Training for an ultramarathon: Foot care and first aid (Part 2)

This article about ultramarathon training and preparation was originally published in my own blog on January 13, 2010. It’s one of my most popular blog posts ever. I re-ran Part 1 (preparing for a multi-day race) a few weeks ago.

Without healthy feet, you are not going to get very far, and blisters early on in an event may cost you hours of time, or even keep you from finishing at all. So the focus of Part 2 of this series is how to take care of your feet, with some notes as well on First Aid kits and other safety gear.

Prepare your feet beforehand: Elite racers may not have to do much – they seem to have bombproof feet, and I don’t know if that is because they are genetically born that way and that’s why they become so good at distance, or because they have put so many miles on that they have toughened up their tootsies. I think it’s probably a combination of both. Well, the rest of us can’t change our genetics – all we can do is put as many miles on our feet as possible, both walking and running, to toughen them up. Some racers advocate other ways of toughening the skin, such as a daily 15 minute foot-soak in lemon juice for 3 weeks before the event. I have not tried this.

Prevent swelling: A lot of blistering happens on a multi-day race because of swelling that starts two or more days in. Your feet become bigger and shaped differently, and suddenly your favourite shoes don’t fit any more. Anything you can do to prevent swelling will help to prevent blisters. Getting your electrolytes out of balance will contribute to swelling, so take proper electrolyte supplements.

When not actually running – whether stopping on the trail, or in camp after each day’s stage, elevate your feet as much and as often as possible. For this to truly be effective, your feet must be higher than most of your body, so just stretching your legs out on an adjacent chair has only limited effect. Find the time to lie down on your back with your legs resting on a chair, or even straight up against a wall – especially for the first hour after you get in.

I’ve found compression socks to be incredibly useful. You can buy compression socks for runners – in fact, Injinji has a new toe sock out that is also a compression sock that I am dying to try. I have not yet raced in compression socks, but I think they are a good idea and would try them if I had them. I just use those granny socks, the ones for old ladies with varicose veins, that you buy at the drug store – and I put them on as soon as I get in (yes, before showering – because the swelling starts as soon as you stop running, and it is much easier to prevent it in the first place than to try to bring it back down later). I often sleep in my compression socks too.

I’ve enjoyed the nights on a race that I sleep in my Hennessy Hammock – the slightly curved nature of the hammock naturally elevates your feet above most of your body.

Deal with swelling: OK, after a few days you are probably swelling anyway. Keep up the elevating and compression socks. But you’ll probably need to do something about your shoes. Most of you will know to bring a pair of shoes that is one size larger for later in the race. What I have found that works really well, too, is changing my insoles. At last year’s 6-day 232 km Coastal Challenge, I raced in my size 9 Mizuna trail runners (which I love) with insoles.

I started with Sole Footbeds – the thick and cushy “Softec Ultra” model. After a few days, I moved to the thinner “Softec Regular”. On Day 6, I got rid of the Sole footbeds and put the regular Mizuna ones back in. Perfect fit, keeping my favourite shoes on for the whole race. (My shoes are a pretty loose fit anyway, partly because of my Injinji toe socks – you might want to bring a pair of larger shoes with you as well, just in case).

Prevent blisters: There are two schools of thought on how to prepare your feet for race day. Some people say keep them dry and tough, even calloused, to be resistent to blisters. Others say keep them soft and malleable, that it is the callouses themselves that cause the deep blisters, and they massage vaseline or baby’s diaper rash cream into their feet – both to keep the skin soft and to keep the moisture out.

So far, I am of the “keep them dry” school. I may try the “soft” approach at some point, but I fear that softening my skin will, on me, promote blisters. (The idea of dealing with socks lined with vaseline also grosses me out). Each person just needs to figure out for himself which approach will work best for him.

Don’t race in new shoes; make sure you break them in. (I know you know that – I just have to say it for completeness)

Each runner has parts of their feet that are more prone to blister: the little toe, the heel, the outside of the big toe. You know your feet. Tape up those spots before you even start – that prevention will save you so much time and hassle and pain down the road! Put the tape on the night before the race – that makes the tape stick better; it may even stay on the whole race (and since there is no wound or blister under that tape, you don’t need to worry about infection or changing “dressings”). Leukotape (or here for Canadians) is preferred by many racers I know. Applying that Tincture of Benzoine first ensures that your tape will stay on for days, and perhaps even for a week.

