Tag Archives: top of foot pain

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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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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Active-state functional connectivity

Task-positive and task-negative brain networks (Fox et al, 2005)

I’m currently preparing for a talk on a recent paper (Powers et al, 2011) using resting-state functional connectivity MRI to study large-scale networks in the human brain. (Okay, actually I’m procrastinating working on the talk by writing this post.) Different brain regions are anatomically connected via projections from one area to the next, allowing long-range communication across the brain. This functional connectivity can be observed as synchronized BOLD signal in connected regions while a person is at rest or performing a task, and such correlated areas have been found to correspond with functional sub-networks within the brain. For instance, an extensive “task-positive” network (shown in warm colors at right, from Fox et al, 2005) is thought to comprise multiple sub-networks including, for example, a task control system composed of the dorsal anterior cingulate and frontal operculum, and a dorsal attention system involving areas of superior frontal and parietal cortex.

While out for a run yesterday I was struck by the remarkable parallel between such integrated brain systems and our non-brain “networks” of muscle, fascia, tendons and ligaments that coordinate distinct yet complementary functions while we run. Unfortunately but necessarily, this appreciation was triggered by the heightened bodily awareness that accompanies injury. About a month ago during a particularly intense and hilly run, I noticed a nagging tension in both hip flexors. I followed this the next day with a short, easy barefoot run during which a dull ache appeared on the top of my foot. Simply a classic case of the novice barefooter’s too-much-too-soon, right? Over the subsequent weeks, I’ve dealt with recurring minor flare-ups of both these top-of-foot and hip issues and assumed they were unrelated and exacerbated by distinct factors – my continued increase in barefoot / minimalist mileage and hill running, respectively.

But it wasn’t until my monthly sports massage this week that I learned just how connected – possibly causally related – these problems were. As my therapist applied pressure just lateral to my hip flexor a subtle burning appeared in my extensor tendon along the shin and foot. Release of hip pressure … relief of extensor ache. Application of hip pressure … return of extensor pain. And so on. I was astounded by the consistency of this pattern to the point that I even questioned my own sensations. There was an undeniable connection between my hip flexor and extensor, such that tension in one translated into pain and impaired function in the other. Although I’m not happy to report that my “anterior leg network” hasn’t fully recovered, its continued dysfunction has further highlighted the strong connectivity I suspected during the massage. While running a moderate uphill climb yesterday, my hip flexor predictably tightened up. Moments later, an ache appeared along the top of my foot and ankle. Then – just to mix things up, my knee began to burn as I felt my knee cap riding out of alignment. While certainly not a pleasant finale to the run, this sudden cascade of pains clearly demonstrated a deeply integrated anterior chain, from foot to knee to hip – and likely beyond.

Tom Meyers' Anatomy Trains

A clear picture of functional brain organization requires understanding not only the role of single units – a neuron or isolated region, but also the critical interactions between such elements. Similarly, effective communication within and across our musculoskeletal sub-systems, along with an integration of mind with body, is essential to properly function as a runner. The springy tendons of the foot cannot propel us along without power from our quads and gluts, stability from our core, and motor commands from and sensory feedback to the brain, together coordinating a smooth, fluid ride.

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