Friday, May 31, 2013

Dealing with a Stress Fracture

Unfortunately, I've picked up a stress fracture in my ?3rd metatarsal of my left foot. Yeah, I know, it sucks.Training was going really consistently and I was hitting some good intensity and doing some great strength workouts. I had a little bit of soreness in my left foot for a week or so. Not the kind of soreness you really take notice of, though. Then, on a downhill return doing hill repeats BAM - something really hurt. I had to pull up and walk back to my car. I knew there and then that something was up and I had a nasty feeling it was a stress fracture in my foot which is a common overuse injury among runners. I made it back home later that evening (I was in Wollongong at the time) and got busy Googling. I didn't find a whole lot of related info for triathletes, so I thought I would put something together as a little resource for later on.

'What's a stress fracture, and how'd I get it?'
A SF is an overuse injury occurring when muscles become too tired to absorb shock. The result is energy from running (or other stress loads) is then transferred more by the bone which causes a tiny crack called a stress fracture. More than 50% of stress fractures occur in the lower leg (i.e. ankle and foot) and, for runners, that usually means metatarsals 2-5, or, in the tibia (shin). Keep in mind, though, there are 26 bones in the foot and they're also suseptable.

Commonly, SF's are cause by a rapid increase in training stress (in either volume or intensity). Dodgy old running shoes can be a factor, also, so make sure you're changing them every 500-600kms no matter what. A new pair of shoes will cost you less than physio. Besides, the colours of running shoes seem to turn over quicker than Apple products so you ought to stay in the loop! 
For the ladies, you're at an increased risk. Medical reviews show a phenomenon called the 'female athlete triad' of disordered eating, amenorrhea (dodgy menstrual happenings) and osteoporosis increases your chances of picking up a stress fracture due to decrease in bone mass - so keep an eye on the symptoms of the 'triad' and stay on top!

Symptoms of a stress fracture
It hurts, basically. Not like this guy, though. He 'Shit the F*cking bed'.
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Usually, pain will occur during exercise before subsiding during rest. You can have bruising or swelling around the middle of your foot (for metatarsals 2-4) or on the side if it's a Jones Fracture (5th metatarsal). 

Diagnosis:
If you suspect you've picked up a stress fracture, get to a GP or a Podiatrist ASAP. If you're Doc isn't a POD, or is a newb (as was my case) they might think 'Hmm no visible trauma, get an Xray'. Xrays might not show the fracture so the Doc may just tell you to HTFU, so make sure you get a bone scan in order to get a proper diagnosis to begin with. Early diagnosis is essential for good management.

Treatment:

  • Rest. Rest. Rest. Take the weight off and avoid walking as much as possible. Depending on the case, healing will usually take 4-6 weeks but may take much longer, particularly if you push it during the acute stage and induce more stress. Crutches may help.
  • Immobilise that sucker. Get a CAM shoe or similar. 
  • Ice can reduce inflammation and pain during the acute stage.
  • Stay drug free. Evidence suggests avoiding NSAID's as they can inhibit bone healing.
  • Hit up your Vitamins - 1200mg of Calcium and of Vitamin D2 (400-800 IU) can help, particularly early on.
  • Encourage blood flow. Gentle massage can help.
'Can I exercise?'
Based on anecdotal evidence, you can, but at the risk of prolonging the healing. Basically, you should be resting as much as possible, staying off the foot in weight-bearing activities, and exercising patience. 
  • Cycling: It seems the medical community is kind of divided on this. Some have given guys the go-ahead to cycle, some have put up red flags. Early on, probably a no-no. Wait a few weeks. Doctors may clear you, but baby it, please! Start small. 20-30 minutes on the wind trainer. Any sign of pain STOP and R.I.E! Don't rush it. Folks who do more seem to take a longer time to heal and run into chronic problems down the road.
  • Swimming: This is recommend as a 'cross-training' method for runners who've picked up a stress fracture. Actually, the aerobic cross-over is pretty good from swimming to running. There's lots of anecdotal evidence out there that suggests runners who spend a good deal of time in the pool don't lose a lot, if any, of their running fitness (this is coming from triathletes who are from a pure running background and then jump into huge swimming blocks). Again, baby it. Avoid pushing off the wall and stay away from kick sets or flippers. This is a good time to do LOTS of pull and band work. Make Coach Paulo, Darren Smith and Joel Filliol proud. This is also a good time to smash a swim block, work on technique, etc - see below in Goal Settiing!

  • Running: Ideally, get in for a second scan. An xray should pick it up after a couple of weeks and by 4-6 weeks your Doc should be able to give you an idea on how it's healing. Once you get an all-clear (anywhere from 4-12 weeks out) start small. Like, really small. Try 5 minutes first. Baby it. Nothing more than 20 minutes first week back. Focus on frequent, small runs. Build slowly. Get some conditioning back before trying anything remotely intense. Make use of a treadmill, if you can, as it will take away from of that energy from impact. Soft surfaces like grass are also good. And for goodness sake, don't go barefoot.
Bottom line is to baby it. Take your time and do it right. This can be pretty tough, which is a segway into this next section.

Psychological Implications:
Firstly, if you're an athlete who's never had to really deal with injury before, it's really hard not to feel a bit like this guy and dwell on the negatives:

Frustration and anger are normal enough reactions. After-all, an injury is a setback from our initial plans and objectives. It's important to understand that most athletes are going to experience injury or illness at one point, or another. There are a few strategies sports psychologists recommend in order to deal with the injury and move-on.
  • Goal Setting: Necessary tool in any athlete's mindset. Get some direction. Set short-term, manageable goals and get to it. Having some goals which can be quantified is great to track your progress and get some assurance you're moving in the right direction. Stuff like spending a bit more time in the gym doing your rehab exercises each week or doing a bit more aqua-running. As triathletes, we're lucky in the sense that if we, as in this case, bust our foot, we can still work in the pool. So, having some swim related goals is a realistic and measurable goal - perfect!
  • Visualisation: Yep. Sounds a bit like Power Bracelets but there are a number of peer reviewed studies that show visualisation of positive athletic situations - past and future - can help you maintain a positive outlook to even rehearse skills. Try visualising a key race or practicing transitions, for example. 
Future prevention: staying smart!
  • Eat well, nothing as good as a balanced diet. Keep up the Calcium and vitamin D if you have the risk factors stacked against you. Crap little carbonated bevvies, booze and tobacco reduce bone mineral density - avoid that sh*t, although I hope no athletes really need to be told to lay off the smokes.
  • Good footwear - remember, 600kms max in your shoes (200-300kms in race kicks). 
  • Avoid big changes in training stress - don't increase the volume or intensity too quickly. 5-10% a week!
  • Stay on top of niggles - if you feel a little tenderness in your feet, rest immediately. Don't let it turn into a stress fracture.

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