The clinic: heel pain with a history of plantar fasciitis.

I am a 51-year-old runner. I have been running for eight years. I usually run three and a half miles, three to four times a week. Recently I have developed an aching pain in my right heel. This occurs when I walk and especially when I run, pushing off on my right foot. I had plantar fasciitis in this foot about three years ago.

Is the pain on the back of my heel related to the plantar fasciitis? What should I do? Will this get better if I rest? I would like to continue running as long as possible, but worry that I should quit.

Pauline Ludlum

Chicago, IL

At 51 years old, your running career is not over! You may need to make several adjustments in your training in order to continue running, but your outlook is still good. Your current heel pain is very likely related to your history of plantar fasciitis. You should be able to manage very successfully with appropriate conservative care.

The plantar fascia is a tight band of inelastic tissue that runs from the toes along the arch and inserts in the heel bone. Pulling of this ligament on the bone during running can cause micro-tears within the ligament and muscle leading to inflammation, pain and swelling. The band of tissue continues around the back of the heel, which may be causing your current symptoms. Activities that increase the pull of the plantar fascia on the heel bone will worsen the condition. Additionally, a tight Achilles tendon can place excessive stress on the back of the heel.

Treatment should begin with removing the stress caused by repetitive excessive pull of the plantar fascia on the heel bone. This includes relative rest and cross-training with low impact activities. Deep-water pool running is your best choice both to reduce heel stress and maintain your training gains. Cycling is also acceptable.

You should also ice your heel. Fill a bucket or large pan with cold water and ice cubes, then immerse the heel directly into the icy water. You will probably be able to tolerate the cold for about four to five minutes at a time. and repeat every 20 minutes several times a day. Using non-steroidal anti-inflammatory medications such as ibuprofen, as directed, will also help eliminate pain and inflammation. A night-splint can be helpful and effective for stretching the plantar fascia and Achilles tendon.

Before you return to running, make sure you are using shoes that provide adequate arch support. You may need to consider using orthotics or inserts that can help reduce excessive motion and redistribute pressure off the heel. Find a professional running shoe store with a knowledgeable staff to help you find the right combination. Since you've had problems before, it would be a good idea to see a podiatrist or a sports medicine professional to evaluate your biomechanics to determine whether a prescription orthotic might help prevent recurring pain. Stretching the Achilles tendon before and after running is an essential part of effective prevention. Also make sure you allow adequate rest and recovery between workouts and make any increases in your training very gradually.

Matt Werd, D.P.M.

Lakeland, FL

If the pain is primarily on the back of the heel, the problem may be at the insertion of the Achilles tendon. All the above treatments will help, but adding a 1/4-inch heel lift (in both shoes for balance) will also help.

Paul Taylor, D.P.M.

Silver Spring, MD

Osteoarthritis of the hip

I am 49 years old and have been running, biking, and swimming for the past two years, training for and participating in triathlons, and I really love it. Recently, my doctor has diagnosed osteoarthritis in my right hip and advised me to stop running. He said that continuing to run would make my problem worse and lead to hip replacement surgery. Is there any way around this? Do I really have to give up running and, therefore, competing in triathlons?

Trevor Morgan 

Portland, ME

This is a frequently asked, heartbreaking question. Most running injuries respond to correction of training errors, and rest and rehabilitation. However, degenerative osteoarthritis in weight-bearing joints is a different situation. Continuing to run with an arthritic hip will cause it to further deteriorate and speed the progression of the arthritis. Ordinary walking loads the hip joint with three times your body weight at each step. Running increases that amount even more. It is fortunate that you. already cross-train with cycling and swimming thanks to your triathlon training. These two activities will help you to preserve fitness and prevent increasing pain and disability.

Melvin M. Brothman, M.D

Amherst, NY

Consider aqua-jogging to replace running on land for training. Aqua-jogging has been shown to have significant carryover to land running. While minimizing land running with aqua-jogging won't eliminate the risk of progressive osteoarthiritis, it may help prolong your triathlon career.

Francis G. O'Connor, M.D

Fairfax Station, VA

Marathon running and carbohydrate replacement

I have run five marathons with a personal record of 4:15. During my long training runs, I would like to use some form of carb-replacement. Yet I find the mere thought of eating something sweet, like a power bar, nauseating. I've tried everything, including sports drinks, sports bars, gels, and candy. Any suggestions?

Monica Langdale

York, SC

You are not alone with this problem and my hunch is that it has something to do with the change in your body chemistry during endurance exercise that creates an aversion to food in general, or specifically to sweets.

As you know, carbohydrate replacement improves the average time to fatigue during endurance exercise. Research has shown that taking carbs before exercise helps, but having some during exercise is at least as important. However, you don't need specific sports products to accomplish this. Use what works for you. Choose foods that provide a lower glycemic index prior to exercise (such as a whole-wheat bagel or oatmeal and skim milk). Low glycemic foods make your blood sugar rise more slowly than sugar, and as a result, they tend to be less sweet. During exercise, choose foods that are higher in the glycemic index, but still, not too sweet. Some suggestions include crackers (saltines or grahams), bananas, potatoes, or white bread. The key with these dry foods is that you will also need to take in plenty of water during your workout, but it does not need to be a carbohydrate beverage. Choosing salty snacks will be an advantage for you since you are a four-hour marathoner and you will need to replace sodium. You m ay also find that salty foods will be more palatable.

Try taking your carbs after the first 60 to 90 minutes, hen every 30 minutes or so. Consume about 0.5 grams per pound of body weight every hour. If you weigh 130 pounds, that is about 65 grams per hour or about 30 every half-hour.

To increase the palatability of sports drinks you might try freezing a bottle (remove a little before you freeze it, since it will expand) and carry it in a waist pack. By the time you drink it, it will be partially thawed, very cold and slushy, and you may find it easier to take.

You can also experiment with homemade drinks. Dilute fruit juice, one for one, and add one teaspoon of salt or light salt (for the electrolytes). Or try one tablespoon of sugar, a pinch of salt, one tablespoon of orange or lemon juice, and 7.5 ounces of ice water. That's from Nancy Clark's New York City Marathon Cookbook, which is an excellent resource if you want more ideas and great recipes.

The key is to find what works for you. There is no hard and fast rule that you must use the commercial carbohydrate replacements. Plan ahead and try different foods and timing of food intake during your training runs. Have a high-carb meal two to three hours prior to the event (one hour if you can tolerate it), drink plenty of water before beginning and then begin your carbohydrate replacement about 20 minutes before you think your body will need it.

Sarah Harding Laidlaw, M.S., R.D.

Littleton, CO

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 workouts, pace, Surface), athletic and medical history, sole wear, recent changes in training, etc. Type or print your letters. Handwritten 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.