The Clinic.

Q. Mail Order Orthotics 

Popular running magazines have advertisements for custom orthotics through the mail. They send you a box containing a foam material that is used to get an imprint of your foot, then additional information is taken by phone to determine the other specifications. The cost is less than half that of orthotics made by a podiatrist. In my case, I had inflammation at the base of my second and third toes. I am 54 years old, six feet tall and weigh 170 pounds. I run about 15 to 20 miles per week. A podiatrist recommended trying over-the-counter orthotics to see if they helped. I tried one brand that helped, but my guess is that this mail order product could really do the trick.

What is the difference between mail order orthotics and orthotics made by a podiatrist? Can you really get well-fitted orthotics by mail? Are there certain kinds of problems that would be appropriate to handle in this way?

Jim Pattee Albuquerque, NM

A. Due to the changes in the health care system, patients are taking on more responsibility for their own medical care. Mail order orthotics is just one more example. In general, as is true with all self-treatment, the risk is that a proper diagnosis and complete care of the problem will be missed. In your case, pain under the second and third metatarsals or metatarsalgia, which is fairly common among runners, can be caused by an underlying biomechanical deformity like an elongated or depressed metatarsal head. Your over-the-counter inner sole helped by providing shock absorption. It can also be addressed simply by placing a metatarsal raise on an over-the-counter orthotic. It is often difficult to position the metatarsal raise in the perfect spot and requires a professional. Unfortunately, the store-bought inserts can wear out fairly quickly and in the long run a custom orthotic may be more cost effective.

I would guess that a mail order company could provide a fairly good product. The foam casting is a great way to cast for orthotics, but it can be very difficult if you don't know what you're doing. One or two degrees can make the difference between an orthotic that helps and one that results in more problems. Does the mail order company provide any adjustments? It's not uncommon to need adjustments after the first fitting to fine-tune their support. Make sure you can get an adjustment or return the orthotics if they don't work out.

If you had good improvement with an over-the-counter product, maybe your podiatrist or orthopedist can adjust yours with a metatarsal raise. This may be the most cost-effective way to go and may be effective in eliminating your pain completely. This way you also have the benefit of professional advice...and here's some professional advice--don't forget to stretch your calves.

Lori Barnett, A.T.C., D.P.M Emmaus, PA

A. Sometimes you can get the orthotic help you need from your running shoe store. Some of the best stores are experienced with placing metatarsal pads, arch pads and tongue pads (which give a firm grip on the mid foot to prevent pistoning of the foot back and forth) in the new shoe. Always get an agreement with the store that you can use the shoes indoors for a week or so and return them if they're not comfortable.

Marvin Bloom, MD. Burlingame, CA

Q. Help With Cold, Rainy Marathons

I have just completed a marathon during which I suffered from a case of dehydration and hypothermia. I am trying to figure out what went wrong so that it won't happen again. I am 47 years old, 6'4" tall, and weigh 180 pounds. I've completed over 10 marathons in the past with generally improving times including 3:12 last winter. I have been injury-free, average about 30 to 40 miles per week and increase that to 40 to 45 miles per week to prepare for a marathon.

For the recent marathon I felt well prepared but finished with a personal worst. The weather was less than ideal at 40 degrees and rainy, but I have trained and raced in similar weather before. I went out at my usual pace and held it for 10 miles. After 15 miles it was a struggle even to run at all. Late in the race I tried to pick up the pace but felt nauseated and just gradually slowed down in response to howl felt. I drank water or Gatorade at every station.

At the end of the race I felt really sick. I was moved to the medical room, and warmed up with blankets and warm Gatorade. It took 45 minutes to get warm, but eventually I began to feel better. The medical staff diagnosed dehydration and hypothermia. What went wrong? How should I dress for these conditions? Are dehydration and hypothermia related?

Bob Bachus Marietta, GA

A. You can't have a great race every time out. That may be your most important lesson. Your previous marathon successes raised your expectations. But on those days everything went right. Just write this one off as a learning experience. Here's your opportunity to gain racing wisdom.

First, dress with layers that allow you to strike a balance between your body temperature, your clothing, and the weather. The first layer should move moisture away from your body so that you don't get chilled, Fabrics like polypropylene, and lycra are designed for that purpose. Cotton is a poor choice because it hangs on to moisture. The next layer should continue to move moisture out and should insulate by trapping warm air. Fabrics like fleece and wool are good for this. The outer layer should protect you from the elements and complete moisture transfer by releasing perspiration to the air. Gortex and similar products work best, but other rain resistant fabrics can do the job.

