Going The Distance : Foot Prep and Triage. Heel Blisters

A couple of weeks ago, I attended the Endurance Society’s “Infinitus” event. This was a multi distance trail race with events that were 888km, 88k and 8k in length, as well as having 72hr, 48hr, and 24hr races for largest distance. The 888km race itself took place over 10 days, and the terrain and weather made for interesting conditions. Some parts of the course were wet and swampy, other parts were hilly, and as with any good trail race it really brought out the worst in peoples feet. For the last three days of Infinitus, I tirelessly worked to fix up peoples feet so they could get in more laps. In particular, by the time I showed up some of the 10-day racers were in a really bad place. One racer in particular needed significant work after almost every loop to ensure she could continue with as little pain as possible. Other racers came to me with the following issues, more or less in order of how often they happened

• Heel blisters
• Blisters between toes
• Blisters beneath pinky toe
• Heavily bruised or lost toenails, often with blisters beneath the nail
• Maceration
• Blisters on the ball of the foot

Almost every case could have been mitigated, or at least delayed, with the proper preparation. In the rest of this multi-part series, I will discuss the problem, what the likely cause(s) are, how to reduce the likelihood of it happening, and how to triage during a race. Sadly I didn’t take pictures at the event I described, as I was too busy getting racers moving again. If a particular description is unclear, please add comments, and I will either respond or update the article to remove any confusion. The series will cover common problems, solutions, taping techniques and other useful tidbits of information. First up in this multipart series, I talk about heel blisters, likely causes, mitigation, and triage solutions.

Shopping List

As far as triage goes, I used a LOT of different products, but for the most part used the following

• Leukotape P rigid sports tape    – best tape for foot issue presentation and triage by far
• Hypafix    – used in areas where something more flexible than Leukotape is needed
• Trail Toes – the BEST product to protect your feet (and other areas) by far. Far superior to body glide.
• New Skin    – provides a protective layer on damaged skin
• Sterile Needle tips    – the best tool I’ve found for draining blisters. 21 gauge is the most versatile
• Moleskin    – protect blisters from additional damage/pressure
• Alcohol wipes    – used to clean or prep skin, hands, etc
• Foot powder    – used to remove excess moisture from feet
• Tincture of Benzoin    – use to provide enhanced adhesion of tape to skin. Can also add a protective barrier like New Skin, but takes longer to dry.
• Scissors – duh. cuts the tape, moleskin, etc.

For your own race going needs I highly recommend getting Trail Toes, a small bottle of New Skin, a small bottle of foot powder, and a foot care kit from Trauma 1 kits (also available at GORUCK.com). The foot care kit includes some needles for popping blisters, some small Trail Toes pouches, and a bunch of other useful items for triage. Follow the links for the specific contents. Its important too to use good quality products. I am a firm believer through a LOT of trail and error that DryMax make the best socks for events where water and/or mud can be involved. They have a lot of different products, and everyone I have tried is excellent. I particularly like the Drymax trail crew sock. Check out my comparison with Prosok. Additionally blisters and other issues can be caused by debris entering the shoes and socks and increasing friction and skin abrasion. This can be prevented somewhat with a good quality set of gaiters. 

Problem : Heel Blisters

Cause

Blisters are caused by a few factors in combination, but in general friction is the main component needed. Friction is compounded with heat and moisture to accelerate blister creation. At its simplest, friction against the skin causes the layers of the skin to pull away from each other, ultimately filling with fluid, giving you a painful blister. Obviously heat and moisture make the skin itself more pliable and hence why the effect is accelerated. So heel blisters are caused by friction of the sock or shoe against the back of the heel, as the heel of the shoe moves independently of the foot. Obviously if there is no sock, the shoe is more likely to rub and product a blister, and similarly if the shoe is loose it will cause a lot of friction against the heel.

Prevention

Given the cause above, there are two main approaches to preventing heel blisters.

Approach 1 is to prevent the movement of the shoe heel against the foot. For this you need to make sure you have a properly sized shoe. In addition you need to ensure that you are laced correctly. Its worthwhile learning how to do a lace lock. With a properly fitted and laced shoe, there should be little movement of the shoe against the heel of your foot.

