Andy Lovy's Wisdom

Contents

About This Page

For several years we have been honored and delighted by the participation of Dr. Andy Lovy, who has run many multi-day races himself, and is one of the best sports physicians in the world. Over the years he has written up numerous tips for ultrarunners, also summaries of research he has done, and has sent them to us to be used as we see fit.

What we saw fit to do with it was to consolidate it all into a special page of its own, which you see here. There is no special order to this material, other than it is roughly in chronological order.

ATY 2008 Advice

First, some disclaimers. What follows is the result of over fifteen years of administering medical and mechanical needs to runners. (For those of you interested, a brief biographical sketch of my credentials is available.) However, what I say here should in no way be construed as medical advice. Advice belongs to the realm of your personal physician, who knows more about your physical condition than I do. These are merely some thoughts, concepts, and ideas that I have found useful while working with runners over the years.

Before attempting anything as daring, challenging, and adventuresome as a 24–72 hour race, it makes good sense to have your doctor check you out to make sure you are physically fit enough to participate in the event.

Over the years, working with runners and staff at Across the Years, I have found the following issues to be the most important. Of course, they are important in general as well, but my comments are really geared toward maximizing your performance and fun at ATY.

The major issues are:

• Blisters;
• Gastrointestinal issues;
• Musculoskeletal issues; and
• Post-race issues

Blisters

It is necessary to differentiate between blister control and blister management.

Blister control begins five or six months prior to an event. This is when one tries any and all combinations of socks, ointments and combinations to insure that blisters should not form during the event. It is also useful to simulate the actual race conditions. The track at ATY has a fairly hard dirt surface, with several turns; training on a like surface is an advantage. The turns put a lot of lateral strain on the feet , resulting in pressure points that eventually become blister areas. The surface itself can cause one to push the foot further and further forward in the shoe, resulting in toenail problems. Feet sometimes fatigue, resulting in a different footfall later in the race. It is an advantage to have different pairs of shoes, built on different lasts, even by different manufacturers, so when one develops a hot spot or discomfort area, a change in shoes can frequently alleviate the problem. It is also useful to have one pair of shoes larger than your routine size, as your feet swell, they hit pressure points, and a larger shoe is useful. During the race, if there is time set aside for rest, it is useful to take the shoes off, massage the feet, and look at them closely for hot spots and pressure points. It's far easier to take time to do that, than to have to deal with the blisters that will form later. We also know that as one tires, one's feet hit the ground differently: harder, softer, or at a different angle, so careful attention to those hot spots is worth the time. It's far better to take a few seconds to adjust, than the time needed to treat the blister once it is formed.

Blister management is a separate problem. With Chris and the medical team on site, they are about the best there is for taking care of blisters that have already formed, and they are available for consultation and actual taping and other foot hygienic issues prior to the race. I encourage you to avail yourselves of that. An ounce of prevention is better than a pound of cure.

Gastrointestinal Issues

This is one of the most common problems that plague runners during a long race. The diet one uses for their normal every day activities is clearly not sufficient to fuel a body for those very long periods. It once was estimated that about 20,000 calories are required for a 24 hour race; that figure is for a well-trained individual. Here again, many different approaches need to be tried prior to the race itself so that fuel intake and expenditure are enough to get one through the race.

A balance between fat, carbohydrate, and protein is needed. One cannot run on carbohydrates alone. The muscles consist mainly of protein; therefore protein needs to be provided to prevent deterioration at too fast a rate. The body also needs a certain amount of fat. The normal ratio of 40/30/30 usually needs to be modified to 45% carbohydrate, 40% protein, and 15% fat, but again, it differs amongst people and even from race to race. Have various foods available in each category, since the taste buds go stale and a change can sometimes revive a runner.

There is much research available regarding the use of vitamin D, Omega 3s, and glucosamine/chondroitin. I would suggest adding them to your mix prior to the race to see if they will be absorbed and helpful. Have alternatives when your main menu no longer seems to be working.

The most important thing, of course, is the maintenance of hydration. Dehydration is the most common cause of nausea, emesis, and weakness, so a balance between water and electrolytes is important. Each individual needs to work out the proportions that work for oneself.

Once nausea sets in, rehydration is the first line of defense. A simple guideline is that one should be urinating a nearly clear stream every one to two hours. If the urine seems concentrated, a golden yellow, or you do not urinate for several hours, that is a sign that dehydration is, severe and needs to be a priority concern. Alternating electrolytes with water is usually useful, but you have to go with what has worked for you in the past. Too much water with no electrolyte is dangerous because it can trigger a condition known as hypervolemic hyponatremia. With too much water, there is not a sufficient concentration of sodium in the bloodstream and that can lead to confusion, and in some cases even death. Pretzels, bananas or a potassium supplement usually helps here. Frequently, ginger in the form of capsules or ginger ale helps settle the stomach. Pepto Bismol usually also helps. If you are on a medication for any internal or abdominal problems, check with your doctor before the race to make sure that you are taking the appropriate dose of your medication for the event.

For any multi-day event, expect that there will be highs and lows. Do not give up because you are in a low. Try different things, different foods, drinks, or even take a longer break to allow your body to process some healing before going on. The more simple carbohydrates you ingest early, the greater the need is to continue them. The natural response to simple carbohydrates is for the body to create and mobilize more insulin, until there is more insulin than required, causing a fatigue factor, otherwise known as crashing or bonking. It is better to save simple carbohydrates until the final stages of the race, when you need or want the extra energy boost. Let the crash occur after the race is over!

Musculoskeletal Issues

Your muscles will be under unusual stress as the race continues, and will deplete themselves of nutrients and build up waste products; therefore attention to their needs is important. It is reasonable to train for the type of race you are entering. If it is a trail race, training on trails will yield the best results. For ATY, it is a flat course with several turns, so training should include a preponderance of that sort of terrain. Stretching, both before and during the event, is beneficial, and may prevent injuries caused by fatigue. Appropriately fitting shoes and foot hygiene are also important, and at every break, attention to your feet in terms of blister control and all the large muscles being stretched out is useful. In the event of a sprain or strain, again, stretching, icing and sometimes appropriate wrapping will help.

If you want to use an anti-inflammatory, one Naproxen (Aleve) every twelve to sixteen hours is useful, since it is long acting. If you want to use Ibuprophen (Advil), take 200—400 Mg every four to eight hours, not to exceed 2400 Mg in a 24-hour period. Make sure that you check with your personal physician before using any medications.

I have found that the use of cranberries, either dried or in the form of capsules, to be very useful in acidifying the urine and burning off lactic acid. Usually one pill is useful for 24 hours. Carbonated drinks are also beneficial for burning off lactic acid, but make sure your stomach is not sensitive to it. All these things should be tried out in training runs to determine the most effective use and dosages. Never attempt to experiment during a major race.

