2. Heel Pain in The Distance Runner - Three Common Causes

Robert Raines, M.D.
Lone Star Orthopaedics
Cincinnati, Ohio

Pain in the heel and achilles tendon area is the most common musculoskeletal complaint of distance runners. Heel pain can afflict any runner, As in all medical conditions, the key to a successful outcome relies upon the correct diagnosis. In this article I will outline the causes, symptoms and treatment for the three most common causes of heel pain in runners: plantar fasciitis, achilles tendinitis, and heel stress fractures.

Plantar fasciitis is the most common cause of heel pain in runners and non-runners. Plantar fasciitis is an inflammatory reaction to small tears of a large tendon-like structure on the bottom of your foot. These tears are believed to be caused by a combination of a tight achilles tendon and plantar fascia tendon in the face of repetitive loading. This inflammatory process results in the tell-tale symptoms of plantar fasciitis: sharp pain that originates on the bottom of the heel that is most severe after a long period of rest (typically the first few steps in the morning or after long car rides or movies.) This area may be slightly swollen and red, but is always tender to touch.

When it comes to treating plantar fasciitis, the news is both good and bad. The good news is that it can almost always be cured without surgery(over 95% in one study); the bad news is that complete resolution of the symptoms may take 1 year. As for running, let pain be your guide. If it hurts, stop. I prescribe a 5-step program for my patients that I have never seen fail in those patients who follow the rules. The steps are:

1. Achilles tendon stretches: the cornerstone of treatment, this must be performed for two to three minutes at least 5 times daily and should endure even after resolution of pain. Healthy feet depend upon a well-stretched achilles tendon

2. Plantar fascia stretches: this should be done for 10 minutes before getting out of bed. Pass a luggage strap or belt loop around the balls of your foot and gently pull your toes and forefoot towards you with your knee straight

3. Icing of the heel: icing for 10 minutes before bed will reduce you swelling and pain. You need only do this for 2-3 weeks until most of the swelling recedes

4. No barefoot walking: your heels need cushioning to reduce pressure. Keep slippers by your bedside and don’t walk without well-padded shoes

5. Heel cups: I prefer over-the-counter silicone heel cups. They are inexpensive, portable from shoe to shoe, and provide the cushioning your heel needs.

Most importantly, remember that throughout the process you will have good and bad days. Monitor your progress monthly, not daily. Also, most of your relief will come after the 3^rd month of treatment. Don’t be impatient. Follow the program.

Achilles Tendinitis is the second most common cause of heel pain in runners. The cause of achilles tendinitis is thought to be similar to plantar fasciitis: an overtight achilles tendon in the face of high repetition activity. As the tendon begins to wear, inflammation develops which leads to pain with activity, redness, tenderness to touch and often a swollen knot in or around the achilles tendon. One of the best ways to discriminate achilles tendinitis from other forms of heel pain is its location: on the back of the heel (never on the bottom of the heel) where the achilles tendon inserts into the heel bone.

The most important factor in treating achilles tendinitis is to control the inflammation. The inflammation significantly weakens the tendon, and in chronic cases can predispose the patient to an achilles tendon rupture (where the tendon rips off the heel bone completely.) This is a devastating injury that will require surgery and may permanently hamper your ability to run. Therefore, I treat patients with tenderness, redness, swelling, and pain that causes a limp in a short leg walking cast for 4-8 weeks. Once the inflammation is reduced, I start them on a devoted achilles tendon stretching program and give them a heel lift. If the inflammation is moderate, I prescribe a removable walking boot for a month then stretching. Mild tendinitis is treated with icing, a heel lift and achilles tendon stretches until the pain resolves. Chronic cases recalcitrant to casting may require surgery.

A Heel Bone (Calcaneus) Stress Fracture is less common than those above, but can afflict runners and other athletes who perform repetitive weight-bearing activities. These injuries affect women overwhelmingly but can occasionally occur in men. Women of all ages are susceptible. Generally, the pain develops during periods of increasing mileage. The pain is a deep soreness that is relieved by rest. Unlike plantar fasciitis, it is unusually with the first steps in the morning. The sine qua non of the diagnosis is pain on the sides of the heel bone, not on bottom (plantar fasciitis) or back of the heel (achilles tendinits.) Swelling and redness are rare.

