October 16, 2014 by Ana To Athlete

Sesamoid Update – 1 year on

“At some point you need to stop making a comeback and start running towards who you are meant to be next” – Lauren Fleshman #womanup

Hoorah for beating the odds – once again!

Sesamoid fractures have a pretty serious reputation for not going well. There is little evidence-based research available for treating practitioners on best standard of care, and even when that has managed to be achieved, they tend to be slow to heal and long to recover from.

Being a Physiotherapist and knowing all of this information, I was shaking in my boots a little at what I was staring down the barrel of just over a year ago now. Compound that fear with the knowledge of what I had done to my foot (doing an Ironman on a stress fracture is not something I will ever do again…), along with my history of poor-ish bone density thanks to a decade of Anorexia, and I was pretty much crawling with my tail between my knees into that surgeon’s office and pleading with him to save my life. Ok, dramatic…but running IS my life, my first love, my sanity and makes my soul happy. So NOT running again was simply not an option.

I am happy to say that even with the odds seriously stacked against you, with a great medical team and some serious dedication to a long and conservative rehabilitation process one can come out the other side flying. Once I got to the point where surgery was the only option left – 8 months of conservative treatment already tried and failed – I had to make a choice. I had to put my big-girl panties on and suck up the situation; there was zero time for feeling sorry for myself and about 24 hours a day to dedicate to doing an awesome job of this rehab process. As discussed in previous posts this included everything from sleep to nutrition to Physio – and most importantly, a great medical team: a brilliant sports physician who understands my passion for running as well as my medical history; the best foot and ankle surgeon in Australia; and a sexy Physiotherapist (OK that was my husband so I may be biased….but it probably helped the treatment come along….!!).

Which brings me to the now. My surgeon was clear and stern with me from the start that it would be a 9-month rehab process before running would even begin, and 12 months before my foot would be adapted to what we had done to it: bone grafting the sesamoid plus breaking, elevating and plating the 1st metatarsal (dorsiflexion osteotomy) to take load off the sesamoid underneath it. 8 weeks in plaster non-weight-bearing was followed by another 8 weeks partial weight-bearing in a boot; then a very gradual increase in walking and loading the area. When I was in plaster I was doing a lot of Pilates, strength work and all-importantly, resting and eating well. My arms got pretty buff at this point – crutches plus strength work= guns!! As soon as I was out of plaster I was into the pool. Initially not allowed to deep water run, but I was allowed to swim if I used a pull-bouy and didn’t push off the wall with my right foot. This made me feel about 100% more human just being back in the sun and in the water again, even if it was limited. Towards the end of that 8 weeks in the boot, I was able to start deep water running and freestlye swimming (kicking). Then came the fun part.

The “real” rehab began once I was walking more and out of the boot. My right calf muscle was over 3cm smaller than my left at this point…I had a lot of work to do. Not to mention adapting to my new biomechanics – the first time I stood on my right foot, I felt like I had a marble under my 2nd metatarsal! Now a lot more of my weight would go through that bone rather than the 1st metatarsal/sesamoid complex, and so I had to go slow to allow the bone to adapt – it’s common at this stage to get stress fractures in the 2nd metatarsal if rehab is too aggressive, due to the increased load. I was allowed to start cycling (using carbon-soled bike shoes so the toe doesn’t bend) at this stage.

Due to my job being so physical – Physios are pretty much on their feet for 8+ hours a day – it would be another month or two before I could introduce any extra walking outside of work, which was frustrating. This was (mentally) probably the hardest part – not being ‘disabled’ any more, but feeling like you’re not actually working towards running either. My patience paid off and once I was able to walk for exercise, things moved quickly – at 7 months post-op, I was walking 30mins every other day with minimal swelling and less than 2/10 pain (ie. Acceptable pain levels given the surgery I had)….which meant I was allowed to jump on an Alter G treadmill and start running, 2 months ahead of schedule!

My surgeon was very strict with the Alter G protocol to follow. I started with 50% body weight for 20mins at just 10km/hr. This felt easy as my fitness was pretty good by now from the swim/bike/deep water running routine; that was a key part of this stage going so well. Over the next month I built the AlterG sessions up to 40 mins at 70% body weight including intervals, allowing me to build some speed and rhythm in. I had the luxury of having my husband and Physio accompany me and give me feedback on biomechanics and technique – it was like getting used to running on someone else’s foot! It felt very strange. I will be forever grateful to my sports physician for making access to an Alter G so available to me; not everyone has the luxury or the joy of this.

At 8 months I was given the green light to start my road running return program, which was also very conservative…it started with 30 minutes walking with 8 x 1 minute run throughout. But I was the happiest person on the planet! I kept up the Alter G sessions for a few more weeks just for my sanity more than anything else – it was still a novelty and better than drugs being able to push myself again (from a cardiovascular perspective), plus the fitness boost it gave me was invaluable and transferred beautifully onto road running.

