I have a large file of feet pictures on my computer. Pictures of toes, heels, balls of the feet, and arches. Pictures of blisters of all shapes and sizes. In addition, I see all kinds of feet when I work events. Over the years, I have worked races ranging from short distances to ultramarathons, to multi-day stage races.
I am probably one of a limited number of people in the world who gets excited at photos of bad feet. I like them because they tell stories.
The first full multi-day event I worked was Racing the Planet’s Atacama Desert six-day stage in the high desert of Chile in 2004. The stressors of being on your feet for long distances day-after-day for six to seven days often bring out the worst in feet.
A lady in that race wanted us to remove her toenails at the end of day two. Another runner had the worst case of trench foot I have ever seen. That was nine years ago and my techniques have changed for the better, but the feet remain the same – bad!
I believe that feet tell a story.
The photo here is from the Racing the Planet Iceland. I don’t know the owner of the feet. I don’t know the level of training and experience the person had prior to this race. I also don’t know what experience this person had with foot care planning before a race and during the race.
Here are my observations about the story behind these feet.
- Almost every toe has something going on.
- The photo was posted online for stage five, meaning the runner had to tolerate these toes for four plus days.
- These blisters don’t typically happen in one day. My guess is they started on day one, progressed to blisters on day two and then got worse.
- My bet is the shoes’ toebox was too short in length and/or too low in height.
- The runner may have worn two pairs of socks, which could have made the fit too tight.
- The toenails don’t look too long but it’s hard to see if they have any rough edges or are thick, both of which can lead to toe blisters.
- These toes scream pain – especially if they are encased inside shoes.
- It’s possible the toes received some degree of care, but it is hard to tell from their condition.
- Four of the toes have major trauma.
- We cannot see what is going on under the toes, but from the outside edges of the big toes, you can see blistered skin of the left one and maceration on the right one.
- The left big toe has blood showing in the blister on the outside edge.
That’s a lot of information pulled from a photo. I wish I knew the toes’ owner. It would be nice to learn more about his/her race. What shoes and socks they wore. How the trauma to the toes progressed day-to-day. What care they received. Whether they finished the race.
My guess is that with proper care, much of this could have been prevented. That care could have included lubricants, moisture control skin protect, tape, modified shoes, and nail care.
What story do your feet tell?
Here’s the link to the Racing the Planet’s Iceland race. Racing the Planet does four desert races every year called The 4 Deserts: the Gobi in China, the Atacama in Chile, the Sahara in Egypt, and Antarctic. Every year they add a new location for that year. Past sites have included Australia, Nepal, Namibia, Vietnam, and 2014 will be in Madagascar. You can check them out at Racing the Planet.
Filed under: blister care, Foot Care, Footwear, Health, Sports, toenails
Which is more important, blister prevention or blister treatment?
For more than 17 years, I’ve taught foot care techniques to anyone who will listen. I have taught classes at running stores, REI stores, events, and more. In addition, I have worked medical at many races, helping provide foot care to participants. These races have been in Death Valley, Chile, Costa Rica, BC Canada, Colorado and Washington, and many in California. This year I will be at Western States 100, Badwater, the Gold Rush Adventure Race, the Jungle Marathon in the Amazon, and hopefully at races in Colorado and Namibia.
I have never counted the feet I have worked on but I would put the number well over 3000. I remember one race in Colorado in 2010 when I saw the same lady 10 times. It was a six-day stage race and she’d come in every evening and morning! I’d patch her feet in the evening and she’d take it off when she went to bed in her tent. She had foot wear issues that gave her blisters on top of blisters. She was never into prevention mode – only treatments.
In this picture, taken from the cover of the 5th edition of Fixing Your Feet, we see treatment taking place. I love the picture. I even know whose foot it is. What I can’t tell you is what he did for prevention. I wish I knew.
My question in this blog post is what should we spend more time on, blister prevention or blister treatment?
Prevention can take many forms: good choices in footwear, the right socks, lubricants and powders, toenail care, skin care, taping, Engo patches, correct lacing, the right insoles, and training and conditioning.
Treatments likewise offers many options: blister draining, many different types of patches, taping, ointments and salves, a multitude of tapes, wraps and straps, silicone pads, Engo patches, toe caps, and lubricants and powders.
So here are a few questions:
- Does prevention last only until the race starts?
- What are your best prevention options?
- How much do you count on aid station personnel to manage treatments?
- Do you know how to treat your feet?
- Do you carry materials to treat your feet?
- What are your best treatment options?