Post-Race Issues

Although the race is over, the body is still adjusting. Here are some thoughts on how to make the recovery more efficient and with less pain.

Your muscles will continue to be working. It is important to go for a short run, walk, or jog the day following the race. If one does not, it is the second day after the race that the lactic acid and deterioration will have its maximum build-up, creating a lot of pain and difficulty even walking, let alone running. There is a general guideline that full recovery takes approximately a day per mile, so if one has run 50 miles at hard race pace, it will take about that long (50 days) to fully recover. Don't get discouraged if after a few weeks you are still unable to get back up to your full speed. Tissues need time to heal!

Paying attention to hydration and food intake is key. Also, proteins to build the muscles back up, and carbohydrates to re-load them with fuel is important, as is the judicious use of fats, to help the body metabolize. I have found that the use of support hose or pantyhose to be highly useful. The movement of the muscles while wearing the hose helps mobilize the lymphatic system, and helps move excess fluids from the muscles back into the blood stream, making recovery much more efficient. It is not unusual for urinary output to go down during competitions, so expect that there will be a buildup and more frequent stops for a while afterward. As long as the urine is clear, or slightly yellow, it is okay, if there appears to be any darkening, thickening or blood, then this may be a normal part of recovery, but I would have your doctor make sure by having that checked out.

There is more, of course, but I hope these point will give you some guidelines— and again, remember these are guidelines. Many do quite well by following their own routine.

Good luck.

Andrew Lovy, D.O.

ATY 2007 Medical Observations

We spend a lot of time on pre-race preparation and on race issues, and not nearly enough on post race issues. It's not unusual for runners to have temporary pulmonary edema for 24-48 hours after a race. Need to encourage fluids, electrolytes at least 48 hours after the race, and that goes for 24/48 and 72-hour runners. Ginger, ginger pills, and electrolyte fluids may help with the post race nausea. Cardiac issues also exist with potential arrhythmias and cardiac strains. It's important to let your doctor know, if you are gong to one within a week so the race, that indeed you just complete an endurance event, so that they are not unduly frightened by results, I have seen CPK levels go into the thousands, and that does not mean cardiac damage, but muscle damage due to running long distances.

ATY 2006 Medical Observations

As usual, the 2006 version of ATY was terrific. This is one of the best ultra events on the planet.

Once again, people went out there and put in incredible performances under challenging conditions. The aid station is the best in the world. When you go by, you have more variety than any gourmet banquet at a quality restaurant, something to please just about any palate, and the staff always willing to go that next extra step to help the runners. I am also most grateful that the people manning the aid station are part of the extended medical family as well, alerting us to any situations developing on the track, providing ice, electrolytes and any other items that would help us deal with medical problems the runners face. So, let's spend a bit of time on the medical aspects we found.

The challenges to the medical team are unique to ultrarunning as well as to this particular setting. Although the course itself is quite simple, the track mostly forgiving, it does have issues. We noticed patterns of injuries that we worked diligently to understand and then attempted to overcome.

Once again, hydration was major. It is important to realize we are in the desert, it is dry, it is cool, you loose a lot more fluids than you think you do. Drink more than you think you need, and mix it up with water and electrolytes. A good guideline is to check that you are urinating at least every few hours and it is clear.

This year the rain packed down the track. There was less dust than usual, but many micro-irregularities were present. Eventually, this may have resulted in more knee and groin problems than in past years. Trail runners are used to this, but track and road runners may not be. One suggestion: bring at least three pairs of shoes. One should be a half to full size larger to adjust for swelling, and one should be a well broken in pair that will give with the irregularities and so they have less of an impact. It is also useful to have either shoes from different manufacturers or different shoe styles from the same manufacturer. This way, small changes in the way the foot fits into the shoe may help with fewer hot spots.

Blisters were a major issue with many runners. Try out different combinations, whether socks, shoes, ointments, etc., and then stick with what has worked in the past. Some runners wore new shoes for the race. Not a good idea. Shoes should be well broken in, and at even the slightest hint of a hot spot, the feet should be checked. If there is not a blister, then if you stride differently to avoid the hot spot, you can last longer.

Other problems can occur in the body's attempt to adjust, such as hip or knee pain, leaving you with more than one place that hurts. For example, more runners than usual had knee problems, I am not sure of the cause, but Chris O'Laughlin and I think that it may have something to do with the surface. Frequently the knee is where it hurts, but the problem is further up the running chain, such as the hip or groin, so it is not a bad idea to stretch out periodically, and have your crew massage and help relax muscle groups.

I also noticed many runners were walking the straights and running the curves. If that is what you normally do, go ahead, but the human body really does great running in a straight line. It is most efficient then, but has many biomechanical issues on curves. Over time, running the curves can result in many of the problems we saw. About 15 years ago Dave Collins told me about that. In track runs he would actually place sand filled cups at strategic points and run to one, walk to the next, run to the next, etc. At the time, he was setting national age group records. I thought that was interesting, but a bit silly, and I tried to run until tired, then used his system. One fine day, I decided this one would be a throwaway and started my walk cycle right at the start. Runners were whipping by me, etc. but in the end, I actually ended up with more miles than I usually do. Worth a thought.

Remember, it is a lot easier to prevent a problem than to treat it during a race. The best we can do sometimes is to make it liveable until the end.

Another key issue that came up during the race was that of preexisting medical issues. It is important that you take the medications prescribed by your doctor and/or chat with him/her if changes need to be made.

Running can deplete medications faster than normal, or sometimes cause medications to stay in the body longer due to liver and kidney clearance issues. Be safe. If on medications, take them, prior to any event of this nature, and test the impact of medication changes with authorization of your physician. Lets face it: ultrarunning is an extreme sport, putting the body and mind into very challenging situations. It takes lots of training and smarts to be successful at it, and success is not always measured in miles completed, or time it was done in, but the health benefits that accrue.

Fighting Lactic Acid

What are the main sources of lactic acid? Does consumption of animal protein cause it?

There is so much yet to learn about the body under stress, etc. Much of I say here is from the literature in many fields, plus a lot of clinical work at races with runners. Anything I say can (and should) be challenged. sometimes I find something that works really well, but the reason it works has nothing to do with why I think it works.

First, lactic acid is a byproduct of muscle work. The more and harder you work, the more the muscles create lactic acid. There is a fund of literature that is saying that the original work on lactic acid was flawed, and the real culprit in terms of pain, fatigue etc., is not lactic acid, but damage to the muscles themselves. The muscles get inflamed and break down (called myositis), and on biopsies, they look terribly disorganized and damaged, as if a disease process has destroyed them. Of course a month or so later, they reconstitute, usually stronger and with better alignment than before. So, rather than either or, at any given moment it could be both, Once myositis is the primary problem, there is little one can do besides rest.