Approach 2 is to pre-tape your feet using Leukotape, to minimize the impact of the friction. A future post will demonstrate correct taping of different areas of the foot, including the heel. Why Leukotape? In my extensive testing, Leukotape provides the best combination of adhesion, low friction coefficient, and enough rigidity and sturdiness that the tape takes the brunt of friction rather than your skin. If you pre-tape, make sure you so so well before your race to give the adhesive even longer to bond to the skin. If you are particularly prone to them, use both techniques. I also highly recommend that you apply Trail Toes lubricant liberally before a race, and every few hours during. This great product has two useful effects. First it reduces the friction coefficient of the skin, reducing the impact of wear from the shoe. Additionally it acts as a moisture block further preventing skin breakdown.

Triage

Remove your shoes and socks and take a look.

Hotspots If you start to feel a hotspot on the heel of your foot, you should treat it immediately. If you have yet to tape the foot, stop and do so. If your foot is wet and/or dirty you will need to prep the skin. To prep, wash off the foot as best as possible. Use your newly removed sock to remove debris, and follow up with an alcohol wipe or other wipe if necessary. Keep this wipe handy. Next you will need a dry surface. Dust your foot with a little of the powder to remove moisture, and then remove as much of the powder immediately. The alcohol wipe is useful here too. If your skin still feels like it won’t take the tape, you can swab the area with tincture of benzoin at this time to help adhere the tape to your foot. Apply a cut section of tape, ensuring that you round off any corners. Again, I will cover taping technique in a future post.

Blister If you didn’t capture the hotspot in time, and have a blister, you have a decision to make. Drain, or don’t drain? If the blister is still relatively small or you don’t plan to race further, you will not gain much from draining it. In this instance, you will need to cut a section of moleskin to surround the blister, with a hole cut into the moleskin in order to relieve the forming blister. Ensure that the shape is round or oval, to prevent additional problems to arise from the moleskin itself catching. Then you should cover the moleskin with Leukotape to keep it in place the same way you’d tape your hotspot above. If the blister contains a lot of fluid, and/or is really large, you should drain it. My technique is to take a sterile lancing needle and make piercings around the blister. Depending on your skin, where the blister is, and your own characteristics, the blister might drain easily, or the drain holes might seal up quickly. If you are able to completely drain the blister, you will want to prevent the blister from refilling. My technique here is to take a small piece of gauze (you can cut the sticky parts off a band aid, and use the padding) and place over the drained blister. Next, tightly adhere Leukotape over the padding. The gauze/padding will absorb any remaining fluid from the blister, and the tight tape will both prevent fluid accumulation from recurring as well . Its often easier to apply if you stick the padding to the Leukotape before applying the latter. This technique will protect the skin, and provide a new surface (the tape) to absorb the friction. SEE IMAGE If you cannot fully drain the blister, do the best you can. and then use moleskin and tape as with a small blister. The goal here is remove the pain from pressure and additional friction, and prevent worsening the situation.

Torn blister In this situation, you continued through the hot-spot, a blister formed, and it popped and tore by itself before you ever had a chance to mitigate the problem. As with the blister, you want to make sure you do not exacerbate the problem. You also want to protect the new skin. My preferred technique here is to use the New Skin product on the skin. You may choose to remove the excess skin or leave it in place. Personally I will usually leave the skin flap in place, apply the New Skin underneath it, and replace the skin flap back to its original position. If you can get the New Skin to dry with the skin flap on top, you have a little extra protection. Ensure that you wait for the product to dry – it just takes a minute or two – before the next step. I will warn you, when you apply the New Skin it hurts like hell! The burning pain will dissipate quickly though. Once the New Skin is dry, you will need to protect the skin further. Given that the problem occurred, you have an issue with friction that you need to mitigate. I would personally use moleskin and Leukotape, or gauze padding and Leukotape over the area just as with hotspots or regular blisters. Which I use depends on how the blister looks and will come with experience.

Get Moving Again

You’ve stopped to triage, and now you need to get going again. You can either choose a clean, dry pair of socks if they;re handy, or replace your existing socks. If you go for the latter, you can improve their comfort and performance by removing as much debris and moisture as you can muster. To remove debris, flick the socks aggressively, or slap onto a clean surface repeatedly. To remove excess moisture, use both hands to wring the socks as tightly as you can. This should remove the majority of moisture, and the heat and friction of your feet once moving should remove some of the remainder. Before replacing your shoes, perform the same procedure with the insole of your running shoe. Only now are you ready to lace up firmly, and start moving again. Take some water, a bite to eat, maybe an anti-inflammatory if you need it, and enjoy the rest of your race.

Next installment : Toe blisters