Tag Archives: recovery

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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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.

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Running the Minimalist Road: Worth the Risk?

Alcohol. Politics. Relatives. Ice cream. The common thread? All are best enjoyed in moderation (just kidding, family … I love you all dearly!). Running, on the other hand, is one activity we should feel free to indulge in to the extreme. Maybe not in terms of mileage, speed or intensity, but in terms of foot support – or more precisely – lack of support. Just a year or two ago I would have argued defiantly with the me of today, having been skeptical of both barefoot zealots and advocates of cushy, motion control shoes. It was from this conservative, middle-of-the-road stance that I launched my minimalist experiment, gradually transitioning to lighter, less supportive running shoes, ranging from huaraches to racing flats.

Readers and friends will attest to the fact that this past year has been undoubtedly the most challenging of my fifteen-year running history, strewn with an unwelcome and unprecedented chain of frequent, relentless running injuries. As recent as a month ago, I began to seriously reconsider the tradeoff between the risks and benefits of my attempted transition to minimalism. Sidelined once again, this time from intense calf strain, I picked up Barefoot Ken Bob Saxton‘s book Barefoot Running Step by Step for some inspiration. While I typically avoid promoting specific products or gear, this man is not only the father of barefoot running and a running guru, but also a witty, endearing writer. Reading this book at the nadir of my frustrating recovery generated the perfect storm. Running should be easy, fun and painless; if it is anything else, you’re doing it wrong. My recent runs, in contrast, were filled with with aches, tension and anxiety. While I noticed a definite improvement in my form, some lingering bad habits in conjunction with reduced protection from less shoe left my bones, tendons and muscles dangerously vulnerable. Clearly something had to change.

Desperate, but willing to experiment as always, I ditched the fear that my feet were still weak from injury, ditched my goals of rebuilding my pre-injury marathon-level mileage, and ditched my shoes … my flats, my vibrams, my sandals. Starting at just half a mile, my feet were laden with blisters and my spirit was humbled by my evidently horrible footstrike. Despite having transitioned fully to an otherwise barefoot lifestyle, the layer of foot protection I consistently relied on while running was blocking a source of sensory feedback essential to reap the full benefits of barefoot running.

Although I’ve run bare – or nearly bare – countless times before, these previous efforts had been lacking two critical ingredients: 1) Awareness of my form and 2) Mentality of a novice runner complete with a willingness to progress SLOWLY. With a touch of restraint and patience, lots of intentional relaxation and a boatload of mindfulness, over one month I’ve developed the ability to run four miles completely bare, blister-free and often with an obnoxious grin plastered across my ecstatic face. Once I abandoned the preconception that my feet still weren’t strong or tough enough, the transition was remarkably easy. The secret, I quickly discovered, is first and foremost to relax and run however feels fun and easy. This revelation was aided by several indespensible tips from Ken Bob’s “cheat sheet”, such as bending the knees, landing first on the forefoot followed by the heel and toes, a forward lean that propels you into a falling motion, and steps so light the feet barely kiss the ground. The greatest challenge hasn’t been mastering the technique or covering the mileage; rather, it’s been fighting the inevitable “barefoot running exuberance syndrome”. I’ve addressed this by adhering to the following super-conservative plan (of course, this isn’t ideal for everyone, but is working great for me!):

1. Run at most every other day.
2. Start at 0.5 miles, increasing by no more than 0.2 miles per run.
3. Stop at the first sign of pain, and don’t even think of increasing mileage if the last run wasn’t awesome.

Having followed steps one and two religiously, I have yet to worry about step three.

By venturing beyond the comfort zone of minimalist running, I’m finally seeing the logic behind many of the claims from other barefooters that I had previously dismissed as radical propaganda. Running barefoot doesn’t guarantee correct form or injury-free running, but it does make it a heck of a lot easier. The chronic hip and calf tightness I’ve felt for years literally melts away when my shoes are off.

The sidewalk greeted my feet with this message after my most recent barefoot run.

And best of all, the skills I’m learning bare are translating into easier, healthier, more fun shod running as well. This past month of supplementing my longer shod runs with short barefoot runs has facilitated a successful recovery from months of injury, as I’m learning to run in shoes with the same ease as without them.

So if you’re thinking of exploring minimalist running but are afraid to bare your soles, I urge you to consider … is moderation really worth the risk?

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Back to basics

In the long run, coping with life’s challenges and hardships can provide unforeseen benefits such as a more grounded perspective and sense of empowerment. Similar strengthening can also occur during a runner’s battle with injuries. For instance, I’ve emerged from prior injuries having learned critical lessons in patience and adaptability. Yet this growth has often also been accompanied by an awareness of concomitant physical losses, including reduced strength and stamina, missed races and training setbacks. My most recent injury, however, has demonstrated that when the injury is severe enough and the struggle to recover is sufficiently trying and lasting, even these physical losses can be converted into gains. How, you ask, could a five-month hiatus from running, ignited by a metatarsal stress reaction followed by a lateral foot injury and then severe calf pain, turn one into a stronger runner? By radically transforming their technique and definition of running.

