How to Evaluate a Potential or Actual Injury

Question: I completed my first 400K last weekend. After the ride, I noticed that my big toe on each foot has a blue half moon under the nail on the lower, outer quarter of the nail, which I assume is blood. I have typical soreness in my feet, but no pain. I am preparing for my first 600K in two weeks. Are these discolorations an indication of an emerging problem, which should send me to a doctor or delay my planned ride? —Fred Corsiglia

Coach John Hughes Replies: First, Fred, congratulations on completing your first 400K brevet and getting ready for your first 600K!

(A brevet is an event on a pre-determined course that must be completed within a time limit. Fred had to complete 400K (250 miles) within 27 consecutive hours, which includes both riding time and all off-the-bike time. Fred will have to complete the 600K within 40 consecutive hours.)

You’re asking a great question. Last week I introduced the concept of a “showstopper.” A showstopper is anything that causes you to interrupt your season, not do an event or to stop an important ride before you’re ready to stop the ride. Roadies often ask me if X is a potential injury that could become a showstopper. In my over 40 years of riding, I’ve suffered more than a few injuries. As a coach and a crew member, I’ve dealt with many, many more problems. Here’s how I evaluate a potential injury.

Warning: If in doubt, see a health care professional! I am not a trained health care provider, although I am trained in backcountry first-aid and have decades of experience with cycling injuries. If ever in doubt about an injury, though, see a doctor!

How To Do the Evalutation

Using Fred as an example, here’s how to evaluate whether a potential or actual injury is a showstopper.

What are the symptoms?

Where is the injury? Is it in a point of contact (butt, feet and hands) or in a muscle or connective tissue? If it’s in a point of contact, like Fred’s, it probably isn’t a showstopper. If it’s in a muscle, a tendon (which connects the muscle to bone) or a ligament (which connects bones to each other) it may be a showstopper.

Is it painful? Pain is the body’s warning system that something isn’t right. How strong is the pain on a 1 – 10 scale, with 1 being barely noticeable and 10 being the worst pain the roadie could imagine? The higher the pain level, the more likely the injury is serious.

Is it just painful on the bike, or also off the bike? If it also hurts off the bike, it’s probably more serious. Is the pain getting worse? If so, it’s probably more serious. Fred reports “typical soreness in my feet, but no pain.”

Is it inflamed? Inflammation is the body’s way of protecting an injury. Inflammation stiffens the affected area and makes movement more difficult. If it’s inflamed, the injury probably is more serious. Fred reports no inflammation.

Are there other symptoms? Red streaks near an injury, and a fever, are both signs of infection.

How did it happen?

Suddenly or slowly? If the injury happens quickly – for example, a pulled muscle – it is much more likely to be a significant problem, whereas if it develops more slowly, it’s less likely to be a big problem.

Probable cause. Is the injury the result of pressure on the nerves in the ball of the foot, resulting in a sensation of hot feet? Or pressure on the hands, resulting in numb, tingling or weak fingers? Or is it a saddle sore caused by friction? Most saddle sores are caused by pressure on the sit bones, not friction, so correct diagnosis is important.

If the affected area is a muscle, tendon or ligament, how did it develop? Is the injury the result of over-exertion on a ride? For example, a roadie doing a ride that is significantly longer or a climb that is significantly harder than the rider is trained for? Or did the injury develop over time, starting with a bit of a sensation that developed into ongoing pain?

Additional questions to ask

Is the injury part of your “power train?” Is the affected area a muscle, tendon or ligament in the leg(s)? If so, continuing to ride may make it worse.

How serious is it? If the affected area is inflamed and/or the pain level is above about a 4, then it’s serious, and continuing to ride may make it worse.

Could it become a health issue? Is the problem an open sore that could become infected or an already infected hair follicle that could become worse?

Could it be treated simply? An open sore should be cleaned, an antibiotic ointment applied, and the sore should be bandaged. (Neosporin has three different antibiotics, one of which may cause an allergic reaction. Doctors recommend polysporin, which only has two antibiotics and won’t cause an allergic reaction.)