I am not aware of any research indicating that pain, soreness, etc., is related to the source of protein i.e., vegetarian, vegan, or omnivore. Once in the system, the body turns it into what it needs regardless of the source, the issue is: What other products — good or bad — are the result of the source of the nutrient. That too would be an interesting project. I am aware that at the top end of elite runners, there are vegetarians, vegans and total omnivores. It's hard to do research at that level since there are so many variables. But a thought: Sometimes in medicine, we try to look at either/or scenarios. It is either myositis, or lactic acid, etc. In real life though, it is much more complicated. Could be both or neither, with another factor causing the soreness and pain, but we have not isolated it. I like to think, based on the clinical work I do, that it is probably both. Deplete a muscle enough and it will inflame and cause myositis. Work it hard enough and there will be a lactic acid increase that you can actually feel. Myositis takes time to heal. Massage and manipulation does very little other than to increase circulation to the area, promoting healing. However, massage, etc., have been shown to work the lactic acid out of the muscle and into the lymphatics resulting in some relief.

Also, I may have the theory wrong etc. but over the years have found that, by acidifying the matrix (with cranberries, etc.) one can actually burn off some lactic acid, giving relief. This has worked for so many years with runners from world class to novice, that I do it, and one day, if I get rich enough and have the resources, would love to do more research on it. There was a rush on Tart Cherry's, etc., etc., and I am sure they all have a place.

A few other comments: There are indications that lactic acid itself can be converted to fuel. We all know that the glycogen stores are not responsible for muscle performance nearly as much as free fatty acids. And lactic acid is part of a breakdown process that can be recycled, although not reversed. One way has been to do interval training. Run hard, build up the lactic acid, then run or walk slower to move it around, and repeat, until the body (muscles) and chemical cycles get readjusted, Then some of the lactic acid is reconverted to fuel and stops being the enemy.

There is much evidence that muscles do not degenerate or deteriorate as rapidly when they are full of glycogen, so one really important "secret" is to keep them full, do not let them get so depleted that they then begin to destroy themselves.

Tom Glonek, at Midwestern University has done work on free chained fatty acids and soft cheeses. One part of the chemical is easily assimilated protein and the other is fatty acid, so liberal use of those cheeses stalls the build-up of lactic acid. It's the same with other food stuff. According to some literature on peanut butter, peanut butter has a lot of lineic, and linoleic acid, major in replenishment of muscles and preventing breakdowns.

So, take home message, train with intervals as part of it, keep the muscles full and supple to slow down myositis, and do what is needed to allay the development of lactic acid in the muscles. (Massage, acidification, etc. ) Hope this helps, if not answers, at least stimulate you to think of the nearly infinite variables that exist in a human body in motion.

Andy's Multi-Day Tips

This summary came to us following the 2004 race. Until now it has been found in the ATY FAQ.

How about some tips from a medical professional?

The Across the Years race offers some unique opportunities for runners. It is held at Nardini Manor, an estate that has been modified by the owners to be as user and running friendly as possible. There are almost no restrictions or limitations beyond which the staff, the aid station, and others will not go to see that the runner's needs are satisfied. This does not, however, preclude the need for participants to arrive prepared for the event in which they will be participating.

Ultimately, I may write a booklet on some of the cautions and medical aspects of ultrarunning. This is not it. What I would like to do is give both potential participants and anyone who has already participated in such events some tips that may be of some use to them. These are suggestions, guidelines, and guards.

Of course every runner has to listen to his own body and coach. Before I ran my first twenty-four hour races, I contacted Myra Linden, one of our great ultrarunners of the eighties. She sent me approximately fifteen pages of preparation, almost including the type of shoe lace that does not come undone.

I read through this avidly, making mental and physical notes. Her last paragraph said: 'When the race starts, you can throw all this out!' I guess her point was without preparation there is no performance, but even with the best of preparation things happen that will modify your game plan.

1. Prepare for the event you will be participating in. The seventy-two-hour event is the only one of its kind in the United States and possibly in the world, so it gives a unique opportunity to test out your capabilities. Preparation for any endurance event requires a certain amount of speed and mileage. I leave it up to you and your coach/trainer to assist you in that endeavor. Be advised a twenty-four-hour race is not a series of marathons back to back. A seventy-two-hour race is not three twenty-four-hour races. The time and distance at twenty-four hours may be irrelevant in terms of the total distance. Plan for the entire event and not just for segments.
2. An important race is not the time to do major experimentation and expect to succeed. What works best for you should be figured out well in advance of the race. If there are shoes, socks, food supplements, other equipment, etc., that work best for you, those are the items you should bring to the event. I have seen too many runners try something, or wear something new only to have that new item cause disaster. It is wise to bring several changes of clothes and to be prepared for any weather eventuality. It is also wise to put additional layers of warmth on when needed. Conservation of body heat leads to increased efficiency of the muscles. I have seen many runners cramp up and have major spasms because they ran cold. Better to be a bit warm and open layers than to chill.
3. Preparation truly is from the ground up. Foot care is essential. Prevention of blisters is vastly preferable to attempting to treat them during the event. Work out a blister management plan prior to the race. Many use a thin nylon sock under a thin polypropylene or cotton sock. The two socks rub up against each other, which will frequently dissipate heat. Use whatever ointment works best for you, apply it liberally to likely problem areas, perhaps the night before the race, so it is already on the skin, and then another layer prior to the race. When you put your socks on be certain that every crease has been smoothed out. A tiny crease over time can lead to a blister that can either slow your performance or completely stop it.
4. I will give you my ointment mix which I have found to be effective. I had been involved in ultrarunning approximately ten years and sustained my share of blisters, rashes, and irritations, to the point of almost having to pull out of races. After experimenting with various combinations this one seems to work best for me, with very few complications. To date no one has reported an allergic or hypersensitivity reaction. All the ingredients can be obtained at any drug store, and most can be obtained at the Dollar Store. Shelf life is almost indefinite.
   I mix up large batches and put them in jars and still have some in the refrigerator from years ago. Every so often it is a good idea to stir, in case any of the ingredients have separated out.
   
   One part Vaseline. One part Desitin Ointment, one part A & D ointment (yellow compound, because there are other things on the market now calling themselves A & D but actually are other ingredients). Mix these three to a paste, then add Aloe Vera ointment (not cream) and vitamin E ointment (not cream). The amounts of these will be approximately one third of the Vaseline. Again, mix thoroughly. If you are going to be running in gritty, sandy, dusty, dirty conditions, increase the amount of Vitamin E and Aloe Vera. They have healing properties and as you run will heal some of the minor abrasions. If you are going to run in wet conditions, increase slightly the Desitin ointment. It forms an effective barrier. Apply a very thin coat on all friction rub areas, making sure especially to get between the toes, on the forefoot, and on the heel, since that is where many blisters develop.
   
