A stress fracture is a crack in any one of your bones, and it is a true fracture, meaning that your bone is actually “broken”, but is not the result of a single traumatic event or injury.  Stress fractures commonly occur after repetitive strain and overuse of one particular area of the body.  In the foot, the metatarsal bones, especially the 2nd are the most vulnerable.

Each bone in your body is lined with a sleeve of tissue called the “periosteum” which is filled with nerves and blood vessels.  As the strain through a given bone increases, you may have pain and swelling over that area, indicating a stress reaction is beginning.  Pain that does not warm up and go away with activity is often a sign that there is a problem more than just muscle soreness/stiffness.  The pain you feel is from those little nerves/vessels sending a signal to you that there is a problem developing.  This is a sign to reduce the intensity and frequency of your workouts, and to use ice and rest.  If the symptoms reduce and the pain eventually goes away, you can gradually resume your workouts and hopefully your stress reaction will not progress to a fracture.

If you do not heed the initial warning symptoms of pain and swelling, the stresses will continue and you may develop a full-blown stress fracture, where the bone cracks, unable to resist the increasing force.   There is focal pain/swelling over a given area, there may or may not be bruising, and you will have difficulty walking without pain. 

Diagnosis will include a thorough examination by your physician, Xrays, and possibly a more detailed imaging study such as a bone scan or MRI.  These advanced imaging techniques may be used if there is a high suspicion of a stress fracture despite normal Xrays.  Not all stress fractures will be noticeable on regular Xrays.

If you are diagnosed with a stress fracture, the treatment involves time off of your given sport, often wearing a protective boot or shoe, and potentially even no weight on your foot with the use of crutches depending on the bone involved.  It is critical to follow the recommendations of your physician carefully, to allow for proper healing and the quickest return to your sport or other daily activities.

Ways to prevent stress fractures and other overuse injuries include gradual increases in intensity/distance/weight when exercising.  Your body is well-adapted to respond to these healthy stresses when given appropriate time.  Wearing proper shoegear and using athletic equipment that is proportional and fit to your body structure is also important.  Taking the time to warm up and stretch both before and after activity is helpful.  I have also found that cross-training, which is doing different activities throughout the week, will use different areas of your body and reduce stress on any one body part/bone.

Remember, any foot pain that does not respond to a few days of rest and icing should be evaluated by your podiatrist.  An early and thorough evaluation may prevent worsening of your problem, before it progresses to a fracture or other serious injury.

The Elliptical trainer, found at many local gyms, can be a great way to reduce overall joint stress and still get a good workout.  Many people who suffer from knee and/or hip problems will find the Elliptical to be a way to spare the after-pain that they might experience during running or other high-impact activities.

For the foot, there are a couple of problems that the Elliptical trainer can exacerbate or even cause.  The first is nerve irritation, medically called, “neuritis” or a “neuroma”.  The ball of the foot is most vulnerable, and the most common area is between the 3rd and 4th toe joints, causing tingling and numbness in this area as well as into the affected digits.

The other issue that I see in my patients is inflammation of one or more of the joint capsules in the ball of the foot, or, “capsulitis”.  Joint capsules have a large concentration of nerves and blood vessels, and can become inflamed and very painful with excessive pressure.

Why would the Elliptical lead to these problems?-  Well, the answer lies both in the flexed position your foot is on the foot platform, as well as the forward shift of your body weight with each step, similar to cross-country skiing.

Ways to avoid these problems include keeping the elliptical flat, rather than working out on an incline.  You should also try cross-training, where you spend some of your weekly time on other machines such as the bike or treadmill.  Taking a day or two off from exercising is also always good to do when your feet hurt.

If you are an avid fan of the Elliptical and have not had any issues with foot pain, it is fine to continue but just be mindful of any sign of numbness, tingling, or pain, which may indicate an overuse injury such as a neuroma or capsulitis.  If your symptoms continue, see your podiatrist!  Both of these issues can usually be treated successfully in the office, as long as they are addressed early enough.  A thorough podiatric evaluation can also make sure that there is not another more serious problem present.

There are some features of these shoes which have been recommended by podiatrists for many years.  First, they have a stiffer sole, which can provide better support to your arch.  I often recommend to my patients that they do a bending test to all potential shoes, where you try to flex your shoe in the long direction.  Your shoe should only bend where the toes bend, not in the arch or other areas.  If a shoe flexes easily in other areas, your foot is more likely to have excessive flex in this area, potentially causing arch strain or tendonitis.  Even a seemingly good athletic shoe can be too flexible-  a high-priced shoe does not always mean a high-quality shoe.