How important is the event or season? If a roadie has planned the season around and trained for specific events, such as century, a tour or a brevet, then continuing in spite of an injury may be worth it in order to achieve the goal.

What are the consequences? Here’s the caution to just pedaling on and ignoring the pain. Will it become a chronic problem?

Diagnosis of Fred’s toes

When a roadie pedals with a round stroke rather than a flat foot, here’s what happens. As the foot is at the top of the stroke, the heel is down and the toes are pointed up slightly. At the bottom of the stroke the ankle flexes, pointing the toes down to keep applying power around the pedal arc. Then, when the foot comes up on the back part of the stroke, the heel drops and the toes come up.

Here’s what I suspect caused Fred’s problem:

With each revolution, his big toes were pushed up against his shoes as his heels went down toward the top of the stroke. The result was bruising that developed over time. According to the Mayo Clinic, “Most bruises form when small blood vessels (capillaries) near the skin’s surface are broken … When this happens, blood leaks out of the vessels and initially appears as a black-and-blue mark. Eventually your body reabsorbs the blood, and the mark disappears.” (On the Internet there are many health-related websites with varying degrees of accuracy. The Mayo Clinic is an excellent source of reliable information.)

The location of Fred’s bruising could be the result of different factors. During long rides, a roadie’s feet naturally swell, which puts pressure on the feet where they contact the shoes. (By the way, this is what causes the sensation of hot feet, not external heat.) The design of Fred’s shoes may concentrate the pressure on the affected spots on his big toes. He may pronate a bit or have a high arch, which would put more pressure on the outside of the big toes. He may also curl his toes slightly, which would put more pressure on the lower part of the nails.

Some experience-backed injury advice

Lon Haldeman’s advice. My longtime friend Lon Haldeman has set multiple transcontinental cycling records and leads cycling tours across the U.S. When I was racing in the Race Across AMerica in 1996, I developed severe saddle sores, open wounds under my sit bones that had to be bandaged every night. The pain was a 5 or a 6 whenever I got on the bike and sat down. Lon told my crew, “Don’t let John quit because of anything that will heal in two weeks or less.” Every night, the nurse on the crew applied antiseptic and a topical anesthetic, bandaged the sores and gave me over-the-counter pain meds around the clock, careful not to exceed the recommended dosages. I whined and cried – and crossed the country in 11 days, 20 hours.

“Heal in two weeks or less.” This is the key point. Even if it’s a painful injury to the power train, rather than just a point of contact, and if it will heal after a couple of weeks off the bike, then it doesn’t have to be a showstopper. But if it could become chronic, don’t be hero!

How do you know? You can assess the relative importance of continuing during an event or a season, and your own pain tolerance; however, seek medical advice to determine how big a problem something could become. On RAAM I had a nurse with me who assured me it was, literally, just a pain in the ass.

What should Fred do?

Fred’s problem is a point-of-contact injury, not part of the power train, and it isn’t painful. If he doesn’t make any changes, then riding the 600K may aggravate it so that it becomes painful. Fred has set a big goal for 2017: building up to and completing a 600K in less than 40 hours! If he’s willing to risk painful toes, then he could choose to ride the 600K.

Fred can’t get any fitter by riding lots of kilometers between the 400K and the 600K. He’s built all the necessary endurance so that for the next several weeks he should taper to recover fully from the 400K and allow his toes to start to heal, although they may not be fully recovered by the 600K. See my column How To Be on Form for a Big Event, which describes how to taper.

Since the cause is probably repeated pressure on his toes, Fred could take steps to relieve the pressure. The simplest is to loosen his shoes, particularly the toe box. For next season he could get shoes that have a larger toe box or are a size larger. (My randonneuring shoes are a size larger than my normal riding shoes.) With the 600K only a couple of weeks away, now is not the time to change shoes.

(As a pre-emptive measure Fred is testing riding with sandals on short rides and will take his sandals to the overnight stop on the 600K in case his toes start to bruise again from his shoes.)

If Fred or any roadie is ever not sure about whether a problem is, or has the potential to become, serious – see a health care professional.

For more information, see my eArticle Preventing and Treating Pain in Cycling’s Pressure Points.