   This usually stays on for the entire race. I have utilized one application which has lasted for a six-day race. If there is too much grit and you take your socks off, then it is wise to remove with rubbing alcohol or any of the sanitizers, and then re-apply.
5. If you have any medical or structural conditions prior to the race, have them understood and addressed, and share that with the medical personnel prior to the race. The medical people are there to help with race related issues and will not be able to give you definitive answers to problems you have had for years which now how become accentuated by the stress and strain of the race itself.
6. If you are prone to nausea, sometimes the first line of defense is Pepto Bismol or ginger ale. Bring some with you if needed.
7. Diarrhea is a likely occurrence in some because of the differences in the way and the frequency one eats. This can frequently again be managed by Pepto Bismol, ginger capsules, ginger ale or the generic equivalent of Imodium. However, I would caution to not use more than one Imodium tablet every four hours, and not to exceed three in any 24 hour period. The object of this race is to challenge you, and to have a good time, not to create additional medical problems that will be difficult for you to deal with later. Butter milk or yogurt frequently helps if taken early when one has diarrhea.
8. Hydration is one of the most important issues. All issues begin and end with appropriate hydration. The tissues need both water and electrolytes. There are many compounds available that address the appropriate electrolyte replacement as one runs. Again one should have this routine worked out well in advance of the event itself.
9. If there is an irritation spot or a stone or anything out of the ordinary such as a shoe that is not fitting appropriately, etc., it is wise to address that as soon as possible. The time taken to remove a stone or to smooth a crease or to put on a shoe that fits better is well worth it.
10. Many runners bring along at least one pair of shoes that are one half to one full size larger than their usual size. Under normal circumstances it is not unusual for hands and feet to swell. This may sometimes be due to the pounding and gravity, sometimes due to the electrolyte, as fluids shift around the body. A larger shoe can frequently make the difference. Otherwise, learn to lace a shoe differently so that it can expand later in the race.
11. I have found that tights later in the race frequently can assist keeping leg and foot swelling down. They not only provide warmth but the material itself acts as a pump. As you run it can pump the fluid from your legs into the lymphatic and then out.
12. It is reasonable to need to urinate every hour. Some of my best performances have been when I was going to the bathroom every twenty-five to thirty minutes. If you go more than three hours without urinating or you notice that the urine is dark and murky, is harder to initiate, or is painful, then I suggest more hydration—even a cup of water or electrolyte every loop until the problem is resolved.
13. I have found over the years that carbonation frequently helps, and so do cranberries and cranberry juice or cranberry pills, to acetify the urine, sooth the urinary tract and bladder, and I believe these help in mobilizing some of the lactic acid out of the muscles.
14. Fuel, too, is a matter of individual taste. However, some general concepts do exist. If you take in simple sugars early, that is causes the pancreas to generate more insulin. Frequently the amount of insulin is more than the body needs at the time since it is not regulated as well as when you are not exercising. So once simple sugars are utilized, it is necessary to continue for the balance for the race, so it may not be the best idea to eat sugar early. Complex carbohydrates such as pasta, bread, and other products, although they do not appear to have much influence on performance early, get into the muscles and the blood stream, and over time help maintain your pace. We have found that an exception to this is honey which does not kick in the insulin quite as radically, so crashing is less likely to occur. If you are feeling strange, unusual, uncomfortable, or hallucinating, the best solutions frequently are rest to recharge your muscles and your brain, and bring nutrients and circulation back to the brain. Frequently the brain tells the muscles to stop firing although there is quite enough fuel in the muscles to continue the performance.
15. It is also wise to tend to business prior to going down for any length of time. This is a good time to go to the bathroom, hydrate, eat, and then go to sleep. When you wake up all the positive products will be in your system and the negative one will have been flushed out.
16. If one uses an anti-inflammatory or pain killers, be advised that although your metabolism is increasing and it will leave the system more quickly, it still has to go through the normal body processes through the liver and kidneys. My general thought is that if one takes Ibuprofen one should not take more than twenty four-hundred milligrams in any twenty four-hour period. It may be safe to go beyond that but as a benchmark this is conservative and usually does not lead to kidney problems during the race or after. If one uses any of the other anti-inflammatory or muscle relaxants, don't exceed your doctor's recommendations. Masking pain beyond a certain point can lead to pushing beyond your capability, resulting in injuries that need not occur.
17. Listen to the medical personnel there and the race directors. They have many years of cumulative experience in working with runners and running performance. Their goal is the same as yours, except they may have a clearer head about medical issues than you do at the time you are having a problem. Even world records are not worth damaging the body permanently.
18. There are no real rules on mileage. However, there are guidelines. There have been many individuals who have never run further than ten kilometers and are successful at running twenty-four hours because they run at a reasonable pace, address potential injuries before they become severe, take rest, and are able to finish. However, if your longest race is a 10K and you try to run at your 10K pace the likelihood of finishing approaches zero. If the longest race you have done is a marathon or even a twenty-four hour race, a forty-eight will create new situations and challenges for you physically and psychologically. So be prepared to modify your mileage goals since they are less important than continued participation in the event and learning more about what works for your body at the longer distances.

Why Some Ultrarunners Develop a Lean

It has been noticed that some ultrarunners, including your friendly webmaster, sometimes develop a significant tilt during the running of Across the Years, one that never goes away for the duration of the race. We asked Andy what he knows about this. It is caused by exhausted iliopsoas muscles.

On Iliopsoas Exhaustion

There is a lot of theory, a lot of hypotheses, some factual data, etc., and I can only go with what I know and results.

Muscles can only contract. In order to do so, many things need to be in place, like glycogen, electrolytes, etc. When one is missing or not sufficient, the muscle reacts differently. When a muscles is fatigued or does not get sodium or potassium or a host of other chemicals, it stops firing. When that happens, it no longer contracts. The opposite muscle if in the back or spine is still firing, so the body will lean in the direction of the muscles that are still working.

We know it is a local issue, not a global one, since when that happens in any given individual, the lean will always be in the same direction regardless of the type of race or the direction of the turns. A blood test may not pick it up since the global amount of potassium may be normal, but the particular muscles that are fatigued and out of potassium are not.

Potassium is most implicated since it is the electrolyte needed to make muscles fire. Giving someone potassium may help, but the potassium goes throughout the body, not only to the affected area, so there needs to be an attempt at finding out just why that muscle or muscle group stopped working. It is usually due to inherent muscle imbalances, short leg, spinal issues, gait issues, etc., and if those issues are addressed, then the muscles can regain firing and the lean stops, or at least slows down.

There is a firing order of muscles that needs to occur in order to stay upright, or to move, walk, run, turn, and one has not only to work with the muscles that no longer fire, but the other muscles and bones and joints as well, that may be causing the imbalance. What I do is a complete structural evaluation and try to fix the problem as well as I can, not just the symptom, which is the lean. If I find the origin and can temporarily fix it, the lean will minimize or maybe go away.