I was slowly building week by week and up to running 5-10km, 3-4 times a week when we got pregnant this time around….and so I have maintained that level of running over the last 5 months, and will continue to for as long as I can into the pregnancy (I’m now 5 months along and 4kg up). Ironically, the extra relaxin hormone boost from the pregnancy has allowed me to get my full flexibility back in the foot post-op and so running feels better than ever! This could have taken a year or more to achieve without relaxin. I can honestly say now that I don’t even think about my foot anymore – it feels “normal”, strong and functional.

Of course, I am missing racing immensely – between the surgery and pregnancy, it’s been almost 2 years since I’ve raced an Ironman and I cannot wait to get back to it. I am hoping to do an Ironman about 10-12 months after the baby arrives; it would be nice to go back to Busselton where it all went down in the first place and get some unfinished business out of the way!

What I have learned about Sesamoid Stress/Fractures:

– Get a health care team on board that KNOWS WHAT THEY’RE DOING. Search for someone who has experience with treating sesamoids; if your GP/Sports Doc/Physio/Podiatrist does not, then call around until you find a team that does. Don’t be afraid to ask upfront.
– Use an MRI for diagnosis and follow-up progress scans. XRays are not sensitive enough and bone scans are not specific enough. The cost is worth it to know what you are dealing with.
– You need to be aggressive – from day dot. These are typically not super painful injures (well nowhere near a femur or sacral stress fracture – of which I’ve had both – hence being able to finish an Ironman on it without realising), and so they can be deceiving. But you need to take them very seriously, as hard as this can be early on,
– From the moment of diagnosis you should be in a boot; either partial-weight bearing or full weight-bearing if pain allows – needs to be <2/10 pain at all times.
– Use contrast bathing or ice/heat protocols – 20mins of each, 1-3 times a day, to flush swelling and increase blood nutrients to the area.
– Give it TIME. Prepare to be in the boot for 8-16 weeks. Yikes! I know….but trust me, this option is much better than having to go through surgery. Sesamoids have poor blood flow and don’t heal well, but if you treat them like gold from the start you will give it your best shot at healing conservatively.
– Statistically, following the above protocol, 50% of sesamoids will heal and 50% will not (at 12-16 weeks). It depends where the break is, what the blood flow is like, and how well you rest it during this time.
– If you are a serious athlete, love your sport, or have a job that requires you to be on your feet, think about getting a referral to a very experienced foot surgeon early in the process. They typically take a couple of months to get into, and it doesn’t mean that you will have to have surgery – but if it’s a slow healing fracture, they will give you an all-important educated opinion on your time frames, options and prognosis. You can always cancel the appointment if you’re going well, but it’s hard to get an urgent appointment if and when you do need it so plan ahead!
– If you do need to go ahead with surgery, ask the surgeon how many sesamoid stress fractures they have treated and how they have gone. You want the most experienced surgeon with good long-term outcomes ie. Return to full sport pain-free.
– Avoid removing the bone at all costs. Unless it is completely shattered, a good surgeon should be able to either bone graft, pin or shave off part of the bone to salvage it. A foot without one or both sesamoids is, biomechanically-speaking, a disaster zone for arthritis and injuries and is not very conducive with a future running career!
– Further, if you do need the surgery, plan it well and be prepared for a long haul. Be ready mentally and physically to put in the hard yards from a rehab perspective (exercises, pain and swelling management, and lots of rest…), but even more so be ready to be patient from a psychological perspective. There is no point going through major surgery only to rush it on the other side.
– Be rest assured that with a good surgeon, and an even better rehab protocol (think slow-and-steady), you CAN and WILL return to your old athletic self. It’s possible you may even come back stronger after all the time spent with rehab and core strength work, and in my case, biomechanically improved because he fixed the 1st metatarsal angle at the same time, decreasing my chances of getting the injury again.

Currently sesamoid injuries are highly misunderstood by the medical profession and usually by athletes as well, but over the next decade I believe there will be huge improvements in understanding and treatment from medical professionals. In the meantime, those of us who have walked this path beforehand can hopefully shed some light, advice and much-needed hope that there is indeed light at the end of the tunnel!

Happy Training

K xoxo

May 8, 2014 by Ana To Athlete

Exercise and Recovery

I’m going to be a little controversial with this post. I’m going to suggest that for a large majority of ED sufferers, recovery would be best done while they maintain their work or school, and for athletes, their training.