Calcaneal stress fractures are treated in a removable walking boot for 4-6 weeks. No weightbearing exercise is allowed during this time. Activities are resumed when running causes no heel pain. Unfortunately, stress fractures can recur.

Most runners will experience heel pain at least once in their lives. A prompt diagnosis and correct treatment will relieve the pain in nearly all runners non-operatively. Prevent the problem before it occurs: train wisely, increase mileage gradually, and stretch your achilles tendon daily. 

3. Walk, and run better

by Martin Barnard

Runners are willing to try just about anything to get faster, or to somehow get more out of training fartlek, intervals, heart-rate monitors, carbo gels, and even LSD (the running kind, that is). But walking? For that serious runner who is about to turn the page with a smirk, read on. Once commonly viewed as a sign of weakness, walking is emerging as a useful training tool to boost your running performance.

The idea of adding walks to runs in training and during long races certainly isn't new, but it has been winning converts in recent years, especially with the resurgence of the marathon. Walking can be a useful tool for runners of all abilities. Let me outline six ways that walking can help your running.

Surviving a long race

Joe Henderson, the West Coast editor for Runner's World, is a lifelong runner who has written about running for over 25 years. Henderson, once a self-described "running purist," lived by the words "Real runners don't take walks." Now he is a crusader of walks for runners and claims that walking has saved his marathoning career. After mileage-limiting surgery, Henderson thought he would be forced to give up marathons altogether. Now he's averaging two marathons a year. Henderson states, matter of factly, "I wouldn't be finishing any marathons without the walks."

Walking breaks dramatically reduce the stress of continuous running on the legs, without a loss in aerobic benefit. In fact, many runners report that they can cover two and three times the maximum distances they could attempt without walking breaks. If you've entered a long race but just haven't been putting in the miles, consider taking walking breaks during the race. Or if you're thinking of moving up from 10Ks to half-marathons, half-marathons to full marathons, or marathons to ultra-marathons, short walking breaks may be just the boost you need to cross the finish line.

Exactly how long should your walking breaks be? Over the years, Henderson and Jeff Galloway, another walking advocate, have experimented with lengths of walking breaks in search of the best ratio of running to walking. Independently, both arrived at the formula of one minute of walking every 10 minutes, which translates into six minutes of walking per hour. There is no magic formula for exactly when to slow down, but for marathons, Henderson suggests slowing at every aid station, or every few miles. The one in 10 formula translates to 48 seconds of walking per aid station, if you are running 8-minute miles. Walking through the aid stations will also have an important side benefit you'll have time to take in lots of liquid as you go by.

Increasing your weekly mileage

How many times have you heard after a race, "If only I could have squeezed in more miles in training..." Easier said than done. The biggest problem with adding mileage is that it can lead to every runner's nightmare a downward spiral of injury or overtraining. Walking can help avoid this problem both by extending the distance of the long run and by reducing the impact of extra mileage.

If you include a long easy run in your program to build up endurance, then walking can help. For marathoners, half-marathoners, and 10K runners, those long aerobic runs can really punish the body. Walking breaks can make the long runs a little less taxing on the body, so you can recover faster. Depending on your schedule, a quicker recovery might make it easier for you to handle some of the faster miles, making the rest of your training week more productive.

The best way to find out is to experiment. Test Henderson and Galloway's formula, or try your own time frame. Make sure that you insert the walks early enough in the workout or race to reap the benefits later. If you don't take a break until your body starts screaming, you've waited too long. Ideally, you should feel good throughout the long runs and stop when the time is up not because you have to.

Regaining fitness

If you're a beginner just starting out or an experienced runner returning from injury, walking can help you reach your goals faster. When you're out of shape, a training run can seem daunting, especially if you are used to covering the distance with ease. Running harder for shorter bursts is more effective for elevating your fitness level than slugging it out slowly without stopping.