There needs to be follow-up after the race since the full treatment may take a long time and many things need to happen.

Medical Observations for Across the Years

Lots more good suggestions on staying healthy

The race conditions at Across the Years offers some unique challenges medically that I feel every runner and crew person should be aware of to plan for their best performance. The race director Paul Bonnett made it clear at the outset that dehydration and blisters are the most common reasons why individuals drop out or have less than optimal performance.

Having said that at the outset the predictions were still quite accurate. The track itself is crushed gravel. This makes for a rather soft surface initially but as the runners trample the gravel down it becomes slightly harder. However, recovery is much quicker than when running on concrete or asphalt or even artificial turf. There will nonetheless always be micro variations in the surface, since each footfall can be on a peak or a valley of the hard surface causing the foot to land ever so slightly differently each time. This can create more hot spots and problems for the runner as the race goes on.

My first suggestion for the runners is to bring at least two pairs of shoes that have slightly different lasts, so that when the foot tires in one and the hot spots develop another shoe either of a different make or a different model will result in slight footfall differences and help compensate somewhat for this.

My second suggestion is that aside from some elite runners training is essential for maximum performance as is entering the race relatively injury free for the past two to three months. Even the slightest injury at a different race may result in a cumulative effect of stress or strain on various body parts, again leading to musculoskeletal problems.

There are many blister formulas out there now and I would suggest trying several until you find at least one or maybe two that work best for you under these conditions. Most blisters can be prevented if the shoe fits properly and blister control elements are utilized. I have a formula that I have used for over ten years that has been of great benefit for friction points resulting in far fewer blisters in most individuals who use it. All the ingredients can be purchased in a dollar store so literally a lifetime supply can be had for fewer than ten to twelve dollars. (The recipe, reiterated here, is also discussed above.)

The basic ingredient is petroleum jelly (e.g., Vaseline), any manufacturer. Generic works well. Desitin ointment (not cream) is another major ingredient. It can also be found generically as Zinc Oxide ointment. The third major ingredient is A&D ointment. Be careful when you shop since A&D is a trade name and is on many tubes that actually are Zinc Oxide. What you want is the vitamin A and vitamin D ointment, which usually comes in tubes or tubs and is yellow and this is the only somewhat costly element.

Mix equal parts of these three to a smooth consistency. Then add aloe vera ointment or cream vitamin E ointment or cream to this mix using less than a third of these two ingredients than the original two. Again, mix these to a consistent paste. If you expect rainy conditions, slightly more Desitin and A&D will help make your foot more waterproof. If there are lots of rocks and the opportunity for many scratches, abrasions due to a surface add slightly more aloe vera and vitamin E.

Vaseline is an excellent lubricant that does wear out quickly. Desitin is healing and a water block as well as a lubricant as is A&D. The other two ingredients promote healing as one runs.

My third suggestion is to run with a double sock. These are commercially available. I would try different brands. What I use is a nylon socklet, which is very inexpensive, and a thin cotton sock. Lubricate the foot, the heel, between the toes and anywhere there may be friction and put the nylon sock on removing all wrinkles and then the cotton sock again, being careful to remove all of the wrinkles. The two socks rub against each other dissipating the heat and friction into the shoe and not into the foot.

Also, if conditions are wet, such as running through puddles or in the rain, the combination sock acts as a wick and pulls the moisture away from the foot and into the shoe. The shoe may feel soaked but the feet remain dry. I have used one application of this, which was sufficient for six days; however, if grit, sand, dirt gets between the socks or on the foot it is wise to wipe that off and then reapply.

It is also advisable to have at least one pair of shoes that is a half to one size larger for later in the race since feet have a tendency to swell in time. Loosening the shoe with different lacing has always worked for me but sometimes half way through the race another larger shoe with a different last may feel more comfortable for the second part of the race.

Conditions in Arizona are quite dry. Dehydration occurs much more rapidly and with greater devastation than with moderate or high humidity. I usually drink every mile and a half to two miles but at ATY frequently it is every second or third loop. Water is a mainstay, but, it is necessary to include electrolytes to keep the mineral content up and the sodium and potassium levels adequate. With a decrease in sodium, potassium, and water, the muscles do not respond as well and the likelihood of injury to the muscles and/or dehydration is great.

It is almost impossible to over-hydrate during a twenty-four to seventy-two hour race. A standard and reasonable guideline is urinating clear. If one does not urinate within five to six hours it may be necessary to super-hydrate every loop until one not only urinates but also urinates clear.

There is a product out called E-Caps which has been found to be very useful to maintain sodium, potassium balance and I would suggest using them as directed unless you are going faster than anticipated, in which case I would increase the dosage moderately.

The race has potassium pills, which are also very useful for muscle fatigue and do not adequately "twitch".

There may be a drastic temperature change at night. Do not be fooled into thinking that because it is cooler and you are not sweating as much and that you do not need as much hydration. If anything you may need more in order to keep the core body temperature at its optimal level. It really doesn't matter whether it is cold or hot liquids since the core body temperature will neutralize. Warm liquids, such as hot chocolate, coffee, soups, etc., may taste better warm so you will hydrate more, but you can survive on cooler drinks as well.

It is also necessary to maintain sufficient levels of carbohydrates to fuel the muscles as well as some protein to prevent tissue breakdown. I would suggest experimenting on long distance training runs or other races as to what feels optimal for you. It is not unusual for runners to do quite well for a period of time and then apparently completely crash. Re-establishing carbohydrates — simple such as honey, fructose as found in fruits, and complex carbohydrates such as found in breads, pastas, etc., are best.

It is also advisable to have a certain amount of fat since that helps to metabolize the carbohydrates. Peanut butter seems to be an almost ideal fuel for this as are any of the soft cheeses with a high fat content. The high fat content cheeses are not really advisable at all times under all conditions, but as part of a race regimen can be very helpful.

Another danger at night is the muscles will cool. Some people run well under those circumstances but once you stop and you feel chilled it is better to stay slightly warmer and compensate with increased hydration than to chill and have a muscle spasm. When one takes a break of more than a few minutes it is reasonable to attempt to stretch the muscles using any system available with repeated contractions. Going around the track the muscles will tend to shorten and want to stay short; stretching them out can revive them considerably.

Once again, it is much easier to prevent any form of depletion type injury than to attempt to treat it once the damage has been done. Blisters are not fatal — they are the body's defense against friction. However, if not appropriately treated they can cause a runner to shift his or her balance, utilizing muscles differently to compensate so that there is no pain, ultimately leading to more tissue breakdown in other muscles.

It is best to address hot spots as quickly as possible. After all, a three to five minute break to prevent an injury is time well spent. ATY nurse Chris McLaughlin is one of the best blister treatment people I know. Once he has worked on a blister early they seldom return to cause further damage.

