The Clinic.

NEUROMA PREVENTION

I had surgery to remove two large neuromas 12 weeks ago and I'm finally able to run again without pain. What are the chances of a neuroma growing back and how can I avoid it?

Betsy Heidenberger

Chevy Chase, MD

A neuroma is a benign enlargement of a nerve formed by compression by other structures in the foot. Surgical removal is the definitive treatment and there is little chance of regrowth. The most common complication is scar tissue, which can leave your foot feeling as if there's a wrinkle in your sock or cause residual numbness.

Make sure that you keep your shoes and orthotics up to date and well fitted with a rounded toe box that won't compress your toes. The fit for the shoe overall should be normal, not excessively large, which would allow for too much movement and friction inside the shoe.

Patrick J Nunan, D.P.M.

Cincinnati, OH

STRESS FRACTURED MARATHON TRAINING 

Earlier this year I placed second overall for women in the San Diego Marathon (!) but then made a huge error in training judgment by taking little time off before starting to train for another marathon. I developed hamstring and groin pain and saw an orthopedist who thought I had a hamstring and/or adductor injury. I did not have an ray until recently, months after the pain developed, and now I found out that I had a stress fracture of the pubic ischial ramus all this time. Eventually I want to run again and would like advice on the best way to deal with this injury so that I can come back strong as soon as possible.

Jenny Prokas

Portland, OR

In your overall healing process it is extremely important to examine your training program prior to the onset of your pain. Most overuse injuries, including stress fractures, occur when you have made too fast a transition--either increasing mileage, changing your running surface, or moving from base mileage to speed work without adequate build up. Also, you may be a candidate for a bone density test. Although stress fractures can happen to high mileage runners who have normal bone density, you may want to make sure your bone density hasn't suffered from nutritional or hormonal deficiencies.

Paramount to your return to running is to allow your stress fracture to heal completely. Pelvic stress fractures can take 12 to 16 weeks to heal. You may need crutches for a short period until you are able to move around during your daily activities without pain. Once you have no pain in your usual day to day activities you should be able to begin deep water running and flexibility training in order to preserve fitness. After about four weeks (depending on your progress), you can start a strengthening program for your lower extremities. Coordinate both flexibility and strengthening with a physical therapist so that you can be sure to progress without aggravating your injury.

At the point that you begin to train, your approach will have to be cautiously slow. Walk without any pain before you progress to jogging. Jog without any pain before you begin to run. You may want to work with a coach and substitute some of your high mileage training for quality workouts, as well as check for biomechanical or other training errors. You may find that you can rise to a very high level of performance without logging in extremely high mileage, which can increase your risk of stress fractures. Although you should be able to return to competition eventually, do not expect a personal best anytime soon. Allow yourself complete recovery and a very gradual return to competitive training.

Robert P Wilder, MD.

Charlottesville, VA

BETTER MARATHON TRAINING

You may be correct in assuming that the collapse theory may be the source of your marathon struggles.

However, you may want to consider some other strategies. How is your pacing in the races? Are you going out too fast? Do not try to build a cushion of time early in the race. Instead, try to run an even pace throughout the event.

Perhaps a longer buildup might help. This approach would put more long runs under your belt. Also, the strategy might enable you to build your long run beyond 20 miles.

Take your last long run three to four weeks before the race. This scheduling would give you three weekends during which you could run nine to 10 mile long runs. Start with three to four miles of the 10 at marathon goal pace and increase to around seven by the third 10-meter.

Make sure you have eaten and drunk enough during your last few days prior to the event. Always keep well-hydrated and replace carbohydrates during the race.

Lee Fidler, Ed.S.

Stone Mountain, GA

I don't believe a runner needs training runs of 20 miles or longer to handle a marathon (20 is 76% of race distance, which suggests needing nearly five-mile training runs to complete a 10k, or 76-mile training runs to make it through a 100-miler). It sounds as if you may be having a pacing problem--beware of going out too fast or pushing too hard through the middle. Budget your energy for the whole distance. The other possibility is that your diet is inadequate leading up to the race or you are experiencing fuel depletion during the race.

Jack Daniels, Ph.D.

Cortland, NY

BETTER MARATHON

I have run 16 marathons over the past 11 1 years with a personal record of 4:17. During every marathon I've had to slow down significantly, walking in most cases after 17 or 18 miles. I have tried using walking breaks every mile from the beginning of the race but it doesn't seem to make a difference. I keep well-hydrated and replace carbohydrates throughout the race. My training has included long runs of 20 miles, half-mile or mile repeats, as well as easy runs, with a weekly average of about 35 to 40 miles. I usually taper for two to three weeks prior to the race.

I am aware that there are basically two schools of thought in marathon training. One is that the total miles-per-week doesn't matter but that long runs are critical. The other school of thought is that you should have a base of 62 miles per week The second school is the "collapse theory" which requires that the daily average mileage consist of one-third of your race distance. My results seem to lend credibility to the collapse theory. Any suggestions?

Ron Marianetti

Novi, MI

HEEL SPUR FRUSTRATION

I was running 20 to 25 miles per week for 20 years until about six months ago when I developed a hool spur from coming down hard on some rocks. After six months of taping, anti-inflammatories, orthotics, adjustments to the orthotics, new running shoes, multiple cortisone shots, icing, stretching, spending every waking moment in orthotics, and virtually no running--there is no measurable improvement and the pain is as bad as ever.

My podiatrist maintains that since taping of the foot did eliminate the pain when the strapping was tight and since the week after the cortisone shots there was much less pain, these are all diagnostic indications that there is still hope. But I am quickly losing hope. Short of surgery, what are the last ditch measures to return to 20 miles a week of running?

Gary Fisher 

New York, NY

First, let me tell you that if your pain began from the injury that you described, it will most likely resolve with time. Unfortunately, injuries like these take a lot longer than most people realize. The treatments you have received have been very appropriate and the unfortunate reality is that nothing is as quick as we would like. It sounds as if you "test the water" every once in a while with a run only to find that you still have pain. Running while you are still injured will only prolong the process. Try swimming, aqua-jogging, or cycling for crosstraining until you know you are pain-free.

Second, you have adjusted your orthotics over time, but have you considered new, custom orthotics? Rigid? Semirigid? Soft? If you have had your orthotics for a length of time and taping your foot improved your symptoms, it would seem that new, custom fabricated orthotics, made by a topnotch orthotic laboratory might be a good idea.

Third, stretching the plantar fascia (the ligament on the bottom of the foot) is very important in solving your heel spur problem. Obtain a referral to a sport physical therapist who can help you with treatment and teach you methods to use daily at home.

It really does sound as if this is a problem that can be in your past as long as you have the patience and forbearance you need to complete the healing process. Have your physical therapist oversee your crosstraining and do not run until your problem is completely resolved. When you return to running, you will need even more patience in order to re-train gradually so that you do not re-injure your heel.

David M Davidson, D.RM

Buffalo, NY

With your history, you should make sure the possibility of stress fracture has been ruled out with an MRI. If you have a heel fracture, you may need casting, bracing, and crutches to allow it to heal.

Mitch Goldflies, MD.

Chicago, IL

RELATED ARTICLE: ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of The American Running AssocIation. 4405 East West Highway. Suite 405. Bethesda, MD 20814. FAX [phone]. or e-mail at [e-mail]. Write a letter including as much relevant information as possible about you (age, weight. etc.) and your injury (type and location of pain), training schedule (typical weekly workout, pace, surface). athletic and medical history, sole wear, recent changes in training. etc. Type or print your letters. Hand-written FAXed letters cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.