Too often we address injuries with a patch; we treat the pain and inflammation with drugs, ice, orthotics, creams and bandages, until the symptoms disappear, without ever understanding how they originated in the first place. A frustratingly stubborn recovery, for which these quick fixes are ineffective, can force a deeper understanding of the biomechanical imbalances that frequently lay at the source. While each runner is unique and must listen closely to their own body to learn such lessons, let me share a few personal experiences that may strike a chord with some readers.

As the cause of my injuries was not immediately apparent, I initially tried to treat them while adhering to my ingrained, unhealthy running habits. Only when I finally realized this old routine would no longer cut it, I launched a new approach to my recovery with a clean slate. I abandoned my goal to rebuild mileage and became determined to simply learn to run again – correctly and painlessly – which I’ve approached by incorporating frequent short, easy and mindful barefoot runs. This simple tool not only teaches proper running biomechanics, but has also revealed subtle differences between my shod and barefoot running form that have likely been the culprit of injurious, inefficient running.

Metatarsal stress reaction

The ignition to my train of injuries, a stress reaction in my left metatarsals, was assumed to be a classic result of too many miles in too little shoe, before my feet were strong enough. Yet this explanation seemed at odds with my intentionally very gradual, cautious transition to a minimal shoe and foot strengthening efforts through barefoot walking. A recent barefoot run confirmed that the culprit may not have been the miles and weakness, but rather, poor running form transferring undue stress to the forefoot. During this particular run along a harsh urban route – my only unpleasant barefoot run to date – I adopted a rigid, tense and sloppy foot strike as I traversed uneven, rough terrain. The consequence was an aching, swollen top of foot, disturbingly remniscent of my old injury.

Lateral foot tightness

Just as my stress reaction was healing and I resumed gentle running, I became plagued with a nagging ache along the lateral foot (presumably the flexor digiti minimi brevis / abductor digiti minimi muscles), from the cuboid to the base of the fifth metatarsal. To no avail, I tried massage, ice, heat and running on every imaginable surface, from concrete, dirt and grass to an Anti-gravity treadmill. It wasn’t until replacing my already minimal shoes with an even lighter, less cushioned and less supportive shoe that I found relief. The subtle arch support of my prior pair had evidently been encouraging excessive supination, placing undue strain along my lateral lower leg and foot.

Calf strain

Finally recovered from my foot ailments after months of rest, I launched back into running cautiously but soon discovered my calves were not up to the task. A month of running with tight calves culminated in intense pain and swelling that spread throughout my calf, ankle and foot, forcing me into another two-week running hiatus. Despite common logic that weak, strained calves would benefit from cushion, support and soft surfaces, I discovered a peculiar phenomenon that the calf pain appeared instantly when running in shoes, but I could run painlessly barefoot … on concrete.

Could it be that each of these injuries did not in fact result from too many miles, aggressive training or insufficient support, but instead stemmed from running with unnecessary tension and improper biomechanics? 

Admittedly I’m eagerly awaiting the days when I can enjoy endless miles with full strength and endurance; but for now I’ve discovered a new source of joy from running. Rather than progressing in terms of mileage or speed, I’m gaining satification from my gradual improvements in form which allow me to run free of pain, tension and injury. These lessons have spawned a new era of growth in my evolution as a runner, one marked not just by improved biomechanics and strength, but also by a rekindled appreciation for the pure joy of running.

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Altered runiverse

I’m not one for elaborate running gear or gadgets. It’s my personal preference not to run with music, a watch or GPS device, and in all honesty, I find the gimmicky marketing for schmancy running clothes and overpriced shoes quite disturbing. However, I recently discovered one running gadget worthy of shameless promotion. It is a genuine godsend to injured running addicts, such as yours truly.

Alter-G anti-gravity treadmill

The wonder-device to which I refer is the Alter-G anti-gravity treadmill. Yes, you heard me … anti-gravity ... as in, reduces the gravitational force on your lower body to allow you to run or walk with forces equal to a fraction of your full body weight. The mechanism is downright ingenious: the runner wears rubber shorts that zip into an inflatable “capsule” attached to the treadmill. The treadmill calibrates to the runner’s weight and pumps air into the region surrounding the legs, providing a subtle supportive uplift. The amount of inflation, and thus the degree of support, can be controlled to allow the user to run at 20-100% of their body weight in 1% increments. This allows runners battling injuries that prohibit weight-bearing activity, such as tendonitis or bone fractures, to run without pain or risk of further injury. The price tag isn’t cheap, ranging from $30,000 -$75,000 depending on the model. But Alter-G’s are continuing to pop up at gyms and medical facilities across the country, many of which offer pay-per-use options (usually also pretty pricey!) to the public.