OK, here is what I love: my Injinji “Performance” toe socks. For people who are prone to getting blisters between their toes, these will change your life! They do spread your toes just the tiniest bit – I like that feeling, but some people don’t. Like anything, test them out before you head to the race. You may have to change your shoe size or even brand to use them, because they do take up a bit of extra room. But I love them – I was one of a handful of racers who never had to visit the foot doctor at The Coastal Challenge (either year!) and if I have to credit only one thing for that it would have to be my Injinji socks.

The other thing I do on the trail is put a lot of effort into keeping my feet dry. Anyone racing for a good finishing time won’t bother to do this, but if you are like me, just trying to finish the whole thing, this is something to consider. First, I carried one, and some times two, pairs of spare dry socks in a ziplock bag with me. If you are racing in a hot climate like Costa Rica, you can dry everything in minutes. (This is only worth the effort if you know the trail is going to be dry for the next while, e.g. after a river crossing). Just find a rock in the full sun, and remove your socks, shoes, and insoles, lay them and your feet out in the sun, and within five minutes everything would be bone dry, except perhaps the socks. Even if you don’t take the time to dry everything, just letting the shoes drain for a moment while you squeeze the water out of the insoles, and then putting the dry socks on, gets your feet mostly dry for the next section of trail. I figure if it prevents you from gettting slowed down by blisters later in the race, it is time well spent.

Deal with blisters on the trail: OK, you still might feel a blister coming on – no system is perfect. Again, this is when I think 5 minutes spent on the trail, now, can save you more time than that down the road. If you feel a “hot spot”, pay attention to it. Remove your sock; perhaps you can adjust something, or just need to remove a stick or a pebble before it causes damage. If there is a blister coming, pop it right away.

Get your alcohol wipe, wipe the needle as well as the skin where you are going to pop it. Press the side of the blister, to raise it, and go in sideways at the very edge, on the opposite side. You want the needle to go in parallel to your skin, so there is no possibility of pricking in too deep. Then squeeze the blister from the side to get all the fluid out. Sometimes the fluid is in between several different skin layers, and you may have to go in with the needle again; go in through the same hole, angling the needle differently to get the different layers. (I know some people say “never pop blisters” – that is fine advice for people who recover on the couch, but not for people wearing shoes and continuing on. You just have to keep it clean and dry afterwards). Cover it with a bandaid – if you have punctured it with only one needle hole and covered it well, it is unlikely to rip open.

Deal with blisters in camp: Back in camp, clean up your feet well and get all of your supplies ready alongside you before you start. Some races have medics there who will treat your feet if you wish. Even though they may provide some medical supplies there, they often ask that you bring your own. The better supplies you have, the better treatment you will get. So look carefully at your race info pack to work out how much you should bring.

Pop any blisters that are causing you pain. If you need to re-pop any that have been popped before, do your very best to go in through the old hole. Once you have multiple holes going, it is more likely that the whole blister will rip open when you are running. Open blisters are to be avoided at all cost – they are very painful, get infected easily, and can devastate your race.

Now tape up the blisters. Make sure you do this at night, because the tape will adhere much better if it stays on all night before you put your shoes back on. Remember that the skin on the blister is no longer attached to the skin below it. If you are going to have to remove the tape again, you will probably peel the whole blister off. So sometimes a band-aid works better than tape, because the middle of the band-aid is not sticky. Or you can put a band-aid on first and then cover it with tape – or find other creative solutions to keeping your blisters’ lids on. While you are at it, tape up any hot spots that threaten to become blisters tomorrow. Remember to use Tincture of Benzoine on any dressings or tape that you plan to leave on for mutiple days.

Keep your toenails on: Toenails that touch the front of your running shoes is one of the most common causes of losing toenails. So first of all, arrive at the race start with your toenails neatly trimmed. Swelling of your feet may also make your toes touch, so follow the advice above about preventing and dealing with swelling. Another cause, I recently found out first-hand, of toenails falling off is from your foot sliding forward in the shoe – even if your shoe if big enough that the toes don’t touch the front. That rolling-forward motion of the foot, with the bottom of the foot sweatily stuck to the insole but the top of the foot pushing forward, starts to unstick the toe from the underside of the toenail. Ewww, you say? Yup, it hurts. So make sure you learn to lace your shoes for the downhills (see photo), using that extra little loop there. When starting a big downhill, it’s a good idea to just completely redo your lacing before you start the descent. (The good news, I found out last year, is that losing a toenail is not as painful as it sounds).