- How well do you understand blister formation and prevention?
For 17 years, athletes have had Fixing Your Feet as a resource to learn important information about foot care. As I patch feet at races, I try to educate the athletes about what I am doing and why, and what could have helped in their feet. If crews come to me for advice, I try to help them too. I have watched athletes and crews work on feet with materials and using techniques I have long preached.
In general, foot care has advanced over the years. Shoes, socks and insoles have become light years better. Lubricants, powders, blister patches, and our tools are better. People interested in foot care are trying new blister patching techniques.
All this is good because every day there are new athletes coming into running, adventure racing, hiking and thru-hiking, walking, and other feet stressing sports. Let’s make sure they understand the importance of prevention before treatment.
Lisa de Speville, who lives in Johannesburg, South Africa, is a close friend who often emails with insights on blisters and foot care. Yesterday I received the following email and asked whether I could share it with my readers. Her email contains insights on little toe blisters, issues with minimalist shoes, and fit of shoes modified with gaiters.
Here’s her email.
Last week I ran in the 5th edition of the Namib Desert Challenge. I had the pleasure of running in their inaugural event back in 2009 and so it really was a treat to return. Great event, well-organized, wonderful region of Namibia and a lovely warmth and hospitality from the organizers.
Since about June last year I’ve been running in more minimalist shoes. I’ve always enjoyed a softer, more tactile shoe and I took to the pair of Asics Gel Fuji Racers that I won at a race immediately. I liked them so much that I was even running them on road. I like to keep trail shoes for trail and road shoes for road so in about August I bought a pair of Inov-8s. The brand is relatively new in SA so I thought I’d give them a try (my road shoes have been Addias Response or Supernova for more than 10 years). Let’s see… I’m in the Men’s Road X 255 (6mm lift), which is not flat as a pancake. Both the Asics and Inov-8 are quite roomy and my feet enjoy this.
Certainly over the past three months I’ve felt a change in my soles – more firm and muscular, which stands to reason if they’re strengthening and working harder. It is muscle after all. Before I started adventure racing and running ultras my feet were 1.5 shoe sizes smaller and I have a feeling that my feet are another half-size bigger in recent months.
So, the time comes for the Namib Desert Challenge and I get my favorite race shoes stitched with Velcro for my desert gaiters. Everything is ready. I hadn’t worn these shoes for a while. They were still relatively new – perfect for going into a multi-day race - as I’d bought two pairs of the same at an end-of-range special many months ago. I’d flattened the first pair so they were in no condition for this race.
When I put my foot into the shoes in the days before the race to get a feel for them again they felt a little tight, especially across the width of my forefoot. And more than just newness. This is why I figure my feet are a certainly a half-size bigger. Nothing that some lace-loosening wouldn’t sort out.
I started to develop what I call ‘triangle toes’ almost immediately. This is the one thing I avoid like the plague because I hate having sore little piggies. Triangle toes is where the underside of the little toe – and sometimes the neighbor next door – becomes pointed. A blister forms here and can result in a ‘toe sock’ – where the skin of the whole toe comes off, almost like a sock. It’s nasty and I not very fondly recall some incidents of almost toe sock about 10 years ago in adventure races. Since then I take special care pre-race to make sure my little toes stay ’rounded’ and that any harder, potentially triangular skin, is filed off regularly.
I dealt with the resulting blisters – stage 2 or 3 they came up on both little toes - by draining, leaving overnight to dry and then added some tape for the stages. I tried to flatten the triangle under the tape, but it ended up triangular again at the end of the stage. For the most part they gave me little trouble.
At the start of the 55km ultra stage on Day 4, I was debating whether to remove the inner soles for give my feet more room so that the little toes would have more width. It felt odd so I started with them in and my laces not too tight. By the first waterpoint I needed to change something so I took out my innersoles. I had to re-tape a toe a little way further because the change in space altered something. After this, no problem.
I’ve never run in shoes without innersoles and it really changes the feel of the shoe. The Adidas Response TR shoes really suit my feet – I’ve been running in them for 13 years! Taking out the innersole changes them to the Inov-8 feel. Flat and bland inside, which isn’t a bad thing – just different. It also makes the sole feel so much more flat and less cushioned – I felt like I was running in a non-cushioned shoe… for 47km!
Fortunately I was none the worse for wear but, for sure, if my feet hadn’t been conditioned from 10 months of running in ‘flat’ shoes my feet would have felt it. I ran the 5th and final stage without the innersoles too.