Another feature of the MBT/Shape-Up is a rocker sole.  This type of sole has a natural curve along the long axis of the shoe, allowing your foot to roll through each footstrike.  This takes pressure off of the forefoot, or front part of your foot where the ball of the foot is, metatarsals, and toes.  It also helps to prevent collapse of the arch if combined with the stiff sole.  I have had several patients who are plagued with pain in their great toe joint, or “first metatarsal-phalangeal joint”, either from bunions or arthritis, who have had relief of symptoms with a rocker shoe. 

One group of patients that I would NOT recommend this shoe for is anyone with balance or gait problems which makes them less steady on their feet, such as many elderly individuals.  The rocker sole is a less stable platform and may lead to falls in a susceptible person.

So, do they really tone your legs and buttocks?  Well, my personal opinion is that they probably do a little, as you are forced to use more of your muscles and balance control while wearing them, but I’m not sure if it is enough to really make a big difference in physical appearance or strength.  Perhaps if your feet felt better in the MBT or Shape-Ups you would walk more, which would certainly be better for your overall health!

Once you have the virus, it may become active by forming a tough lesion on the foot that can be mistaken for a callus.  The key differences in appearance are that a plantar wart tends to be more circular and focal in area, and also has tiny black or red “dots” on it.  These black dots are actually small blood vessels called “capillaries” which grow into the wart to provide nourishment.  It is the virus which signals the growth of these vessels.  One of the ways that your podiatrist can confirm that it is indeed a wart is by gently removing some of the callus tissue on the surface, and you will see pinpoint, fresh red bleeding.  This is painless.

Warts live within the top layer of skin, or epidermis, and do not extend deeper into the areas where you have fat, large blood vessels, nerves, or muscles.  It may feel as though the wart is very deep with roots due to the hardness of the skin around it, but this is not the case.

For initial treatment, it is fine to try some of the over-the-counter remedies which can be applied daily.  They are generally safe for most children and adults, but I recommend caution if you have a very young child, are pregnant, or have a general medical condition that may affect the health of your feet, such as diabetes.  In these cases, it is best to talk with your podiatrist first.

If the over-the-counter medicines do not seem to be working after 3-4 weeks, it is time to seek professional treatment.  In my practice, I generally discuss either topical treatment with a stronger chemical or having the wart excised (removed after a local anesthetic).  Both have proven to be effective and are equally good options depending on the patient’s goals and appearance of the warts.  One may be recommended over the other depending on the patient and their situation. 

Once you have contracted the wart virus, you will always be a carrier, but may not always have warts.  The virus can be active or dormant, and certain situations, medical or otherwise, in your life may make the lesions reappear.  The good news is that the common plantar wart is not generally thought to be a threat to your overall health, but it can certainly be a nuisance to those who have struggled with them.

An “Ingrown Toenail” is sometimes a bit of a misnomer, because generally the nail is not actually growing down into the skin of the toe.  It is usually the result of irritation to the skin, either through shoes or improper cutting, which causes redness and swelling.  Once the skin is swollen, even a normal-shaped nail will further irritate it, which can lead to infection if left untreated.  Less commonly, the nail itself is naturally curved, which can predispose individuals to this problem if the skin gets even a little irritated and swollen.

For prevention, be sure that the toebox, or front part of your shoe, is wide enough and tall enough to avoid undue pressure on the nails.  Also, take care to cut the nails in a gently-rounded shape, avoiding digging in too deeply at the edges.   Make sure that your shoes are long enough.

If you think you are developing an ingrown nail, first try soaking the toe two or three times daily for 15 minutes in warm water.  Epsom salts may also be added to further draw out any fluid.  After the soak, apply some topical antibiotic ointment such as bacitracin or Neosporin, and cover the area with a bandaid.  If this does not seem to help, it is time to see a podiatrist.

When evaluated by your podiatrist, sometimes a minor procedure to address the problem will be recommended, which can usually be done in the office.  If it is your first time with toenail problems, removing a portion of the offending nail back to the base of the nail plate may be all that is needed.  This is done after local anesthesia is applied to the toe.  The growth center, or “matrix” of the nail is not affected, so your toenail will grow in normally in this area after 9-12 months.  This gives the irritated skin ample time to recover and hopefully this will be the only treatment needed.

However, if you have suffered from pain related to ingrown nails more than once or chronically, there is another step to the above procedure which can be done.  The matrix on the edge of the nail may be killed permanently after the nail portion has been removed, either with a chemical called Phenol or by cutting out the matrix.  This is called a “matrixectomy”.  The advantage to this is that it permanently fixes the issue, and the remainder of the nail will still be allowed to grow in normally.

For instance, pain on the back of the heel can be related to your Achilles tendon where it inserts on the heel bone, or, “calcaneus”. There may or may not be an associated bone spur. Treatment for this type of heel pain is different, often relying more on immobilization in a walking boot, physical therapy, and sometimes surgery to address the problem. It is not the same as plantar fasciitis and the treatment must be specific.