Beware chafing and abrasion: You may find problems aside from your feet. On multi-day races, or in a new climate, you may suddenly start chafing in places you have never chafed before: from your backpack straps or waistbelt, under your arms, in your unmentionables and, for women, from your running bra or between your thighs (that’s why I recommend tights rather than shorts). Use lubricants – especially around your unmentionables.

When you feel a spot starting to heat up, deal with the chafing right away. Tape works if you catch it early (not on your unmentionables!). The absolutely best thing is Opsite wound dressing (Americans purchase here, Canadians here). This stuff looks like clear sticky plastic; it is waterproof and completely breathable; you put it on and it just feels like putting your skin back on. (A few years ago I scraped a wide swath of skin off the inside of my wrist the night before heading out to Peru; I plunked a piece of Opsite on and it stayed on for two entire weeks. I literally watched my skin heal under it). This stuff is expensive, so I wouldn’t waste it out on the race course, where you are sweaty and dirty and it probably won’t stick properly. But when you are back in camp, get yourself clean and dry and put a bit piece of Opsite over the areas that are chafing (or on any shallow scrapes or burns – as long as they are very clean). I suggest trimming any sharp corners of the Opsite patch so they are rounded, so they don’t catch on anything and start to peel off.

First Aid kit to carry: OK, take a look at how complete this kit is:

Let’s look at each item, going clockwise from top left:
Sterile wound dressings: A couple of sterile gauze dressings – good for covering a wound as well as for cleaning up blood around a would, as well as a non-adherent dressing won’t stick to oozing scrapes (this matters a lot when it is time to remove the dressing).
Steri-strips: For wounds that would require stitches (I use them at home rather than going to the hospital – in spite of our free health care! It’s faster, and you don’t scar as much). Far more reliable than butterfly closures. Carry two sizes.
Needle in a tube: For popping blisters.
Tweezers: For removing splinters, thorns, stingers. Any good tweezers will do, but I sure like my Uncle Bill’s Sliver Gripper, for its light weight and fine precise point. My old one came in a little bottle – I think now they come with a little guard for the tips.
Crepe bandage: This is not really essential. What a crepe bandage is good for is fixing a wound dressing to an arm or a leg quickly. But the athletic tape you are carrying does double-duty here – you are carrying it mainly to help get you home in the case of an ankle sprain but, if need be, you can use it to tape dressings on. (Note: this is not the same as a tensor bandage; see section on ankle sprains, below).
Friar’s Balsam or Tincture of Benzoine: You apply this anywhere you have to tape, and it makes that tape stick like anything. The main times where it is important that the tape does not slip or come off are: (1) closing a wound with Steri-strips, and (2) taping sprains. Considering you are probably sweaty and damp out there, you may find that you are not able to tape anything without this stuff.
Alcohol wipes: To clean up and disinfect a wound.
Selection of band-aids: Pick a variety of shapes and sizes, and a brand that stays on when wet.
Ibuprofen: Ideally in a sealed unit, as shown; otherwise scrunch two or three tablets up in foil, but inspect them from time to time in damp climates. You may have to replace them.
Athletic tape wrapped on lip balm: This is the most space and weight efficient way I have found to carry the athletic tape.I am 5’6.5”, and I need 26.5” of tape to tape an ankle sprain (see video, below). So adjust up and down according to your height (and perhaps add another 6” in case you need tape for anything else).
Antibiotic cream or ointment: I don’t actually carry antibiotic ointment with me. I figure that an alcohol wipe or two are good enough until I get back to camp – but some people might prefer to have it with them. If possible, save a mostly-used tube to carry with you in the field, so it is as light-weight as possible.

Sound like a lot? Now look how compact it is to carry. That is a lot of contingency for not much weight. Everything except the (optional) crepe bandage packs up into a very slim ziplock bag. (I keep the lip balm out because I use it frequently during the day).

