Irrational fears. We all have them: snakes, heights, public speaking … stress fractures. Runners tend to be a fearless breed, that is until it comes to debilitating injuries we just cannot run through. For me, the dreaded stress fracture has always been at the top of my list of deep, gut-wrenching fears. And considering how my thin, caucasian, female frame and my thousands of miles logged each year put me at an elevated risk, I’ve been pleasantly surprised at how well I’ve avoided this terrifying injury. That is, until six weeks ago. Having survived and mostly emerged from the obligatory stages of post-injury traumatic stress, I now feel relatively well equipped to share my experiences with this runner’s nightmare come true.
So what was the straw that ultimately broke the camel’s, uh … metatarsal? Two-months into a transition back from a perplexing injury in my left foot, I had been slowly increasing mileage and experimenting with a variety of footwear, terrain and barefoot running. Was it the barefoot running? Unlikely. Ironically, given some mild strain along my first metatarsal, I had decided to “play it safe” and take a hiatus from barefoot running the week leading up to the fracture. Ignoring my own advice, I instead switched to running full-time in racing flats.
Was it too much too soon? Possibly, although I had been mindfully transitioning very gradually and cautiously. Despite roughly following the 10% rule (no weekly mileage increase greater than 10%), I had unintentionally completed a particularly taxing week of training. On my first back-to-back run since returning to running I got lost, extending my planned “easy” six-mile trail run into an hour and a half adventure through a canyon. With only subtle warning signs, the fracture appeared just a few days later during an otherwise normal run.
As the term implies, a stress fracture is the result of too much stress to a bone, from any of a variety of causes. In my case I suspect a number of factors were at play. I’m an odd case of an oversupinator and underpronator, failing to complete the normal lateral to medial rolling of the foot during the stance period. Coupled with an unusually tight flexor hallucis longus tendon, my second metatarsal was undoubtedly under excess stress that would otherwise be supported by the stronger first metatarsal. My stressed bones were all the more vulnerable in a minimalist shoe that provided less protection than a standard shoe, yet less sensory feedback than bare feet to warn me of the impending fracture.
I’ve always expected the onset of a fracture to be signaled by a definite aha moment – a sudden, stabbing unmistakable pain. Not so. Rather, the presumed onset of my fracture was accompanied by a gradually increasing numbness in the second toe and a subtle tightness along the top of the second metatarsal, neither of which qualified as painful. A tender, pea-sized lump soon appeared over the metatarsal, which I dismissed as an irritated extensor tendon. The next day, a gentle “recovery hike” sent me to the ER with electricity-like pain and an inflamed, swollen foot. Unable to walk without searing pain, I still vehemently denied the possibility of a fracture, instead self-diagnosing a case of capsulitis. Two-weeks post-injury, an X-ray confirmed the dreaded presence of a full, but non-displaced fracture across the head of the second metatarsal.
Considering the abundance of confusing and often conflicting medical and anecdotal advice, what is the best treatment approach for a rapid, healthy return to running? After researching and experimenting with numerous alternatives, the following proved most effective for my personal recovery.
1. NSAIDs and ice. You should control the unbearable pain and swelling with non-steroidal anti-inflammatories (NSAIDs) and ice, right? Wrong. While they may provide temporary relief, they will likely impair the body’s beneficial inflammatory response critical to healing the damaged tissue. There is now abundant evidence that NSAIDs actually delay fracture healing (Burd et al., 2003; Butcher & March, 1996; Giannoudis et al., 2000) and can often exaccerbate inflammation.
2. The boot. I wore the boot a total of just a few hours, and saw little benefit. While it did alleviate a bit of foot pain while walking, it also misaligned my legs hips and back, making it quite uncomfortable and exhausting to walk at length.
1. Bone stimulation. If I were to attribute my rapid healing to any single factor, it would be low-intensity ultrasound bone stimulation. FDA-approved for treating fractures, bone stimulation is supported by research demonstrating singificantly faster bone healing. I’ve been using an Exogen bone stimulator since week two, for 20 minutes twice daily. They’re not cheap, and if you purchase one from eBay, be sure to follow these guidelines to prevent getting ripped off.
