Leg Pain

Preparing for the Marathon

How to avoid last-minute injuries

Dr. Michael M Cohen


Runners- Listen to your body!


Injuries often have a prodromal period.  That means a part (or parts) of your body will send you signals that things aren't quite right.  Your sore foot, Achilles, hamstrings or shins may not necessarily become quickly evident at first.  You may notice it in the morning when you arise or in the beginning of your run, but then it fades and disappears as you continue.  Granted there are ‘good pains’ and ‘bad pains.  For instance, delayed onset muscle soreness is a good type of pain that is proportional to the intensity of training.  The deep muscle pain appears within a day or two of your long run and wanes with light exercise and anti-inflammatories.  Bad types of pain present differently.  They are almost always there whether running or not, and should not be run through.  This type of pain may be accompanied by certain visual changes such as swelling, redness or painful lumps, auditory changes such as pops, grinding or snapping, or sudden weakness of the ankle or foot.  These acute signals may need the evaluation of the sports physician.  Heed the warning signals carefully as a failure to do so may cause a benign problem to develop into a frank injury, ultimately ruining your chances of enjoying healthy workouts or even racing.  Such attempts by athletes to push the envelope in an effort to prepare for a certain race often results in futility, oftentimes resulting in an injury which ruins the entire racing season.  I have seen too many runners suffering from torn fascia, tendons and fractures because of exuberant training techniques. Much of this is brought on by athletes, enthusiastic coaches and parents who are relying too much on the internet for information and treatment. Moreover, I have seen many injuries occur because runners try to cram in more miles and speedwork right before a race. Training cannot be treated like a final exam- you cannot cram for it and the body is not conditioned to sustain a sudden increase in volume. Follow the time tested10% rule by increasing your total running mileage by 10% a week.

Attend early signals (prodromes) by adjusting your speed and mileage accordingly, alter your running form as in the case of a sore Achilles or hamstring by shortening your stride, staying away from inclines and hills and learning to roll over the ankle rather than emphasizing the push-off, especially during the early part of the run.  Warm up by walking at least 1/4 mile before stretching. Check to make sure your running gear is appropriate for you.  Your running shoe should be appropriate for the distance, and type of foot you have. Shoes should be discarded after 400 miles of running or walking, especially in Florida where the EVA (the white stuff in the outsole of the running shoe) collapses quickly in the heat. EVA is made of a type of rubbery material which has been expanded with microscopic air cells to give you cushioning during the run. After a run the air cells collapse and it will take 24-48 hours for them to re-expand. So better yet buy two pairs of the same shoe and alternate daily to allow for maximum shock absorption. Try to stay away from flats (light racing shoes) during the prodrome period or when recovering from an injury.   Make sure to ice after running and use anti-inflammatories judiciously, you do not want to mask important signals.  

When feeling the prodrome skip a day or two of running and cross train instead. You’ll find that with sports specific cross training your technique will actually improve. This may include aqua-jogging and strength training. Avoid training with back-to-back hard days, especially if you are over forty. When resuming your runs after injury return to running cautiously.  Be patient, don't let feelings of guilt send you back to the war zone before you've recovered.  Remember that training and recovery are Siamese twins who cannot exist without each other.


Dr. Michael Cohen is a former triathlete and marathon runner who achieved a personal marathon record of 2:37 at age 21, 2:50 at age 39, and at 50 was a Top 3 age group finisher in both the ING Miami and Disney Half Marathons. In 1997 he placed third place overall in the Florida Gatorade duathlon series.  He is a Board-Certified Foot and Ankle Surgeon and Diplomate of the American Board of Foot and Ankle Surgery. He is a Fellow of the American Board of Foot and Ankle Surgeons and Board Certified and Diplomat of the American Board of Podiatric Medicine. He practices with the Foot, Ankle and Leg Specialists of South Florida specializing in lower leg injuries and reconstructive surgery of the foot and ankle. The practice includes Robert Sheinberg DPM, Al DeSimone MD, Fernando Moya MD PhD, Alexander Bertot MD, David Shenassa MD, Carlo Messina DPM, Franz Jones DO and John Goodner DPM. The South Florida Institute of Sports Medicine in Weston is located at 1600 Town Center Blvd., Suite C, (954) 389-5900 and in Pembroke Pines at 17842 NW 2nd Street, (954) 430-9901.




The Elusive Stress Fracture in the Runner

By Dr Michael M Cohen DPM FACFAS


Nothing is more frustrating to a runner than an injury which occurs just when the training schedule calls for ramping up mileage or intensity in time for competition. Over my 35 years as a foot and ankle specialist treating runners in our community, I have personally witnessed not just the physical, but emotional toll these injuries can inflict. I can truly empathize with them as I myself have fallen victim to these same unfortunate circumstances and on multiple occasions. As runners, we forget that our sport is not a passive but violent one, as each foot strike results in an impact equivalent to 3 or 4 times our body weight. To put it bluntly, training is a form of self-inflicted injury with the hopes that the ongoing cycle of injury and healing will ultimately lead to stronger muscles, tendons, and bones after recovery. This is a positive and most desirable outcome we refer to as "conditioning". Unfortunately, training exuberance tips the balance in favor of injury, sometimes with the best intentions of the coach or athlete and leads to the body’s inability to regenerate or strengthen properly. This is when breakdown (injury) occurs resulting in a concept I call "reverse conditioning" secondary to overtraining.  