Ankle sprains: First, some myth debunking: forget about the tensor bandage. A tensor bandage is stretchy, and stretchy things cannot support anything… because they stretch. (The purpose of the tensor is basically the same as a Superman bandaid for a kid with an owwie… purely psychological). Doctors will tape your ankle in a way that stabilizes it nearly completely, but that means that you pretty much cannot move it. They don’t realize that we’re a bit crazy – we want to keep going. So here is a way that you can tape your ankle, with a minimum of tape, keeping the mobility in the directions that you need to be able to walk, climb, and even leap. I have used it on myself, and was able to walk myself out from a remote backpacking trip, and I have also used it on a fellow racer in The Coastal Challenge who was most grateful.

So, the idea is that you use the length of tape on your lip balm to get you through the day. Once back at camp, remove the tape and clean up, do what you can at that point to bring the swelling down, and then before bed tape it up the same way, using Tincture of Benzoine and two layers of tape, so that the new tape wil be sturdy and remain on for the remainder of your race.

Snakebite/insect sting kit: If your route passes through remote areas where there are venomous snakes, I really recommend taking along a Sawyer Extractor (available at REI). Yes, chances are slim that you will get bitten – but the consequences are very grave. The extractor will not remove all the venom by any means; the idea is you get it on as quickly as possible, to remove some of the venom, thereby buying yourself just a little bit of time while help is on its way to you. The extractor comes with several sizes of suckers on it, so can even be used for insect bites – although it is probably not worth your while to stop while racing for an insect bite unless you are allergic. I do want to emphasize: this will not remove all of the venom. The idea is it just removes a portion, with the aim of reducing the severity of the reaction and buying you some time. If you are bitten by a snake, you still must seek urgent emergency first aid.

Take a look at these photos (see what I go through for you!). I pricked a tiny little hole in the top of my hand before applying the extractor, so small that it didn’t even bleed when I squeezed it (I wanted to go for blood, but I chickened out). I applied the Extractor for one minute (you are supposed to leave it on longer but I didn’t want to get too much of a hickey). Even so, you can see that it got a little drop of blood out. The Extractor comes with different sized heads – I used a larger one for the photo, but a smaller one would have applied even more suction. Like I said, it probably will not save you on its own, but it buys you time. The key is to get it on immediately, before the venom starts to spread away from the wound.

This is an item that you will probably never need… you just need to assess the risk vs. weight thing for yourself and decide whether or not you are going to carry it anyway. I do.

First Aid kit for camp: I have mentioned most of the things that you want in this kit above. Here is a brief summary:
– Rubbing alcohol (disinfects while drying), antibiotic ointment e.g. neosporin, antibiotic powder, Leukotape, athletic tape, scissors, Opsite dressings, variety of bandaids, sun block, antifungal cream e.g. Canesten
– Medications etc: Ibuprofen, Rolaids, alka-seltzer, anti-diarrhea meds (my favourite is carbon pills – I don’t know if you can buy them in North America, but they are easy to get in Central and South America, and they work quickly without getting into heavier antibiotics), water treatment tablets
– Also spare supplies to replenish your portable First Aid kit in case of use or water damage

Other useful things to have with you: Most multi-day races require racers to have plastic racing boxes that the organizers load and truck around for you. Some things that I have found useful to have with me, aside from a good range of clothing and shoes and camping gear, are:
– plastic boxes, to keep things in your racing box organized
– lots of spare ziplock bags, useful for carrying small quantities of food like pretzels or candies, race maps, cameras, and spare dry socks
– an inflatable pillow, even a small one, for your head or, more likely, to elevate your feet or knees at night
– constipation aids… sorry for bringing it up, but lots of gels and blue sports drink coupled with very early mornings is not a good recipe for lightening the load. You don’t want to run with all that on board. Bring prunes and things to much on, as well as some pills like Metamucil.
– a peg-free travel clothesline such as the Flexoline – get lightweight hooks or carabiners to put on the ends so you can hook it on whatever is available.
– spare items that are essential, but that could get lost or damaged: sunglasses, sunhat, lip balm, water bottle.

OK, there you go. I hope that helps. Please feel free to add anything in the comments, below. Happy racing!

And for more detailed info on foot care, check out John Vonhof’s excellent site Fixing Your Feet.

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