Avoiding Lesser-Known Injuries

This is just part of our coverage of this year's Philadelphia Marathon. You can read all of the articles at at www.philly.com/marathon2012. And don't forget to join us there on race day to follow the action.

By Alfred Atanda, Jr., M.D.

When I was a sports medicine fellow at the Rothman Institute, I had the privilege of serving as an assistant physician to provide medical coverage for the 2010 Philadelphia Marathon. Personally, I have run hundreds of miles in my lifetime. I’ve also had various injuries over the years, as I have played competitive soccer for the past 25 years. However, I didn’t have a lot of personal experience with competitive distance running and the physical toll that it takes on one’s body.

As a sports medicine orthopedic surgeon, I have treated many recreational athletes that have sustained running injuries. But what my six or so hours in the medical tent at the Philadelphia Marathon taught me was that running 5-10 miles per week in the mornings before the kids wake up, or on the company treadmill during your lunch hour—and competing in and training for a marathon are two totally different things. 

A lot of the injuries and ailments that I treated were things that one would expect such as muscle cramps, ankle sprains, groin strains, and tendonitis.  However, there are several injuries, both minor and severe, that one may not expect to see in the medical treatment tent of a marathon.

Toe Nail Injuries/Foot Blisters

Your feet are quite susceptible to injury during a marathon. The repetitive action of pounding the pavement for several hours at a time eventually takes its toll. Toe nail injuries and blisters, although not expected, plagued several runners that I saw that day. The big toe, or hallux, is susceptible to a nail bed injury since it’s higher and extends out further than the rest of the toes. If the toenail gets ripped up, or avulsed, it is usually quite painful. Fortunately, the nail bed only gets pulled up partially and doesn’t result in any long-term permanent damage.

Blisters on the feet result from excessive rubbing between the skin of your foot and socks/shoes. This typically occurs on the balls of your feet or on the sides where your feet are widest. If severe enough, blisters can sideline you on the day of the big race.

Most people realize that they are developing nail bed issues or blisters while they are training and deal with them accordingly. However, it is quite plausible that the first time you will encounter these problems will be the day of the marathon. Other than good luck, ensuring that you have proper footwear is the only thing that can prevent these issues. I would make sure that you have relatively new shoes that fit appropriately and are designed for distance running. Also, be sure to wear ‘running’ socks designed to keep feet dry and wicking away moisture.


You would think that after you’ve spent months training for your 26.2 mile trek that you would know how to regulate your fluid intake while running. Yet some of the most common complaints that we encountered on marathon day resulted from dehydration, fatigue, and heat exhaustion. Your body needs ample fluids and electrolytes in order to power your muscles for several hours during a marathon. During training, factors such as overactive nerves, adrenaline, anxiety, and lack of sleep aren’t usually present the way they are on the morning of a big race.

Symptoms can range from fatigue, dizziness, nausea, vomiting, synope, and muscle cramps; all things that you may not associate with poor fluid intake. You can’t really control adrenaline and anxiety, but you can make sure that you get a good night’s sleep the night before. Also, it is not adequate to just drink lots of water, but you need to ensure that you drink fluids rich in electrolytes such as Gatorade.


Rhabdomyolysis, or “rhabdo”, is a condition where skeletal muscle tissue breaks down and releases muscle protein, myoglobin, into the blood. There are a wide range of causes such as infection, metabolic disturbances, crush injuries, excessive inflammation, hyperthermia, alcohol withdrawal, or prolonged seizure. A cause that is most important to the long distance run, however, is extreme physical exertion, particularly in states of dehydration. A runner may find herself feeling cramps, achy, and tenderness of the affected muscles.

With continued muscle breakdown nausea, vomiting, confusion, abnormal heart rate, and shock may ensue. The runner’s urine may turn a dark, tea color as myoglobin is filtered and excreted by the kidneys. Adequate hydration and maintenance of electrolyte balance can help prevent rhabdo.

After months of training, the last place you want to be is side-lined in the medical tent on race day. But now that you know the signs and symptoms of some common (and uncommon) ailments that can plague marathon runners, be sure to take the proper steps to avoid hanging with the docs after the race!

Alfred Atanda, Jr., M.D., is a pediatric orthopedic surgeon and sports medicine specialist at the Nemours/Alfred I. duPont Hospital for Children and is the surgical director of the Sports Medicine Program.