Pain on the medial, or inside, part of the heel which is sharp, burning, or radiating can be related to a nerve irritation or entrapment such as Tarsal Tunnel Syndrome or Baxter’s neuritis. Again, treatment can be very different than for traditional heel pain, and these nerve conditions may not respond to anti-inflammatories or orthotics the way plantar fasciitis does.

Lateral, or outside, heel pain can also be related to a nerve problem but may involve the peroneal tendons as they travel around the tip of the outside ankle bone, or lateral malleolus. The peroneal tendons are important in preventing your ankle and back of foot from rolling out and supinating too much, so those with a higher-arched foot type are more prone to this issue.

The take-home message is that if your heel pain is not responding to initial remedies such as rest and more support in your shoes, see your podiatrist. Not all heel pain is plantar fasciitis, and not all plantar fasciitis goes away without a little professional help!

The most common ailments seen in the the podiatry section are, thankfully, not too serious, but they can certainly make walking 60 miles difficult or impossible.  On a hot day, blisters are probably our #1 complaint.  Big ones, small ones, clear, bloody, and even under the toenail are no surprise.  

For the medical side of things, we have two clinics scheduled in August to get all of the fantastic volunteer medical staff well-versed in how to evaluate and treat each walker.  I am proud to be coordinating training for the podiatry section of the tent, with the goal of keeping as many of you on the course as possible.

But, as a registered walker in the 3-day, how can you avoid having to visit me after the finish line??  Good question, so here are some tips…

1.  Make sure that your shoes fit well, being both long enough and wide enough.  Please break them in for several weeks prior to the 3-day, including wearing them on your longest walks.

2.  Running shoes tend to be better-made than a typical cross-trainer or walking shoe.  Wear these.  If you have trouble choosing the right model for your foot type, visit your local podiatrist.  I would be happy to assist anyone who is convenient to my Bellevue office.  Or, a good specialty shoe store if you have pretty healthy feet can also be helpful.  Try Super Jock and Jill or Sound Sports in Seattle, or Foot Zone and Shoes-N-Feet on the Eastside.

3.  If you are prone to blisters, try a 2-layer sock such as Wright socks to help prevent chafing.  They sell them at REI and Shoes-N-Feet.  Also, do not wear 100% cotton socks.  They stay wet with perspiration and can really irritate your feet.  Choose synthetic sport socks instead.  Bring several pair so that you always have dry ones.

4.  Bring a supply of bandaids, moleskin, “second skin” and antibiotic ointment.  These are supplied for free in the medical tent, but if your blisters are not serious enough to be seen in the tent, it could save you a trip.

5.  Consider wearing arch supports or custom orthotics in your shoes for even more support-  60 miles is a long way.  Again, break these in several weeks in advance.

6.  Stretch well before and, more importantly, AFTER each day’s walk. 

7.  Products such as Bodyglide can be applied to areas where you are prone to chafing.  Try these out on shorter walks prior to the event.

Look for more updates on the 3-Day as it approaches!

To fix the problem, I plan to wear my athletic shoes more often while at home, but I still need something a little dressier, and ok, “cuter” for work.  For my foot, I need a fairly stiff sole so that I don’t put too much strain across my big toe joint.  Dansko clogs work great for me in the colder months, so my plan is to find a summer pair with the same basic build.  They also have some built-in arch support.

Fortunately, Dansko makes a variety of summer shoes that fit that criteria.  Stores like Nordstrom, Shoes-N-Feet, and REI carry several.  My hope is that with some smarter choices, my feet will be feeling better soon.  Another option is considering a custom arch support called an orthotic to put in my shoes.  Custom orthotics are generally stronger but thinner and more lightweight than traditional over-the-counter devices, and can work well in most shoes, including sandals.

So, does this mean that you should get rid of all of your flip-flops?  My advice for the average foot without any history of foot problems is “no”, but try to reserve them for times when you are not doing excessive standing and walking.  I, too, have a $5.00 pink pair from Old Navy that are a couple of years old, and still seem to come out of the closet every weekend.  That being said, there are some much better choices available from a foot health perspective…

Crocs, Birkenstocks, Teva, and Merrell are just a few brands that have more support and cushioning.  They also tend to have more straps to keep the sandal on your foot.  If you do wear orthotics, don’t feel that you have to stop doing so just to wear a nice sandal.  Stores such as Shoes-N-Feet and The Walking Company tend to carry several athletic and dress/casual models that accomodate orthotics. 

Above all, listen to your feet.  If you are having increasing soreness and think it may be related to a poor choice of summer shoe (sorry, flip-flops), switch to supportive athletic or lace-up shoes for a while.  If the problems persists, see your podiatrist!