Aside from the triangle toes, my only other foot ailments included an injured big toenail on my left (not sure why? perhaps from a kicked stone?). The toenail developed a blister underneath, which was easily solved by drilling into the nail to relieve the pressure. I only discovered this one after the second stage when inspecting my feet. The other blister came up on the long stage under the ‘joint’ of my left big toe, where it connects to the foot. I have some scar tissue there from when I sliced my toe open many, many years ago. It occasionally twinges and at this race, on the long day, I caught exactly this spot so many times on rocks – prodding in. I couldn’t have purposefully aimed as many times in that exact spot! Again, not a bother (fortunately!) and easily solved by draining. On the final stage I didn’t hit it once and so it didn’t flare up again. For the rest, beautiful feet after 230km.
As I haven’t had triangle toes for years, this confirmed for me that width-ways just-that-little-too-tight squeezing of the forefoot is almost guaranteed to cause triangle toes and the resulting underside blisters, with the potential for toe sock, somewhere you do not want to go. In fitting shoes we tend to focus on the amount of space at the front of the shoe but definitely need to pay attention to left-right wiggle room.
Finally… one of the runners had really badly injured toenails (most of them) and the tops of his toes. The reason… too small desert gaiters for his shoes! I don’t know what kind they were (not mine) but they were Velcro attached (around the shoe) and pulling at the top and front of his shoe and causing toe injury. Live and learn.
Lisa de Speville
Johannesburg, South Africa
Adventure Racing: www.ar.co.za
Last week I wrote about prevention and being proactive. I emphasized that you are the key to prevention. I want to share an email I received from a friend that is a great example of this in action. Lisa told me about her friend and gave me permission to share the story:
My friend ran a 50km x 2 (100km total, over two days) race a few weeks ago. Over the past six months he has put a lot of work into his running training and has been running beautifully.
I was away so when I got back I dropped him a text to see how his race went. He told me what happened and in the conversation said that he would be losing many of his toenails. I ask why and he said he forgot to cut his toenails.
As you can imagine I didn’t reply to this at all because I would have thrown some insulting words his way.
He has been trail running for more than a decade and been doing adventure racing for over a decade. He spent a fairly sizable amount on his race entry and it must be about 900km to travel to the race. He put in six months of training to get stronger and faster. And he forgot to trim his toenails! This is more than elementary and is totally stupid. It’s tough to have sympathy (I have none!) when friends do silly things like this. He knows better.
This story speaks for itself. I have often talked about how athletes spend a lot of time and money in preparation for an event but fail to plan for good foot care. More times than I care to remember, I have seen athletes quit a race or be pulled from a race because of feet gone bad. It doesn’t have to be that way.
I’ll say it again, you are the key to prevention.
Filed under: blister care, Foot Care, Footwear, Health, Sports, toenails
I believe strongly in prevention as a proactive measure in foot care.
Tim Noakes’ sixth law of running injuries must be heeded—any running injury can be cured only after the cause is found and eliminated. All of us who run, hike, or adventure race at some point have problems with our feet or sustain foot injuries. The prevention chapters are numerous and lengthy because many factors contribute to foot problems and injuries, and for every factor, there is a preventive measure that can reduce or eliminate it. Prevention is the key to saving your feet. Dave Scott, a good friend and ultrarunner, put the foot problem in proper perspective: “When you don’t take care of your feet during a long run or race, each step becomes a reminder of your ignorance.”
It’s very easy to relinquish our responsibility for preparedness and let someone else dictate what we should do. We tend to listen to those whom we look up to and to those who are more experienced. In many ways this is OK, and it is often the way it should be. However, only you can determine what works for your feet.
Knowing your prevention options is important. That’s being proactive. I get emails every week from athletes who are looking for answers for their feet issues.
Some have my book but others don’t. Some have the book and have gone through the chapters to find possible treatment options. Others have the book and haven’t read it – and want me to answer their questions.
I try. Sometimes it works and sometimes not. While I answer from my experience and knowledge, I don’t have your feet. And that’s important.
Your feet have your abnormalities (hammer toes, bunions, thick toenails, skin that calluses, a tendency to athlete’s foot, a tendency to blisters, etc.), your ankles, your shoes and socks, your fit (good or bad), your training base, your stride and gait, and more.
You are the best person to find what works for your feet. Others may give suggestions. Fixing Your Feet can give suggestions and I may offer a few via email or in this blog, but you need to try them on your feet to find the one that works best.
You are the key to prevention.
