Part I: Prevention
“And so that I do remember
to never go that far,
Could you leave me with a scar?” – Missy Higgins
So you’ve found yourself staring down the barrel of some time away from your most-loved activity, likely due to impending injury, an exercise ban, a fatigue-related illness or something similar. It’s not bad enough that you feel like your legs have been cut out from under you however it is bad enough that you feel some fear and insecurity fast-arising in the knowledge that you need to rest, and you’re not very good at that. I’m going to focus on strategies to help specifically with preventing stress fractures in the early stages, mainly because of the high incidence of them in athletes with disordered eating of some sort. However many of you will find these tips helpful for other situations as well.
Eating disorders occur in up to 19% of male athletes and 45% of female athletes, according to the literature. Which logically speaking puts this group at the highest risk of sustaining the dreaded stress fracture, simply put – too much overload on a weakened skeleton, too much exercise, and not enough nourishment to keep up with the bone turnover. The most high-risk sports for sustaining stress fractures are also those with the highest rates of disordered eating: ballet, distance running, skating, gymnastics and rowing.
But here’s the thing: stress fractures are also arguably the easiest of the overuse injuries to prevent from happening, or at least prevent from worsening once they start. They are thoughtful little devils, in that they give you warning signs as they gently create microcracks in the bone, one painful step at a time. Should you choose to ignore the progressing microcracks, they will get crankier day by day, eventually making it painful for you to walk. Should you choose to really blow them off, you can run yourself into a full bone fracture – bringing with it night pain, throbbing and swelling at rest, and usually some time non-weight bearing (in a cast for the lower limb, crutches for the hip and femur, typically 6-12 weeks IF you eat well during recovery, longer if not).
So while health professionals and researchers are spending oodles of money researching how to best prevent and treat these debilitating injuries, I’m going to talk about the elephant in the room. The fact that most of these stress fractures wouldn’t eventuate, if the athlete made the choice to stop the aggravating activity when it first surfaced its head. A newly formed stress reaction (the stage before a stress fracture) will heal with just a couple of weeks off running – you can usually keep walking and doing all other exercise. Seems simple – just stop running, or dancing. Have a week off.
Only it’s not that simple, because you can’t. You have a voice in your head that wants you to push through the pain, because if you stop running, you’ll get fat and lose everything you’ve been working for. You try to argue with the voice, reasoning that a week off now is far better than 8 weeks in a cast if you keep running…..but you can’t. Simply put: the pain from ignoring/fighting the voice in your head is worse than the pain of the stress fracture. Far worse. And that is something that only someone who has been through an ED would understand; certainly your doctor or physio is unlikely to get it. “You have such a high pain threshold”, they say. Oh if only they could walk a day in your shoes! Physical pain is a mere annoyance; mental pain on the other hand is nothing short of crippling. And it never stops. Like a repetitious steak knife to the brain.
So, my goal for myself and others is to work out strategies to help fight the beast at this crucial moment in time when things are make or break, quite literally:
1) Fight the Fear Head-On. In this day and age, with a little Google-action combined with the high IQ of most high-achieving individuals, it is likely that you already know when you are at risk of an impending stress fracture (Google “foot pain in a runner” and see what comes up….). Next step then: google the treatment protocol. While I spend much of my work life as a Physio hating when patients self-diagnose, in this case it can be useful as a head-on tool for fighting the ED voices that are insisting that you push through the pain. Sometimes, having the weaponry of “if we keep pushing through this pain we won’t be able to run or walk for 6 weeks!” is helpful in the daily warfare and can assist in avoiding a full-blown bone break.
2) Verbalise what is going on to someone that you trust. It’s OK to say “I don’t trust myself to not run at the moment”. Even better if you can get some company – ask a friend to come walking or to the gym with you, so that they can be in charge of not letting you hurt yourself. Or tell your dance teacher or coach what you are and aren’t allowed to do. It’s OK to ask for help, and it’ll give you that exercise outlet without having to fight the self-destructive urges for at least a small amount of time.
3) Create a plan, write it down, and obsessively stick to it. Channel the beast into a set program of a different kind – one that won’t cause further hurt. If you’ve caught it early, you’ll likely need about 2 weeks off pounding activities. So write a plan filled with core work, swimming, cycling and other safe activities and commit to recording your sessions. Often the objectivity of having a written plan helps to quieten the irrational urges that surface.
4) Create a goal that relies on you not worsening this injury. You may have a dance concert in 3 months, a fun run in 4 months, an Ironman in 6 months or even a holiday or event that you’d love to be strutting around in high heels for. Get something visual to remind you of this, and stick it somewhere you’ll see it – screensaver, dresser mirror etc.
5) Visualise yourself at your fittest and healthiest. Defend your health at all costs – you only have one body. Whenever we break it down, whether it be through malnutrition or injury, it takes a huge amount of time and energy to rebuild the body. Same with the starvation cycle – every time you go through the process, your metabolism gets damaged just that bit more and it’s harder for it to bounce back (trust me after 10+ years of that cycle the body becomes very thrifty!). As painful as the ‘now’ is, try to focus on the bigger, long-term picture as much as possible.
6) Distract yourself. Plan activities ahead of time, so that idleness doesn’t allow for unhelpful thoughts to sneak in. Anything you love that maybe you usually don’t make time for when you are training – baking, art, writing, reading, coffee with friends, photography. A gratitude journal can be extremely helpful at this time for focusing on all the wonderful things that you do still have.
7) Failing all of that: get your Physio involved. I have both been a patient, and had patients of my own, who need to be “protected from themselves” (or more accurately, Ana or an exercise addiction or both). You may think you are insane asking for help, but your Physio (if they are decent) will already know that you are struggling to stop exercising, and will have treated others like you before. There are options to put patients in a cast or boot or on crutches even in the early stages of a stress reaction if they aren’t able to stop themselves from making the injury worse. ‘Do no harm’ is always the number one priority, whatever form of protection that comes in. If you can muster the strength to tell your Physio that you cannot stop yourself from running, they will take over with the rest and you are allowed to feel the sheer relief of not having to fight the beast, at least for a few weeks.
In part II of this post I will go into strategies for psychologically coping with more serious injuries or down time from your beloved sport.