There are also massage individuals available at times during the race; if you feel fatigued and your muscles don't appear to be functioning as well as you would like, these individuals can do quite a bit to work the lactic acid out, stretch you, and bring those muscles back to full function. A massage therapist can do a considerable amount of damage if not done appropriately during an event;, the massage therapists at ATY are specifically and specially trained and sensitive to the needs of ultrarunners, and can change your thinking from "there is no way to go on, I can never again get into a decent stride' to "I am feeling pretty good and then can go on."

For runners who are newbies to the longer distances keep in mind that your marathon times are not indicative of how well you can do in a 24-hour or 48-hour. If you attempt a 48- or 72-hour race be forewarned that it is not X number of marathons or three twenty-four hour races, but one continuous race and one needs to go at a speed that will ensure the ability to complete the race unless one has entered with a more limited goal in mind such as one hundred miles, fifty miles, a PR at a distance, etc. A beauty of a 24-hour race is that one can set a pace, finish, rest and come back and put on more miles, or choose not to.

It is also an advantage that one is never more than two hundred and fifty meters from assistance. The medical team can work with you and assist you in many ways during the race but are quite limited in scope when you enter the race with an existing injury. Again for the less experienced ultrarunners it is not unusual to feel tired, suffer pain, or discomfort. A good general rule is to listen to your body and then attempt to compensate if the pain, discomfort, and drive cannot come back to the level you want. Keep in mind this is a race, it is a test of your capabilities and potential and there is no shame in either slowing down or stopping altogether to re-evaluate the situation and possibly even terminate your participation in the race.

Andy's 2005 Race Report

How Things Went at ATY 2005

I had just recently completed the six-day in Colac and there was no way to tell how well I was recovered, if at all. I had a few really decent training days going as much as one to two hours with no pain or depletion, but I am well aware that two hours is certainly not a reliable test of ten, twenty and up to seventy-two.

When I got to Nardini Manor and set up I found out that Chris O'Laughlin would also be there. I worked with him last year and it was one of the really good team experiences, so that delighted me, and in fact I spent maybe three times as much time on medical as I did the previous year while Chris spent at least three times as much plus took ten hours off to go to see his doctor for a major disease problem that would have told the average man to not even try to participate.

I found out very early that my mathematics was grossly in error, and I did not need seventy-two miles for the coveted jacket but eighty-three. I found this out at the sixty mile mark — there were a few brief moments of discomfort and panic but decided that since I am going for the belt buckle at one hundred anyway this was doable.

I don't believe I saw as many blisters in my life as I did at this race. There were three groups of 24-hour runners and each at the appointed time would come in with blisters after having either run too long, too hard, or dehydrated or whatever. I also did manage to slide one fibula back into place and once again was able to affirm that the concepts on palpation of muscles for glycogen, lactic acid, potassium and sodium was pretty accurate and utilizing that capability was able to get many runners back onto the track. The value of muscle energy, myofascial release and even some high velocity kept many runners going, and I am pleased that I can at this point still manage to utilize a degree of skill at the track side to help individuals.

As an aside, being aware of this, no matter how hard I pushed or went I would always leave something in reserve so that I would be able to diagnose and treat if and when the occasion came up. Running this way however does have its challenges. One cannot go for the maximum performance because you never know when your medical skills will be needed. I could take ten to twenty-five minutes off, rest, but just as I walked out the door one or two runners would come in needing assistance. So it was a challenge from that perspective, however one that I gladly accepted and still do accept.

There was one time I think on day three when I had gone past the chip counter and I heard my name called. I had gone approximately two hundred yards down the course and I was told that somebody went down in the tent and they were concerned if it was a heart attack. I jokingly mentioned after that I might have broken the course record, the two hundred yard dash, getting there, although a few moments earlier I was reduced to my "Bataan death march" speed. We did our medical, took the blood pressure, etc., waited for the ambulances to come, saw that the runner was transported safely to the hospital, and then I went back out and continued that loop.

There was one other incident right at the end of the race where one of the runners who had not eaten or drank for the last hour pushed past the finish line just behind me although he was many miles ahead of me, and then collapsed. I am not sure if this was Roger Bannister's neurogenic shock syndrome but we were able to transport him inside, his blood pressure was 118/70, and his pulse thready. It turned out that he was several quarts low on fluids and it took fifteen to twenty minutes for him to recover, but apparently he did and when the ambulances came he refused to go to the hospital, preferring to be rehydrated at track side. I got in my eighty-four miles and then went down for approximately two hours.

When I got up the quest for the hundred seemed to be endless. I am convinced at this point that the track was lengthened with each lap until I finally did reach my one hundred, went back in, came out for the 101 and then toyed until the last hour when I tried to get to one fifteen which is what I did last year but fell short even though I ran the last half hour almost full bore.

I had a chance to work on many manipulative skills, enhance those that I had already done, and worked with some new ones. We even had a young lady who had a panic attack and was able to abort this with talk therapy and eventually an antihistamine. Many runners would come in, get repaired, go out and do wonderfully, some would come in several times until the end of the race, and some were smart enough to know that when something was wrong it was perfectly all right to come in and let Chris or me work on them to help their performance.

I also witnessed some very remarkable competent performances and I don't wish to hurt anyone by forgetting to mention names of some people, but sometimes those memory traces aren't all there. Yiannis Korous was there; he had completed the six-day, had done a fifty-mile race at Sun Mart and was now at ATY. I gained a considerable amount of respect for Yiannis at Colac, which was doubly reinforced at ATY. I knew of the myth of the man but not really the man himself.

Turns out he is not a supergod or a superman as one would be led to believe. He is a human who has perfected the skill and art form of running and is able to utilize it week after week, month after month. He faces the same issues that we all face: blisters, problems with gait, problems with shoes, problems with nosebleeds, everything that could possibly happen. He has it repaired as quickly and as well as possible and presses on, always going beyond his limits. He broke the world record for forty-eight hours, but continued on competently for seventy-two.

Yiannis also has a very good sense of humor when he is not intensely competing. As intense as he was when I would go by and yell: "Way to go Yiannis," he would wave, smile or have some gesture of acknowledgment. Here is a man who at three hundred miles slowed his pace, and stopped to congratulate me on getting my thousand-mile jacket.

For the New Years party I waited for him and serenaded him with "Never on a Sunday" on my mandolin, which brought a smile to his face and his comment was that made him very happy, and we chatted a little bit.

His team was also under considerable pressure since this man is quite a perfectionist in order to get maximum performance, but they had hula skirts, funny hats, anything to break up the monotony. He is truly a remarkable athlete.

Michelle Santilhano - Originally entered the forty-eight then switched to the seventy-two when there was a cancellation. She ran magnificently and I believe during the course of the three days spent at least some time circling the track with every single runner making nothing but positive thoughts, feelings, vibes and comments about them. A truly joyous person who should be one of the poster girls for this board of ultrarunning.

