to lance the blister. It would not have been safe.

Arch of the foot blood blister

Arch of the foot blood blister

The photo here is from last week’s Badwater Ultramarathon in Death Valley. The runner had completed the 135-mile race. I talked to him at the finish line and told him the pitfalls of lancing a blood blister. I told him to shower and be careful of popping it and to come see us in the medical room if it did pop. It popped when he was in the shower, the best of all places.

I cleaned the area with alcohol wipes and lanced the blister with a #11 scalpel. I made three cuts so any more fluid would be forced out as he walked. I expelled the blood and applied a generous layer of antibiotic ointment. A gauze 4×4 was placed over the top and then the foot was wrapped with Coban, a wrap material that sticks only to itself. I gave the runner a Zip-Lock bag with a small tube of ointment, several more 4x4s, a Popsicle stick to apply the ointment. I told him he could unwrap the Coban and reuse it multiple times. Then I asked him if his Tetanus was up to date after which I gave him the usual infection speech.

Recheck the blister three times a day for signs of the infection. Each time you check, apply a new coating of antibiotic ointment and change the dressing. Early treatment can keep the infection from becoming more serious.

An infected blister may be both seen and felt. An infection will be indicated by any of the following: redness, swelling, red streaks up the limb, pain, fever, and pus. Treat the blister as a wound. Clean it frequently and apply an antibiotic ointment. Frequent warm water or Epsom salt soaks can also help the healing process. Stay off the foot as much as possible and elevate it above the level of your heart. If the infection does not seem to subside over 24 to 48 hours, see a doctor.

It’s wise to keep a tube of antibiotic ointment in your foot care kit. You may never get a blood blister, but then again, you might. And if you get one, it may not rupture, but then again, it might.

It’s better to be prepared by knowing how to care for blood blisters.

 

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