What 6 Days of Ultramarathon Running Taught Me

The event was Adelaide 6 Day / 48 Hour Ultramarathon 2014, the first 6-Day ultramarathon running event in Australia since 2006. Here are a few specifics of the event:

• The surface was a 1.13km asphalt surface loop.
• The track varied from flat to having a significant camber. Runners changed direction every 24hrs.
• There were a small number of competitors: thirteen 6-Day competitors and seven 48-Hour competitors.
• The 6-day winning male an 720.94km (almost 3 marathons a day). And the 6-day winning female 624.65km (just under 2.5 marathons per day)!
• This was my first ultramarathon experience. I did not run! I provided foot care from 8am - 1pm each day. The following are my observations of the race.

Adelaide 6 Day/48hr competitors (Billy's hiding behind Tassie Pete!)

Six ultramarathon running observations in six days

1) There's a large variation in structural and functional characteristics

• Many ultrarunners are far from biomechanically perfect (yet look at what they're capable of)! A few very obvious things that caught my eye were:
• asymmetries in arm swing, leg length and foot size
• significant spinal problems
• tight calf muscles
• marked (dare I say it) overpronation
• Running techniques varied greatly but heel strikers predominated. Many ultrarunners spend a fair bit of time in 'grounded running' (the 3 images below are of 6 day runners on the final day):

"It’s a gait that is at a speed almost immediately above the walk/run transition and there is NO flight phase (which is part of the definition of typical “running”); it is more of a bouncy gait; a gait used by slower runners; it is possibly a more economical gait solution at the walk-run transition speed." Craig Payne (2014)

• There was a broad range of running shoes in this race. Hokas were popular! But there were still plenty of ’standard’ running shoes in use. There was not a lot in the way of minimalist footwear (and there were no Vibrams 5 fingers in case anyone was wondering). Some runners brought 6 or more pairs of shoes while others wore the same pair all race. One runner was wearing a pair of shoes that were 10 years old!
• And there were varying levels of preparedness and support. From two crew members who did shifts over the 6 days; to being totally self-supporting; to a spur of the moment decision and calling the wife 60kms into the race to tell her where he’ll be for the next 2 days!

Initial (heel) contact far ahead of the body. An example of grounded running with no flight phase. Initial (heel) contact closer under the body. Initial (forefoot) contact close under the body. Another example of grounded running.

2) Shin pain was common

The main structure seemed to be tibialis anterior (muscle belly and/or tendon). Runners blamed the hard running surface. So I posted the question on Podiatry Arena to find out the exact mechanism and this was confirmed - tibialis anterior has to work harder eccentrically when running on a hard surface. Differential diagnoses for this in ultramarathon running include: muscle trigger points, delayed onset muscle soreness (DOMS), anterior compartment syndrome, stress fracture, tendinosis and medial tibial stress syndrome.

• Here’s a bit more information about the tibialis anterior trigger point.
• This explains the reasoning behind the cold spray in the spray and stretch technique I used in Adelaide. Essentially, the cold spray is used to stimulate receptors in the skin which has an effect of distracting the trigger point activity allowing the muscle to relax more to stretch.
• This is the paper on delayed onset muscle soreness referenced on Podiatry Arena - it's worth a read.

Soleus stretch

Gastrocnemius stretch Tibialis anterior stretch

3) Toe blisters were common

There were quite a few blisters under the ball of the foot; but many more toe blisters! Strategies in use included taping (Fixomul, Rocktape, Compeed), toesocks, silicone gel toe covers and shoe modifications (see observation 4). Of their type, the two most common toe blisters were:

• Pinch blisters of the 4th and 5th toe
• Toenail blisters

Pinch blister on the 5th toe

Lancing a blister with a scalpel blade is painless! This is bleeding under the nail (black toenail) requiring a hole in the nail to release the blood. I gouged this with a scalpel - it provided immediate relief. This blood blister under the nail was accessible without having to put a hole in the nail. The cause of this one was shoes too loose and the toe hitting the end of the shoe. Part interdigital blister / part blister under the toenail. Easily lanced for relief.