Hypothermia occurs when the body loses more heat to the environment than it produces and can occur at temperatures well above freezing. Chronic hypothermia is the result of slow body cooling and is commonly encountered where there is prolonged exposure to cold, wet conditions. In this situation, your body has time to increase the metabolic and heart rate. In your case, slowing down in the last 10 miles of a cold, wet race set the stage for hypothermia. You lose more heat than your body can generate, and slow cooling occurs, sometimes to dangerous levels.

Vasoconstriction shifts blood from the periphery to the core of the body, causing increased urine output (contributing to dehydration). Individuals with hypothermia are often volume depleted (further dehydration) and respond to cooling with intense shivering (further dehydration), decreased heart and respiratory rate, decreased oxygenation, decreased blood supply to actively exercising muscles, and fluid and electrolyte imbalances (you guessed, further dehydration).

Here is a suggested fluid intake scheme for preventing dehydration. Maintain daily hydration with water, fruit juices, milk, and other beverages, avoiding alcohol and caffeine, which contribute to dehydration. Twenty ounces of fluid, preferably water, should be consumed an hour or two before exercise. Consume another 10 to 15 ounces of water 15 minutes before exercise. Drink three to six ounces of water every 10 to 20 minutes during exercise. After exercise, consume 16 ounces of fluid for every pound of weight lost from activity. Using a sport drink can enhance fluid intake and absorption, delay fatigue, and speed recovery in exercise lasting more than 60 minutes.

Hypothermia and dehydration can be avoided. Follow the clothing and hydration guidelines and you should be able to avoid repeating your unpleasant experience. Remember that even under the best circumstances, a marathon stresses your body significantly. Add the trouble you experienced and the stress is compounded. Respect your need for rest and recovery. Do not be fooled by a feeling of recovery too soon after a marathon. Resume your base training and progress gradually giving yourself plenty of easy days before you begin to push yourself. Thoroughly analyze the entire race and make notes about your performance. Like any difficult test, it prepares you for the next step.

Richard L. Canlas, MD.

Saginaw, MI

Q. Rest is Key After a Marathon

Last year I made the mistake of returning to training too soon after a marathon. Just a few days after the race, I felt great and started running again. I developed an overuse injury on my right hip joint and had to take a month off to rehabilitate from the injury. I want to avoid this problem in the future. Do you have any recommendations on how much time to allow for recovery after a marathon run? I've just run another marathon and my hip is a little sore. I want to make sure to give myself enough time off.

George Ruiz

Carson City, NV

A. Overuse injuries are not uncommon among marathon runners and are usually attributed to training errors such as increasing intensity or distance too aggressively, excessive hard interval training, or inadequate stretching. The wrong shoes and biomechanical problems can also lead to injury. "Overuse" is a general term that can cover various causes. Know precisely what you're dealing with and how to correct the problem. My first recommendation is to have an evaluation by a sports medicine professional to find the source of your hip pain. You could be developing a pelvic or hip stress fracture, for example, which should not be ignored.

That said, there have been some recent studies looking at recovery of muscle strength and work capacity following a marathon. These studies show that there are definite changes occurring in skeletal muscles after a marathon, and that these changes are mostly resolved within seven days. Furthermore, one study showed that athletes who rested for seven days following a marathon recovered muscle strength and work capacity better than athletes who exercised (45 minutes per day) during the seven days following a marathon.

Fatigued muscles can certainly contribute to the development of overuse injury. It is probably best to rest for at least a week before returning to training following a marathon and gradually build yourself back to avoid other injuries. In any event, you should not return to training until your hip pain is resolved. Pain is a signal of injury or inflammation and should be treated with rest, ice, and anti-inflammatory medication. Use the time off to find a good sports medicine professional to fully evaluate your problem.

Kathrin Annette Weller, M.D.

Eugene, OR

My rule of thumb is to take it easy one day for every 3000 meters raced. For a 10K race this is at least three days; for a marathon (42km) this is 14 days. "Easy" is initially walking and easy running--but no running if pain from the marathon makes you limp. "Easy" becomes "easy running" the second week. One week after a marathon people tend to feel very good but shouldn't take it as a sign that all stressed connective tissue is up to strength, because it's probably not.

Jack Daniels, Ph.D.

Cortland, NV

Ask the Clinic!

Are you bothered by an injury? Do you have a training or diet question? If so, ask The Clinic, in care of American Running Association, 4405 East West Highway. Suite 405, Bethesda, MD 20814, FAX [phone], e-mail [e-mail]. Free personalized sports medicine, training, and diet advice is an exclusive benefit for American Running Association and AMAA Members only. American Running has more than 255 Clinic Advisors representing more than 27 specialities. Include as much relevant information as possible about you (age, weight, etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history, sole wear, recent changes in training, etc. Type or print your letters. Hand-written FAXed letters will not be accepted. Include your name, address and phone number (even in e-mail). Letters cannot be processed without your name and mailing address. Responses usually take three to four weeks, but can take as long as five.