Jack Daniels, head cross country and track coach at State University at Cortland, N.Y., studied the benefits of walking and running for beginners. In a study for Nike, Daniels examined the effects of walking on a group of sedentary women between the ages of 20 and 40. The women participated in four 3-week stints of either continuous running or a combination of walking and running. They exercised for three days each week, ranging from 20 minutes a day during the first 3-week period to 45 minutes a day in the final three weeks. The greatest improvements were realized by the group that mixed walking and running.

Daniels explains, "In effect, the walking breaks turned the workouts into a big interval session, which allowed [the women] to go faster than continuous running for the same amount of time."

The same technique can be used for returning from injury. If your legs can only put up with limited miles, then walking breaks will help you to cover the running miles much faster, which will speed your return to fitness.

Burning Fat

Owen Anderson, editor of Running Research News, theorizes that walking during your hard training runs may be a way to burn more fat. As exercise intensity increases, blood flow to the working muscles goes up to ensure that the muscles get a steady supply of oxygen. The problem with this is that most of the free fatty acids (FFA) released from fat cells during exercise are not located in the muscles they are released from fat stores. Because most of the blood is in the muscles, the FFAs have a difficult time getting circulated to be metabolized as fuel. During a walking break, however, the heart rate drops and the blood is diverted away from the muscles and back into the central core of the body. This increases the concentration of FFAs in the blood, so that when exercise resumes, the blood flows back into the working muscles where the FFAs can be used as fuel.

Another benefit of walking breaks is that they can lengthen the time you spend exercising, which in turn burns more calories during the workout. If you are trying to lose weight, this may be a way to add volume to your workouts without adding stress to your body.

Warming up and cooling down

Walking seems to be a natural activity for warming up and cooling down, since it uses a lot of the same muscles as running. Henderson recommends walking as a good way to ease into a run or slowly wind down from a hard workout. Anderson, however, sees walking only as a form of recovery for non-workout days. He explains, "Not many elite runners use walking for warm-up or cool-down."

Before a difficult workout, jogging may still be the best way to warm-up to get your heart rate up relatively quickly and blood flowing to the working muscles. For those workouts, try walking before jogging to bring the heart rate up to jogging speed, then jog to bring the heart rate up to workout speed.

The same applies to the cool-down. Walking during a cool-down is a form of active recovery, which helps clear the lactic acid out of the muscles faster than if you come to a dead stop. Jogging may be more effective after a hard workout, but usually walking is a more comfortable way to cool down especially in the heat. You'll have to experiment to find out what works best for you.

Cross-training

The jury is still out on using walking as cross-training. The Penn State Sports Medicine Newsletter says that "fitness walking is a good cross-training technique because it involves different muscle groups and different biomechanical motions" than running. Henderson agrees. He recommends walking for cross-training because it "is as close to running as you can get." Walking also fits your schedule and budget just as well as running does other forms of cross-training require extra equipment, time, and/or money.

However, Anderson believes that there are several better cross-training choices for runners. He explains, "I would rank walking behind activities like cycling, weight training, aqua-running, and the Stairmaster." Anderson cited several studies that have shown cycling and aqua-jogging to be very useful to runners, but "there has been very little evidence to support walking."

Daniels believes that cross-training is fine, but he cautions against replacing running workouts with walks. He believes that walking can be beneficial in addition to regular training but that it is no substitute for weekly mileage. Daniels adds, "If the cross-training helps you avoid injury, then it would certainly benefit you, but only because you would be able to run more."

So whether you're a beginner runner just starting out or a hard-core pavement pounder, walking can benefit your running. In your efforts to go farther and faster, don't forget one technique that might help you get there in record time slowing down all the way to a walk.

How walking helps your running

1. Helps you survive a long race on a reduced training base.
2. Extends the distance of long runs while reducing wear and tear on your legs.
3. Improves fitness faster if you're just starting or are returning from injury (interval effect).
4. Burns more fat by mobilizing free fatty acid stores during walking breaks, and burns more calories by extending the length of your workouts. Increases aerobic training when your body can't handle more mileage (cross-training effect).
5. Eases you into your run when warming up and helps you actively recover while cooling down.

Originally from Toronto, Canada, Martin Barnard has degrees in both economics and kinesiology . He is an acquisitions editor for Human Kinetics. Before landing in Illinois, Martin was a Contributing Editor for Rocky Mountain Sports magazine and a Contributor for Inside Triathlon magazine in Boulder, Colorado.