My first indulgent Alter-G run was at M2 Revolution, a cycling gym in San Francisco. More than a month into a foot injury (metatarsal stress reaction) and in the throes of deep running withdrawal, the experience served as both reassurance that my body was still capable of running and an exhilarating reminder of why I love to run. Incredibly, despite its highly effective external support system, the treadmill allows you to run unrestricted, maintain a normal gait and foot-strike, and actually get a decent cardiovascular workout. In fact, my weakened quads and calves felt fantastically sore the next day!

Progression from 36% to 73% body weight

Thanks to the wonderful staff at the office of Dr. Ian Purcell in San Diego, who personalized a discounted pay-per-use package deal, I’ve been able to continue feeding my running addiction while successfully rehabilitating my foot. I’ve run on the Alter-G 6 times over the past few weeks and find it a great way to objectively monitor my recovery. For example, I was able to comfortably complete my first run at 36% body weight. My most recent run, 18 days later, was at 73% bodyweight, equivalent to an average gain of 2% body weight per day. Beyond providing my much-needed running-endorphin fix, the consistent progress I’ve measured with this tracking system has also shone a light at the end of the tunnel, keeping me sane and optimistic through this otherwise unpredictable recovery process.

Now who has an extra $30k they’re dying to spend?

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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?)!

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PriTSD: Post-running-injury Traumatic Stress Disorder

For a while now, I’ve been intending to write on every runner’s favorite topic – injuries. I’m certainly no sports medicine specialist, but let’s face it – my share of close encounters over the past several years makes me almost as qualified. Having stayed remarkably healthy over the recent months, my original vision for this post was to highlight my invaluable (ehem) insights into injury prevention. Had I written that post and adhered to my own advice, maybe I would not presently be discussing post-injury recovery and running withdrawal.

December 26, 2011. House-bound by the bitter cold and snow but needing to release some pent-up holiday energy, I resorted to a treadmill run and treated myself to running the final 4 miles barefoot. A subtle ache appeared on the top of my left foot which, given my surging endorphins, I of course ignored. Over the ensuing two months, this foot issue re-emerged several times without progressing beyond mild discomfort. Assuming myself invincible, I continued to push my limits, simultaneously training for my next marathon and increasing my mileage in minimalist footwear.

Lateral ankle

February 18, 2012. While on my weekly long run, the foot ache re-appeared, but this time worsened from mild annoyance to a cautionary, progressive ache. Of course, I convinced myself it was nothing and completed the 22 miles. The extent of the damage was only evident while attempting to run two days later, each step coupled with a shooting pain along the top of my left foot and ankle. I had run myself into a full-blow case of extensor digitorum longus tendonitis.

Today. Three weeks later and still unable to run. It may appear ludicrous that runners voluntarily run themselves into such debilitating conditions. Yet I’m convinced the very qualities that make us so vulnerable to overuse injuries are also what make us so well-suited for distance running. We persevere, adhere religiously to our goals and tend to have remarkably high pain tolerances. Running is a phenomenal way to heighten bodily, mental and environmental awareness; however, when those sensations are overwhelmingly positive and rewarding it can be exceedingly difficult to detect subtle messages of injury or imbalance. It is therefore crucial to heed those quiet warnings which we too often acknowledge only in retrospect.

These past three weeks have been a genuine physical and emotional rollercoaster. At the risk of sounding melodramatic, for a runner the post-injury period can remarkably parallel the aftermath of other major traumatic experiences. The process begins with denial, during which you stubbornly insist the condition is minor, fleeting and can be run through. This is followed by acceptance of the injury’s severity but also shock and irrational fears that you will never run again. This can also coincide with veritable physical withdrawal, making this the most difficult stage. For me, going from running 60-70 miles/week to zero sends me into a physical and mental downward spiral. The crash is characterized by a paradoxical combination of lethargy and anxious restlessness. During my first post-injury week I essentially shut down, my motivation and productivity in lab and school plummeting.

Eventually, healthier coping mechanisms take hold, allowing you to start taking proactive steps towards recovery. In week two I replaced the couch with cross-training, forcing myself to go to the dreaded … gym. With no apparent improvement from the standard RICE (rest, ice, compress, elevate) approach, during week three I began to seek alternative methods to expedite the healing process. I’ve begun acupuncture, homeopathy (ruta graveolens) and K-laser therapy and have since noticed marked improvement – namely increased range of motion, reduced inflammation and the ability to walk pain-free! I can only speculate whether this change is attributable to any one of these treatments, a placebo effect or simply reflects the natural time-course of my body’s recovery process. Regardless of their source, such improvements are a comforting reminder of the body’s innate healing powers and the critical importance of a positive and proactive approach towards recovery.

I won’t lie. Three weeks and counting of no running is driving me crazy. But I suspect these periods may be invaluable for an endurance athlete’s long-term growth, complementing our physical stamina with invaluable training in psychological endurance. Stay tuned for progress reports … I foresee a strong tendon and lots of running in the near future!

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