Harold Sieglaff, Founder of the race, owner of the only two thousand mile jacket, was not having a great performance in terms of miles. However, his presence on the track was always noted and welcome. He would be literally limping around the track and then I would go by him we would run one, two, three, four laps together discussing lap counting, the state of the planet, the state of terrorism, concepts in teaching; a truly wonderful cultured man who at his worst was still enjoying himself and the scene. In addition to that, for the New Year's party he entertained everyone by playing the standard medley of songs on the clarinet. Truly what the spirit of ultra running is all about.

John Geesler once again proved why he is one of our best runners. Not only because of his capacity for performance but his humanism. He started strong and ran into some difficulties and fell way off pace. We had a bet in that if I could accomplish one half of his distance he would owe me dinner and it was touch and go for a while. On the last day however, one of the new twenty-four hour runners needed some encouragement and he raced for approximately five to six hours circling the track at a pace faster than his first twenty-four hours to assist this person, never hesitating to call out to me, encourage me, ask how many more laps for my buckle or my jacket. Truly championship attitude and once he gets a few things solved in terms of his diet I think his best performances are yet to come although he has already won many championships. (By the way, I owe him dinner)

Sunny - ran terrific, ran into problems, came in for muscle balance, myofascial release, went out and ran beautifully, got blisters. In short he came into the aid station, eight, ten, twelve times, each time going out and running like a champion and finished very high in the standings. Again, it is the spirit of the thing.

There is one time where he was discouraged, said he asked to walk the last twenty hours, being incapable of running. I said I did not think that was true, we worked on it, we worked on his diet and approximately one half hour later he whizzed by me like a Porsche going by a stalled truck and saying: "Look at it now, really wonderful!"

Martina Hausmann ran better than I had ever seen her. She was steady, had her issues and problems with nausea, dizziness, inability to perform, followed all of my advice and eventually wore the track down to do her bidding and again won the women's race.

Tracy   she entered the three-day and ran the first twenty-four hours like a twenty-four hour runner, doing magnificently. When she finally came in day two she had blisters that would make the average individual not be able to walk let alone run but once they were lanced she went back out there and gave a sterling performance until her stomach finally told her that maybe it is better to come back and try this again.

Jerry Schuster I had worked with before. Each run he gets stronger and smarter. This time he asked me a question or two almost every time he passed me for hours, questions relevant to his performance. He ran a steady paced, very competent race, but stopped when his stomach again reached the point that he could no longer keep anything down. Once he puts it all together he is also capable of two hundred fifty to three hundred miles.

Lynn Newton, on his way to a thousand-mile jacket. He got the jacket and the buckle within loops of each other, sat down relaxed, came out put on many many more loops and had a wonderful attitude.

There were so many other runners whose form was near perfection as they raced by; it was beautiful to watch. An advantage of the race is that twenty-four hour runners can start on any of the three days, so while the seventy-two and forty-eight hour runners are partially through a new batch of fresh legs and bodies show up and go whipping by us with grace and capability. Very encouraging and inspirational.

The aid station too was quite remarkable. Most aid stations will have an electrolyte drink and one or two commercial drinks. This aid station had seven or eight different kinds of power drinks and the "You name it, we will get it for you!" attitude on the drinks and the food. Whatever they did not have they had by the next loop. They were always positive, cheerful and helpful; I found them to be a terrific asset medically.

We had reached the point where since Chris or I would be on the track, if anyone needed help they would tell them to go in to our medical section and then as we went by tell us that someone was waiting for us, which saved a lot of time. They also got us ice, bandages and other equipment, anything to make it compatible and positive for the runners.

The weather was a bit cool at night, moderate during the daytime, and we saw a lot of dehydration. Until I reached my one-hundred miles I could not stay down for more than twenty to thirty minutes and then of course it was a struggle to get up and do that first loop before the circulation returned to my legs.

I have to mention the Coury brothers: three brothers ranging from fifteen to twenty who ran the last twenty-four hours. They ran separately, together, chattered, had a terrific time, and as a matter of fact the youngest, Nathan, put in the fastest single lap recorded at this race.

Marty Kennedy ran a beautiful paced race and helped me tremendously, reminding me that my form had deteriorated at a point when she could no longer see my head when she was coming up behind me. This helped immensely and I tried very hard to straighten out.

In short everyone appeared to be watching everyone else and doing what he or she could to help all of the other runners reach their maximum performance. My medical compatriot Chris spent hours repairing blisters more as an art form than as an emergency procedure. He also did a considerable amount of massage, manipulation and healing touch, and when he came out to run, he ran as fast as anyone I had ever seen.

Ron Vertrees, always a smile on his face ran beautifully, confidently, put in a terrific race. Don Winkley did the three-day last year as an experiment. This year he came out, did the two-day, joked with everybody, walked around the track, encouraged everybody and put in some really really good, powerful mileage. He put in a third more mileage in two days than I was able to achieve in two.

The Bonnett brothers were terrific. They worked the aide station, they assisted us with medical, and even did a few loops; James did a loop with me when I got my thousand-mile jacket. Very encouraging, very positive, lots and lots of good vibes at the race.

There was one father-daughter team. The daughter was eleven years old, was out there and did the three-day race. She actually did not race at all, she jogged, sauntered, ran and smiled around the track, appeared to have a terrific time, sat down, ate, acted like the typical eleven-year-old that you would want as your daughter. Always had a smile on her face was always encouraging to other. If this is the future of the human race we are in good hands indeed.

There was another young lady, a sixteen-year-old who just ran a beautifully paced race and made an interesting comment after she had completed the run. She walked up to me and said: "Is there anything you can do to make me feel better?" so we went into the tent and I did some muscle energy myofascial release and was able to release some tension in her lower back that had built up over days. She got up and said, "Oh, that is wonderful, you are my hero"; actually just good application of osteopathic techniques.

Another young lady at the end of the race said she is prone to pneumonia after these races. Lung congestion is not unusual for days after a race, so I did some lymphatic pump on her, which helped her tremendously. An interesting side note is while applying pressure in order to do the pump my right thumb locked, I had not realized it but although I was alert, awake and felt pretty good I too was several quarts low and had ran out of potassium. It took a few minutes for someone else to massage my thumb so I could continue the treatment.

When I see the results I might be able to link up other names with people. But there were so many out there encouraging each other I was a drone walking most of the laps, moving over to allow the inside lane for the faster runners. Was going very slow but was always encouraged by people saying, "Way to go, keep it up, you're amazing", etc., just the thing you like to hear even though you know that you are a bottom feeder in a race of greyhounds.

