Fracture recovery: Running to rebuild

Of the many running injuries I’ve endured, my metatarsal stress fracture has been the most mentally challenging from which to recover. The internet is repleat with advice on how to treat a fracture: rest, supplements, bone stimulators … everyone has their two cents to offer. Yet there’s a perplexingly disproportionate dearth of information about how to return to running once healing has begun. What’s a safe distance to start with? How quickly can you ramp back up? How do you know if you’re pushing too far? Over the past six weeks, my struggle to answer these questions and ensure a safe return to running has incidentally proven to be an exceptional opportunity to retrain myself to run with greater balance, awareness and pleasure. While this has been a rewarding journey in retrospect, I certainly wouldn’t wish this anxiety-inducing learning process on anyone else. In the hopes of sparing others the same nerve-wracking self-experimentation, let me share a few of the lessons I’ve learned along the way.

When am I ready to run?

Running on a fracture before it’s sufficiently healed can delay recovery, or worse – result in a refracture. So how do you know when you’re in the clear to resume running? A good rule of thumb is to wait until you can hop on the fractured foot / leg without pain … and then wait another week. Everyone recovers at different rates, but for me, this would have been around six weeks post-fracture. However, I developed some uncomfortable nerve stimulation in my neighboring toes that delayed my first run to week seven.

How much is too much?

When returning to running from a muscle, tendon or ligament injury, the rule is simple: if it feels uncomfortable, stop – you’re pushing too hard. Not so with a stress fracture. That ache that first emerged at fracture onset will linger to haunt you throughout your recovery, whispering deceptive messages that you’re exacerbating the injury by running on it. But in fact, a certain amount of moderate physical stress is beneficial – and necessary – to stimulate ongoing bone growth and remodeling. The site will certainly ache, as the bone has not regained its full strength, and the surrounding soft-tissue may be aggravated, but this will gradually dissipate with regular, gentle weight-bearing stress. The key, however, is to be able to discriminate between that lingering harmless ache, and the emergence of a novel injury. While I hear claims that “you never refracture the same site”, there are also countless stories of runners who proceed to fracture neighboring bones or develop compensatory soft-tissue injuries. So while that familiar dull ache may be benign, you should probably take heed of new pain in neighboring metatarsals or that worsening tendon strain.

How should I train differently to prevent another fracture?

A bone becomes susceptible to fracture when the amount of stress to which it’s exposed exceeds its capacity to rebuild and recover. Such imbalances might occur for a variety of reasons, including an aggressive increase in training mileage or intensity, or poor biomechanics that incorrectly redistribute impact forces, for example from improper footwear or compenstation for weakness elsewhere. Whatever the cause, the critical step in preventing future fractures is identifying and correcting the original problem.

Leading up to my fracture, I had recently incorporated regular barefoot running into my already minimalist routine. Upon experiencing some mild achiness along the top of my foot, I made the mistake of giving up barefoot running entirely for a week while increasing my overall shod mileage. Granted, this certainly allowed me to continue running with relative comfort … temporarily. But unbeknownst to me, those shoes were not actually protecting my foot from injury, but rather, most likely permitting me to run with sloppy form while masking the sensory warning signs of an incipient fracture. Since my return to running, I’ve adopted the philospohy that if I can’t safely run barefoot, I shouldn’t be running at all. The beauty of running “naked” is two-fold: 1) You quickly learn to run with optimal form, or you pay for it with blisters, sore calves and strained achilles tendons. 2) Any functional imbalance will become immediately apparent as bare foot kisses bare earth, sending you an invaluable warning of the impending injury.

Barefoot running, Iron MountainI’ve kept my barefoot mileage at approximately a third of my total mileage, incrementally increasing both shod and barefoot mileage weekly (see training log below). Sure, this has kept me in check, restraining me from indulging in long shod runs for which my metatarsal is not yet strong enough. But the real perk is the fun of it. The muscle soreness, tension and anxiety I sometimes feel during my shod runs literally melts away once the shoes come off.

How quickly should I progress?

There are training plans available for every imaginable combination of race and runner, for novices and elites, from your first 5k to 100-milers and beyond. But how much and how hard should you run when recovering from a fracture? Although this is possibly the most critical consideration for a safe recovery, it’s also one of the least frequently addressed. To remedy this, I’ve shared below the ad-hoc routine I’ve followed, which has ensured a happy and (thus-far) healthy return to running.

But please take heed of a few cautions before launching into your first run. First, as every runner will recover at different rates, it’s impossible to set a one-size-fits-all recovery plan. For reference, before injury I would regularly log 60-70 miles per week. If your norm is well above or below this, you’ll obviously want to tailor your progression accordingly. Second, I’ve taken advantage of this fresh start to concurrently learn to run with heightened awareness and improved form. To this end, a significant amount of my mileage is fully barefoot, while the rest is run in minimalist shoes (3-6 ounces; 0-7 mm heel-toe drop). How this affects my progression I can only speculate; intuitively one would assume it would require more conservative training, yet in fact, I suspect the benefits of improved biomechanics might actually outweigh any risks. As a final caveat, note that these past six weeks haven’t been without considerable “growing pains”. Almost every run has been accompanied by some degree of achiness near the fracture site, along with mild aggravation in the surrounding muscles and nerves. These symptoms, if mild, are typical and should improve as the injury continues to heal.

Unlike with other injuries, when it might be optimal to couple longer distances with more rest days, I found consistency ciritical for fracture recovery, and therefore opted for higher frequency, but shorter runs. The table below shares these essential measures:

Run frequency: how many days run per week.

Longest run: distance of my longest single run each week, separately for shod and barefoot runs, and combined, since I often finish my shod runs with some barefoot miles.

Total mileage: weekly mileage separately for shod, barefoot and combined (shod + barefoot).

Fracture_recovery_log

And just because I love graphs …

Mileage_graph
These are just the thoughts of one runner … one still experimenting, still learning, and crossing her fingers that these words will be validated by a lasting triumphant return as a stronger, smarter, healthier runner. A runner still looking for all the help she can get, and curious about your own experiences recovering from fractures – your successes, frustrations, tips and concerns – so please share!

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4 thoughts on “Fracture recovery: Running to rebuild

  1. John says:

    In your opinion do you think that vitamins and supplements can make a difference in healing bone fractures whether they be complete or incomplete fractures?

  2. Emilie Reas says:

    Based on the evidence that certain vitamins and minerals (calcium, Vit D, magnesium, silica, etc) promote bone strength, yes I would suspect they would also enhance fracture healing. However, I’m not sure what research has been performed to test their efficacy specifically for fracture healing, versus just long-term bone health.

  3. mylestones says:

    I know this is an old post, but I just have to say THANK YOU for sharing the details of your return to run. I’m in my first week of returning to run after a 2nd metatarsal sfx and have been struggling to decipher the “residual” pain from the not-healed-enough pain. Your post really helped provide some good perspective. I still have tenderness at the top of my foot near the site, but no real pain or discomfort when hopping or running. And it’s been freaking me out! Today I even felt some pain while deep water running–so weird since I never felt any discomfort during pool runs even in the earliest stages of the injury when walking still hurt. Anyway, it’s so helpful to read and learn from the experiences of others, so thank you!

  4. Derl says:

    I was 8 weeks in a boot for a fifth metatarsal fracture. 10 weeks no running (and no elliptical even for 8 weeks). Now 12 full weeks out from fracture I am running again. Brand new trail shoes with rock plate and all soft surface easy running. But I get a definate ache in my foot. And like mylestones says tenderness on top of foot. And I’m paranoid as crap about rebreaking. I mean it really aches but dissipates.

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