2. Supplement. Bone production requires adequate calcium, vitamin D and magnesium. Even if you think you’re getting enough from your diet, it’s a good idea to supplement for added security. Silica is also important for bone development, with the added perks of promoting hair and nail growth. Anecdotally, since I’ve started taking silica I’ve had to cut my nails twice as often as usual! To reduce inflammation naturally, without the potentially detrimental effects of NSAIDs, try turmeric, ginger or omega-3 fatty acids.
3. Rest and activity. Both are critical for the healing process and it can be challenging to determine the optimal balance. In the early stages when the bone is most fragile, immobilization is critical to prevent displacing the bone or otherwise exaccerbating the fracture. But once the critical stage has passed and the site is less vulnerable to reinjury, gentle movement and mild stress are essential to rebuild strength. An overly conservative rest period may actually delay healing and leave the bone and soft tissue weaker than pre-fracture. Non- or light-weightbearing activities will encourage circulation, increase flexibility and maintain strength while minimizing dangerous impact forces. I’ve maintained some degree of sanity with water jogging, the elliptical and running on an anti-gravity treadmill. Of course, these may not be safe for all fractures; beneficial and detrimental activity may be hard to discriminate and only you can determine your safety threshold. For those with a high pain tolerance like myself (which probably includes most injured runners … isn’t that how we got here in the first place?), a good guideline is to stop any activity that increases your level of discomfort. Note the use of the term discomfort rather than pain. Discomfort indicates you are aggravating the injury, whereas pain is a good sign that some damage has already been done.
As with any injury, the first question we runners ask is When I can run again? Although having just passed week six I’m still not running, my progress has been steady and encouraging, with several landmark transition stages.
0-2 weeks: During the acute post-injury phase I was essentially unable to walk without intense, diffuse pain throughout the foot, extending across the top and ball of the foot and through my first, second and third toes. The foot was hideously swollen and I could easily induce pain by pressing on the fracture site, bending the toe, or under vibration testing. This is by far the most difficult stage, during which you will most certainly want to crawl into a hole and hibernate until it passes. But take comfort – it will pass.
2-4 weeks: The swelling reduced somewhat and I was able to walk for short distances (< 10 minutes). Light exercise like the elliptical and anti-gravity treadmill became feasible. This stage likely corresponded with the formation of a soft callus around the fracture.
4-6 weeks: My most significant recovery occurred at approximately four weeks. I suddenly found myself able to walk for longer periods (up to an hour), and perform forefoot-loading exercises like downward facing dog without pain. I suspect this breakthrough was coincident with the development of the hard callus. A follow-up X-ray at five weeks confirmed the presence of this hard callous, visible in the image as a hazy “ghost” around the fracture location and palpable as a firm lump. But take heed; this sudden improvement can provide a false sense of strength. This callus is in essence a bone-like patch that will be gradually remodeled over several months into permanent, stronger bone, so running on a young hard callus still carries high risk of reinjury. For me, the presence of the callus has been sufficient to preclude running, as the physical deformation from the enlargement has introduced additional strain and even bizarre nerve stimulation in the neighboring metatarsals and toes. While the fracture feels ready to run, the surrounding region is sending a cautious message that all is not yet back to normal.
Irrational by definition, ungrounded fears like sustaining a stress fracture may best be overcome by tackling them head on. Having dealt with frustratingly stubborn soft tissue injuries (achilles and peroneal tendonitis, trochanter bursitis, piriformis syndrome … the list goes on), I’ve found odd comfort in the predictable timecourse of bone healing and the straightforward, logical treatment. With every day of healing, my fracture fear slowly dissolves. The (maybe not so scary after all?) nightmare is gradually morphing into a waiting game, as I count down the final days to my official return to running – free and fearless.