That evening I had a lot of help putting things back into my vehicle, went back to the motel I stayed in before since each room had a jacuzzi, repacked all of my gear, went out to dinner with one of the other runners who is quite an accomplished athlete but this whole field was new to him in terms of ultrarunning and we talked about training and running, had a good steak dinner, I got back to the motel, had two more soaks and then spent a very peaceful evening literally waking up every twenty minutes to go to the bathroom, but fortunately not having to do anymore loops.

I started back the following morning and although I felt competent and refreshed I could only drive an hour and a half to two at a time before I had to stop at rest areas and sleep from fifteen minutes to as much as an hour and a half that first day.

At the awards ceremony I got my jacket, which is a very proud moment since this is one of those things that one has to earn. I also got my belt buckle for completing one hundred miles. I asked Chris to come up with me and mentioned that his work and effort on all of the runners precluded him from getting his and it was his ability to work hard that allowed me to get mine so I was going to share my buckle with him, he could have it on the even years and I will take it on the odd years. Then we decided we could get another buckle and have them engraved on the back Chris and Andy medical team 2005 which I think would make a very nice memento for both of us for this race.

I also have to mention that Jordan Ross showed up, was able to find me, and we spent several laps together joking, talking about our plans and our futures, and he brightened me up considerably. He brought chocolate malt, which was, reviving and went to the medical tent and expertly assisted several runners with his high level of medical skills.

Lynn Newton's wife and her friend Adria who is an LPN: When we were at the aid station they manned for us. Adria, as an RN was absolutely wonderful in working with the runners as they came in. Positive attitude, always smiling, very reassuring to the runners. Lynn's wife on the other hand, although she stated she didn't have skills in nursing, helped tremendously by making sure we had all of the equipment needed and talking to the runners and finding out how they were. Early in the race when it got dark we were having some problems with sufficient light for the blisters, she just calmly left, spoke to the race director and within minutes we had almost had a surgical suite type lighting.

Those that manned the aid station included some adults but a high percentage of the children of the race committee and even some of the runners, and they were sensational, getting any and everything that you could possibly want and need and with a very positive attitude, cheering everyone on. One reads and hears about all the negatives and problems of teenagers. I would like to think that those are the exceptions and what we saw in terms of these youngsters and their spirit and capabilities is more the norm.

More About Blister Control

Andy's Plan Reiterated

In my estimation, very few things are more aggravating than to put in the time and effort to train, work hard, pay the race fee, and travel to a distant place, only to have the entire race effort and result hinge on a blister. Over the years I have seen world class athletes, superbly prepared, humbled by a blister at a key moment or at a crucial location, resulting in a finish far below what could have been accomplished. So let's go over some of the issues that you can control.

This is not a definitive text on the subject, just some guidelines. There are good books out devoted to just foot and blister control. They are worth referring to. This article is really aimed at any runner plagued with blister problems, and more of a review of concepts and techniques rather than the definitive dissertation.

The base of course is foot hygiene and attention prior to a race. Look at any potential friction area, nail situation, foot, socks, shoes, anything at all that over time can cause friction resulting in a blister.

A decent guideline is to make sure that the shoes you will wear are proven and have been worn before so there are no surprises. If budget allows, it is reasonable to have shoes for specific tasks, such as trail runs, where there is lots of lateral motion, track runs where there are constant and continual turns, or road races with variations in terrain. It is useful to take long a few pair, usually of different makes with different lasts and slightly different fit. That way, if one seems to develop hot spots, sometimes the easiest solution is to put on another pair that fits slightly differently, and the hot spot is no longer there.

Any friction area or potential rubbing spot should be addressed well in advance of a race. I have seen many shoes where there is an internal defect: a shoe turns inward, or a seam is doubled and the thread is exposed, or the toe box or heel area is slightly loose, resulting in friction and blisters over time. It may not be a fashion statement, but it is possible, and even likely, that the right shoe fits differently than the left, in a pair of shoes. I have run many races quite comfortably with shoes of different makes and styles on each foot, making sure of course that the weights are comparable.

Sock issues need to be addressed. There are literally hundreds of socks out there of various compositions, thicknesses, wicking potential, etc., and it is important here too, to have worked out which are the most effective for you, and in what type of event.

There are many double socks that are effective in blister management. The theory is that the layers rub against each other, dissipating heat, thus resulting in less potential for blisters. My solution has been one given to me by trail runners, where the terrain is different with almost every footfall. Nylon sockettes, under a thin cotton over sock usually works, and is inexpensive. Running through water or during a rain storm can result in folds and pressure points. The double sock seems to act as a wick. Transferring water from the foot into the cotton, and then into the nylon, and out into the shoe, I have taken shoes off after water crossings and hours later, to find the shoe wet, the nylon wet, and my foot dry.

One brand of sock, Injinji, has separate compartments for each toe, much like a glove. If you get each toe into its appropriate position, the skin surfaces do not rub and I have found many runners who have solved their blister problems with this sock.

Ointments, Creams, and Salves

Lubricants can play a major role in blister or rash prevention. There are many out there and it is worth trying many of them out before settling on one that works for you. Each person's body has slightly different chemistries and what works for one person may not work for another.

I have worked on a formulation that, over the years has been very successful for most people, and it is one that you might want to try. Its advantages are: it is very inexpensive, one can almost make up a 20-year supply for just a few dollars, and you can adjust the ingredients for your own body, as well as for specific needs, such as dust, rain, trail, etc. Most of the ingredients can be purchased at Dollar stores and shelf life is almost indefinite.

Begin with Vaseline ointment, Desitin Ointment, and A and D Ointment. Desitin is Zinc Oxide, so it can be purchased generically. A and D ointment is the only pricey ingredient. The company (A and D) has many items out with that on the jar, or tube, but it is usually a variant of Zinc Oxide. What you need is the bright yellow ointment. Mix these three in equal proportions until you have a paste. Then add aloe vera cream and vitamin E cream, or lotions to the mix at about a quarter of the amounts used for the first three ingredients until the paste is firm, not runny.

I store surplus in the refrigerator or freezer. It just requires an occasional stirring if in the refrigerator and it is ready to go. A very thin coat on all friction areas is all that is needed. Usually one application is good for about as long as needed, (I have put on one application and not needed more for a 6 day race.)

If there is grit on the track, it may be a good idea to remove it with liquid gel alcohol and then replace it. If you know that you will be in quite a bit of water or a rainy event, more Desitin and Vaseline is useful. It forms a really good water seal. If you know it will be dusty, small gravel and rocks etc., then adding additional aloe vera and vitamin E is useful. They actually help the tissues heal as you run, suppressing infections and further irritation.

It should be a given that, if there is a hot spot or blister forming, to address it early, before it becomes fully formed. Prevention is always a lot easier and more therapeutic than treating it once it has started. There are many ways to take care of blisters. I merely clean the areas, drain it with a sterile needle, put on the ointment and a very light covering, and get back on the road.