Permission granted to redistribute, as long as you acknowledge the author, FootNotes and the Road Runners Club of America.

4. Running: An Imitation of Life?

Running is much like life. Sometimes you are not sure exactly where it's going to take you. Sometimes it feels great. Other times it hurts really badly. Sometimes a run is frustrating, and occasionally it's satisfying beyond belief.

Reasons for running differ with each person. Some people run to lose weight, some to tone their body, others to train for races and some to relieve stress. By taking a close look at our thoughts as we run, we can tell what in our lives needs to be tweaked or what is working just fine, whether it is physical, mental or spiritual. By getting outside and working your body, the act of running can touch upon all three of these aspects.

The physical part is obvious: Muscles are toned, endurance increases, the cardiovascular system is strengthened, and calories are burned.

The mental and spiritual parts are not so apparent to everybody. Few non-runners will observe a runner and think of mental or spiritual growth, but running is a perfect time to expand completely the extent of your spiritual mindfulness.

When I run, I usually allow my mind to wander for the first half-hour or so. I get into a repetitive stride and allow my mind to drift. After a while, I notice that my mind starts to calm down. I let my thoughts go into a blissful quiet where my brain focuses not only on the views around me but also what's inside.

It seems like I have a thousand new ideas every time I run. Some are life-changing, like deciding to break up with a selfish boyfriend or move to a different city or write a novel. Some are small, yet strangely important, such as figuring out a better way to organize my clothes or arrange my files. It's amazing how answers magically pop into my head if I just let myself listen.

Once I get into my groove and have worked out any pressing issues, I practice a type of meditation. Instead of focusing on what hurts or how much farther I have to go, I say a mantra to myself consisting of reflections with special meaning only to me: 'Be productive and organized. Exercise. Learn. Read. Write. Be patient. Have fun!' I say this to myself over and over as I run.

It took me a few long miles and some soul-searching to figure out my mantra, but now I have it down, and it sounds like a singsong rhyme to me as I plod along. Once I have had enough of that, I make up silly songs or somber poems in my head. Often, I simply look around and appreciate the scenery and feel thankful that I have the ability to see and to run. I feel happy that I'm living life and that I appreciate it enough to know that I'm lucky.

Some runners visualize themselves getting a promotion at work, sprinting to the end of a race or finishing their first marathon. Some repeat their goal for a PR in their mind, with the hopes that this self-fulfilling prophecy will be realized the next time they race. Hey, whatever works.

Running is much like life.

It takes a while to figure it out. We are not born knowing what it takes to be comfortable in life; it's a process that can be learned only through living.

Running is uncomfortable at first because it's unfamiliar. As time goes on and runners run, they learn. They start to realize the importance of staying hydrated, when and how much to eat before or during a run, the appropriate distance to go, the best time of day, what outfit to wear in what weather and whether they prefer running solo or with a partner. They discover weaknesses and strengths, limits and obstacles. Slowly and consistently, satisfaction with the way they are running starts to improve, as does time and distance.

With practice, a feeling of comfort as a runner and an athlete starts to emerge, because body, mind and soul are working together toward that goal.

Running is much like life.

Sometimes something totally unexpected happens to slow you down. It could be a pleasant surprise, such as spotting a fawn in the woods or stopping to chat with an old pal you haven't seen in years. Sometimes the stop isn't so good, when you 'hit the wall' or your knee suddenly twists into an awkward position.

If running doesn't feel good, a smart runner will stop, knowing that a worse injury may be incurred if aggravated. Taking a break and allowing healing to happen is acceptable. By embracing what allows you to feel completely comfortable, goals that once seemed out of reach will soon become easily attainable.

Sometimes you are not sure exactly where a running path will lead. Sometimes a hilly and challenging trail is ahead; other times a smooth and easy path beckons. If the road ahead is trusted, it usually works out just fine, as long as you expect some surprises along the way.

Anne Kymalainen is a freelance writer specializing in outdoor recreation. She can be reached at annewrites@earthlink.net

Other articles by Anne may be viewed at Active.com.

Good luck and great runs.

Gord