One such common running injury is referred to as a stress reaction which in later stages develops into a stress fracture. Most athletes with a stress reaction present with an insidious onset of pain in a focal area sometimes confused with muscle soreness or tendinitis. Stress reactions and stress fractures represent fatigue failure injuries and are secondary to overuse. A stress reaction precedes a stress fracture in the bone fatigue continuum and is hallmarked by microscopic failure without an actual visible break in the bone. X-rays are typically negative in this stage of injury and better imaged with bone scans or MRI. The MRI is a very sensitive imaging technique which depicts swelling in bone at this early stage. As the fracture continues to develop, heat, swelling and pain are noticed during everyday activities. In severe cases, the pain eventually precludes comfortable weight-bearing and physical exercise causing the athlete to limp. 


Stress on bone creates constant remodeling affecting a balance between the cells which eliminate injured bone (like a tiny vacuum cleaner) and cells which replace injured bone with newer healthier bone. Overtraining, either by adding mileage, speed or inclines will tilt the balance in favor of the cells evacuating injured bone. This ultimately results in a negative balance of healthy bone cells progressing to stress injury. Adding insult to injury, weak muscles in the thigh and leg supporting the bone structure by absorbing shock may further stress the physiologic capacity of bone to maintain its integrity causing it to fatigue. This is not unlike bending a paper clip back and forth until heat develops causing the metal wire to fatigue until it snaps into two segments. Stress fractures are very similar as the continued stress of training results in fatigue failure of bone, leading to microscopic cracks and subsequent true fracture if allowed to continue. It is during these late stages of the process that X-rays become a more reliable tool.


Not all stress fractures are the same

Stress fractures are generally classified into two types: low-risk fractures- those that heal well and usually without long term sequela and high-risk fractures - those which do not heal well and often require surgery. The designation of these two classification systems is essentially based on the location of these fractures. Bone stress injury treatment and return to play decision making is based on the site of injury, potential for healing, and risk of significant complication. Proper treatment of the fracture is essential to avoid under or over-treating the condition. Clearly over-treating the fracture may result in an unnecessary disruption of training and subsequent loss of physical conditioning referred to as "deconditioning". Stress fractures deemed as high risk poses a significant risk for recurrence due to inadequate healing and at times may result in potentially devastating complications leading to career ending injuries. Prompt diagnosis and treatment is fundamental in allowing proper healing thereby minimizing the impact of the injury.



Treatment for stress fractures should not focus on boney healing but should include an investigation of what we refer to as the intrinsic and extrinsic causes which resulted in the injury in the first place. Intrinsic factors include 1. Biomechanical- body type, foot type, inherent weakness and flexibility, and a factor many gloss over- running technique, 2. Nutritional specifically insufficient intake of protein, calcium, and vitamin D 3. Hormonal factors- the most notable of which is estrogen. Female athletes with low bone mass have a higher predilection for certain stress fractures. This is especially noted in women at risk. This includes those with low body mass, or have stopped menstruating and/or have a history or family history of osteoporosis. This group will require a proper medical workup consisting of blood tests and a bone density scan often requiring a team approach with various specialists.


Extrinsic factors on the other hand consist of training errors and improper equipment. This includes but is not limited to the influences of terrain, running form, and improper running shoes. To be effective, an individualized developmental plan for an effective return to play schedule should take these factors into consideration. The strategy, particularly when dealing with low-risk fractures, may require decreasing training volume and intensity, using proper equipment, changing running technique, and cross-training.  Using this tactic assures that the athlete does not suffer a substantial loss of conditioning while recovering from injury. Sports medicine physicians realize all too well that extended time off training may adversely affect the recovery. Recouping the body’s strength, flexibility, and ability to balance is significantly hindered with overprotective measures and results in an extended loss of training time. So why create a problem in order to solve one?  With a proper rehabilitation plan, the athlete is given the best chance for a faster recovery while resulting in a protective effect from future injury.    


Alternatively, high-risk stress fractures as previously mentioned have more frequent complications such as poor healing, non-healing, and at times re-fracturing after healing is thought to have been completed. These are very frustrating scenarios which unfortunately often leads the athlete to abandon the sport. The treatment for high-risk stress fractures should be based on the immediate goal of preventing any progression of the fracture and avoiding long-term complications. Because of the significant complications associated with this injury, it is suggested that athletes with evidence of a high-risk stress fracture immediately discontinue their activity. Unfortunately, with these fractures, prolonged immobilization with weight-bearing restrictions or operative management are often the treatments of choice.


So, remember to listen to those nagging injuries and avoid reverse conditioning. Make sure that you heed the signs of injury before the injury heeds you.