4) Cutting away the toebox is popular in 6-day ultramarathon running events

I was surprised how common this practice was! There were varying degrees of mutilation: from cutting only the little toe area; to the top of the toebox; to the whole toebox entirely! The main reason was to relieve pressure on the toes - particularly the little toe. But also for the toes from the end of the shoe. What was the cause of this pressure? Here are some possibilities:

• Swelling made the shoes too small (in width and/or length)?
• Other things made the shoes too small (in width and/or length) such as toesocks and toe taping?
• The shoes were too small (in width and/or length) to start with?
• The foot slid forward due to the hard surface, making the toes hit the end of the shoe?
• The foot slid forward due to the laces being too loose?

Is cutting the shoe open a good solution for this pressure problem? The consensus was it worked perfectly. But what if this was a trail race? Or what if the asphalt surface had a bit more loose rubble on it? Surely it wouldn't have been an option. Is there a better solution? Do ultrarunners need to have a pair of shoes 1-2 (or more) sizes larger than usual for the latter stages of multiday races? Are multiday ultrarunners not purchasing shoes adequately wide in the toebox? Are appropriately wide shoes not readily available (in Australia)?

Pressure relief for the tops of the toes.

The hole at the big toe of the left sock suggests this provided relief to the tips of the toes.

Pressure relief for the toes from the sides. In addition to toesocks, the toes are taped with Rocktape.

5) Many ultrarunners like their laces loose

I would say too loose. To the point of being a contributing factor to blisters (toenail blisters, toe blisters and blisters under the ball of the foot). I need to find out more about the reason(s) behind this as it must be significant enough for runners to ignore common sense.

• Is it a time-saving factor – leave them loose to save time loosening them later when the feet swell?
• Is it because after a while, it's difficult to bend down far enough or stay there long enough to firm up the laces sufficiently?
• Do particular lacing systems make it difficult to get the laces firm enough?
• Is it to relieve pain at the top of the foot? Is this worse when the tongue of the shoe is thin or with skinny speed laces?
• Does it increase ventilation in the shoe when it was hot?
• Is it to stop irritation at the back of the heel?
• Or is it something else?

The next time you get toe blisters or black toenails, have a look at the firmness of your lacing; is it keeping your heel right to the very back of the shoe? If not, firm them up. Use the last eyelet (the holes your laces go through) - we almost always neglect this one and yet it can make a big difference. Or try this lacing technique. Then let me know if it helped or not ... please, I'm curious to know if this is as relevant to the ultramarathon running community as it is for the general running community!

6) Friction reduction worked better for easing soreness under the ball of the foot compared to cushioning

Several ultrarunners complained of soreness under the ball of the foot. Clinical judgement generally saw me apply either 3mm Poron (cushioning) under the insole, or an ENGO rectangle patch (friction management) on top of the insole, or both. Two things surprised me:

1. The non-tolerance to the cushioning. Not only did it not help, it tended to make things worse. This could have been because many shoes had substantial cushioning build into their structure already (think Hokas). Or it could have made the shoe too tight due to the additional bulk.
2. The success of the ENGO patch.

There were occasions when I assumed cushioning would be the best intervention and yet friction management performed better. There was one runner who didn’t like the lack of traction with the ENGO, and this is understandable because it has the potential to reduce traction across the metatarsal heads too much. For this reason, I usually advise caution with full width friction management across the forefoot. Better to use a smaller oval patch and target just the sore area. However, on the whole, the amount of relief this provided without consequence surprised me. I’ll exercise a little less restraint in using this in the future during 6-day ultramarathon running events.

To alleviate soreness under the ball of the foot: either ENGO (on top) and/ or Poron (underneath).

ENGO (thickness 0.38mm) seemed more successful for generalised soreness across the ball of the foot.

Conclusion

Running around a track (rather than running from A to B) proved an excellent race format as my first ultramarathon running foot care experience. It facilitated the preventative / early intervention approach I'm interested in. And by getting feedback every 1.13kms, it allowed me to experiment and have the opportunity to change unsuccessful interventions very quickly. It was a great format for learning. I'm not sure what the runners thought of running around the same track for 6 days though!I get the feeling that as long as they're running, they're happy.