Please, don’t show up at a race with a bad case of athlete’s foot, holes in your socks, shoes that have outlived their support, insoles that are flat as paper, toenails that are long and untrimmed, shoes that don’t fit, huge thick calluses, blisters that are unhealed, thick nails from untreated toenail fungus.
Yes, I have seen all of these.
Again, you are the key to prevention.
Rob Conenello, a sports Podiatrist with Orange Town Podiatry (Orangetown, NY) and doctor on multi-day adventure type races, shared an important observation on a post I wrote in May about Having Toenails Removed.
Rob wrote, “In 20 years as a sports Podiatrist, I can honestly say that permanent excision of the nail plate is a rare occurrence. That being said, the ones that I have removed have usually been on experience athletes who have exhausted all other treatments.
John’s advice is excellent. I find the biggest culprit in obtaining nail hematomas (blood under the toenail), is improper socks. All athletes should wear moisture wicking socks with an anatomic fit that does not bunch at the toes.”
If you don’t remember the post, here’s the link again: Having Toenails Removed.
As you might guess, there were lots of toe and toenail issues at Western States and Badwater. There were blisters on and between toes, blisters under toenails, toenails floating on top of fluid filler blisters, and toe blisters with blood inside. Some were major and some minor – but to the runner whose feet they were on, they were bad.
Here are two photos I took that shows what is often common at race finish lines. Neither is pretty. The first shows a foot with a large blister under the big toenail. The nail has lifted off the nailbed and there is trauma to the whole area. You can see how the back of the nail is pushed backwards and upwards. The second toe also has a blister. Both have blood inside. The big toenail is thickened.
The second photo shoes a foot with some gnarly toenails. These nails are possibly inflicted with nail fungus, which has gone untreated. You can see the irregular nail surfaces and how thickened some have become. There is some tissue damage but it is hard to tell from the photo if blisters are present. The nail on the second toe may have a blister under it.
These show a common problem that many athletes have not learned – proper toenail care. Thickened nails should be filed down to reduce their height and raised forward edge. Typically, all nails could use some degree of filing to clean up any rough edges. The front edge of all nails should be filed smooth so that when you draw your finger up and over the front of the toe, there is no edge felt.
Any nail rough edge can catch on socks and cause nailbed trauma leading to blister formation. Raised, thickened nails and rough edges lead to problems when the shoe’s toebox is too short or not high enough. Wearing a thick sock, or two socks can add to the bulk inside the shoe and cause pressure on the nails and nailbed. Additionally, socks catching on rough edges of toenails force the nail backwards. Any of these three conditions can lead to toe blisters and blisters under the nail, commonly referred to as “black toenails.”
Care of your toenails should be a regular part of your daily hygiene. Trim them and file them smooth. It a new nail is coming in to replace one lost, file it thin and wrap a Band-Aid around the toe to shape it. New nails often come in irregular in shape and height. While you are at it, use a pumice stone on any toe calluses, especially on the bottom of the baby toe.
If you have toenails that are discolored (with white, yellow, or even brown and black) patches on or under the nail, are thickened, or the nail is crumbling, you may have toenail fungus. The earlier you take care of this, the better. Schedule an appointment with your doctor. Toenail fungus can get worse over time.
If nothing else, before a big race or event, spend some time trimming and filing your toenails to give yourself a better chance of completing the race without problems.
I have been a Runner’s World magazine subscriber for years. I know many serious runners don’t care for the magazine, but, the article about runners are interesting, the shoe reviews are helpful, and the ads are informative.
Sometimes however, they get it wrong. In the March 2009 issue, there is an article on page 40 titled, Foot Notes. A sidebar on page 41 is labeled, The Pedi Cure – with four tips. They quote the owner of a nail spa in Massachusettes on nail care in the second tip, Clip With Care. The advice is, “Too long, and they’ll turn black. Too short and you might get ingrowns. Trim the nails straight across to just below the tip of the toe. Use a file to round the corners.”
I hesitate to comment too much on her tips because the magazine does not list her qualifications. However, she has it wrong.
Yes, too long and you stand the chance of getting a black toenail. And yes, too short and they could become ingrown. But there is more learn.
Trim your nails a bit shorter then she recommends or you will have problems with socks and shoes. Then use the file to smooth any edge until it is not felt when running your fingertip over the front edge of the toe. Any rough or sharp edge increases the odds of catching on your sock or hitting the front of top of the toe box.
She also gives wrong advice on blister care. Look it up if you have the magazine and see if you can guess where she goes wrong. I will comment on her blister advice next time.
Too bad Runner’s World can’t find a reliable foot care expert.