Tag Archives: metatarsal

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!

Tagged , , , , , , ,

Fracture fears: A nightmare comes true!

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.

CAUSES

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.

SYMPTOMS

X-ray 12 days post-injury showing fracture at the head of the 2nd metatarsal.

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.

TREATMENT

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.

Avoid:

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., 2003Butcher & 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.

Do:

Exogen bone stimulator

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.

RECOVERY

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.

X-ray at 5 weeks shows a hazy “ghost” indicative of a hard callus.

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.

Tagged , , , , , , , ,

Adventures in healing

Today marks the 8 week anniversary of my perplexingly stubborn foot injury. Had I known back in February that I would still be unable to run today, I likely would have resigned myself to a period of springtime hibernation. But every day brings new reasons for optimism and I can now confidently report having entered a stage of progressive recovery. In retrospect, the unpredictable ups, downs and surprises of this frustrating period have also been immensely character-building.

Like many runners, I tend to have an inflated sense of how in touch I am with my body; I am thus continually humbled by how poorly I sometimes interpret its messages! If you read my last post, you’ll recall that I initially self-diagnosed my top-of-foot pain as extensor digitorum longus tendonitis. However, after 6 looooong weeks of unsuccessfully treating for tendonitis, I began to suspect a more serious injury … could it be a dreaded metatarsal stress fracture? An MRI revealed no clear fracture line, but showed “abnormal signal intensity” throughout the foot, reflecting edema in the bone marrow, consistent with a diffuse stress reaction (for a great review of stress fractures and reactions in athletes, see Fullem, 2012). Oddly enough, this finding came as a huge relief, finally providing an explanation for my excruciatingly slow healing. No surprise that treating weakened bones for tendonitis would be completely ineffective!

At the same time, this diagnosis taught me a critical lesson. Equally important as listening to your body and heeding signs of incipient injury is accepting you don’t always have the answer, and remaining open to all potential causes of a problem. My symptoms appeared perfectly consistent with tendonitis, and perfectly inconsistent with a fracture: aching that moved around along the path of the tendon from shin to ankle to top of foot, but no swelling or pain upon pressing the metatarsals. With an athletic history void of fractures yet scattered with tendon issues, I was convinced this was just more of the same. But to my surprise, under the combined stressors of marathon training and aggressive transitioning to minimalist running, my metatarsals gave out before my tendons.

Over the last 2 weeks I’ve conducted extensive research which has led me to incorporate several new treatments. Although it’s impossible to attribute improvements to any one intervention, together the following appear to have been highly effective at promoting healing in my stressed metatarsals:

Supplements
During injury recovery, the body requires additional nutritional support beyond the demands of normal maintenance to ensure active repair of damaged tissue. For bones, this support includes excess calcium, with vitamin D, magnesium and vitamin K, all of which are essential for building strong bones. Silica has also been shown to promote bone health (Carlisle, 1981Jugdaohsingh et al, 2004; Seaborn & Nielsen, 2002) and as a nice side effect, purportedly also improves hair, nails and skin (although I have yet to notice newly lush locks or a vibrant complexion!). In addition, I’ve been supplementing with glucosamine-chondroitin and omega-3’s for joint support and inflammation control, respectively. I’ve also become rather obsessive about maintaining a balanced diet rich in vitamins, minerals and protein.

Bone stimulation
There’s considerable evidence that stimulating fractures with ultrasound can accelerate bone healing (Heckman et al, 1994; Nolte et al, 2001). I purchased a bone stimulator (Exogen 4000) a week ago and – coincidentally or not – have experienced the most marked improvement yet over this past week. Such devices are relatively pricey and not easy to track down (I found mine on Ebay), but are user-friendly, FDA approved and scientifically validated.

Homeopathy
Comfrey, or Symphytum officinale, is commonly referred to as “knitbone” due to reports of its phenomenal ability to heal bone fractures. I have been applying a comfrey salve topically to the foot as well as taking a homeopathic dose of symphytum multiple times a day.

Activity
The traditional prescription for stress fractures or reactions is complete rest from all forms of weight-bearing activity, often including a boot for walking. For later stages of recovery I’ve seen conflicting advice, with some therapists suggesting the incorporation of pain-free weight-bearing exercise to encourage strength building. As a firm believer that our bodies are more resilient than we’re often aware and under some circumstances are most nourished by active healing, I have opted for the less conservative course. Granted, during the first 6 weeks, my decision to use the elliptical machine, walk and hike (barefoot of course!) was based entirely on a misdiagnosis of tendonitis. Now knowing the state of my bones at this early post-injury stage, I suspect this excessive activity almost certainly delayed my healing. Since my foot has advanced beyond its original highly vulnerable state, I currently follow a simple guideline: engage in any activity that does not cause discomfort. Given my high pain tolerance, I set my threshold at discomfort rather than pain. Running through “discomfort” is what triggered this injury in the first place! This approach currently permits me to walk, do the elliptical and one other secret indulgence to be shared in a coming post (intrigued, aren’t you?)!

Tagged , , , , , , , , ,