Before everyone gets riled up about it, I am not talking about those so severely undernourished that they are at risk of dropping dead from a massive heart attack at any minute, or those with suicidal tendencies….clearly an inpatient program would be best for these patients (at that stage in their recovery, even if those programs for the most part keep people alive but do not really assist in long term recovery and have notoriously high relapse rates….but that’s a post for another day). I am talking about the majority of ED sufferers who are under their individual ideal weight (note I did not say “under BMI 18” – how ridiculous, what about the person with a bigger frame who is still starving but able to maintain a BMI of 21? Are they “less sick”? of course not), are still participating in work or school, and particularly those who are athletes and see that as a part of their identity. I’m talking about the people who are functioning in society, but are significantly affected day to day by their eating disorder – maybe with the accompanying depression, lack of energy and concentration, fatigue, social isolation and the other joyous side effects.

Here’s why. Think about this: What is the biggest challenge in recovery? I would argue that one of the hardest parts about recovery is learning to lose the “ED” identity and to learn who you really are as a person. Only once that has occurred can one begin to truly move on with their lives and to want to nourish their mind and body. Only then do they have a sense of self to take care of – a reason to recover, if you will. For recovering for someone else, or to get out of Inpatient care, or for the sake of a “goal weight”, will never do it. That typically leads quickly back to a relapse and the cycle that entails.

Inpatient care, while necessary to sustain a life on the edge, takes away all the other factors in the patient’s life that will be the foundation of their true identity as they return to health: their job, their hobbies, their social network, and for athletes, their training and usually tightknit support crew – coaches and fellow athletes. Not only does it take those things away, it actually forces the patient to focus 100% of their time and energy on the eating disorder. Their days are spent focusing on food, psychology, analysis, resting, scales, and usually the added bonus of in-house competition between patients on who is the “most sick”. Statistically, success rates aren’t good – the weight is temporarily gained, yes; but in the long term, recovery rates can be as low as 20% for patients who have had an ED for an extended time period. The statistics have not improved even after a few decades of treatment in this way. Why not?

At some point, the patient needs to learn how to function in society in a healthy way, and for this to happen there needs to be a reason for the patient to want to get better. Want being the key word here. When an athlete-patient is allowed to keep training, albeit at a reduced load, there is an all-important reason for them to put in all the hard yards day to day that go with recovering from an eating disorder. There can be clear goals and rewards: you gain X weight, you get to train X amount. You eat X foods, you get to attend X training sessions. If you don’t, you can attend but you have to sit out and watch. Sure, it’s harder to gain weight while still training. But guess what? Eating like an athlete is hard, full stop. Years on I still find it a challenge day to day. When you train hard, you have to work even harder on fuelling your “machine” (body), and the sooner a patient gets used to that process the sooner they can master it. Secondly, gaining the weight as muscle, bone density and fat via increased food and some continuation of training is much healthier and less traumatic for the patient than gaining fat alone on a resting protocol. Lastly but most importantly, there are three overwhelming psychological benefits to this approach:

1) the motivation-reward system is clear and immediate;

2) the social interaction with teammates and coaches is maintained, which is so important;

3) the patient is nurtured through the process of minimising their ED identity and replacing that empty space with their “healthy athlete identity”. {You can replace “athlete” and “training” with anything else relevant – student and school, physio and work, etc.}

The key to this process is to have a fantastic support team who can facilitate this transition. For me, it was a brilliant Sports Dietician (it was her idea to allow me to keep training – every other rehab program I had entered forced me to rest and spiral into depression), a brilliant Psychologist who specialises in treating athletes with eating disorders, a Coach who was on board with the plan, and a flexible workplace (I was still studying at University but my part-time job as a research assistant allowed me to set my own work hours, so I could go in when my energy levels were highest – early in the morning). For the most part, my dietician set out my goals for the week and my rewards – when and if I could train etc. All the while she communicated with my psychologist, who from the get-go has focussed on establishing my identity as an athlete. As he reminded me recently, I have always done best when we focus on what my body can do (as an athlete), not how it looks. All body fat % and weight measures were taken away from me, and replaced by more relevant measures like time trials and power outputs. And the only way I can get stronger, fitter, faster, and keep up with my teammates? To eat. Simple as that. I know when I skimp, I fall behind, and as a competitive person, that is motivation enough to nourish my body.

The best part is that the system WORKS. And it’s not just a bandaid fix – it works in the long term. To this day, years on from the start of my “recovery”, I still have a crappy day at work, feel “fat” as my go-to coping mechanism, and then know that if I go and do a solid training session, by the time I walk back through that door at the end I am going to be happy with my body and what it can do for me. Nothing to do with how it looks or what it weighs. Simply what it can do. And that’s pretty cool. Add in the extra bonuses of a good training session – fresh air, endorphins, improved fitness, mental clarity, relaxation – and it’s a win-win situation.

I make it sound easy and like the obvious solution, which for me, it was (obvious, not easy!). Nothing else had worked over the decade beforehand. And certainly this system wouldn’t work for everyone either, but for athletes, I would argue that it is the best way to structure treatment. Realistically, there needs to be a change in the way we treat eating disorders in Australia as the current inpatient systems are not working in terms of long-term outcomes and relapse rates. There is no easy answer.

Food for thought anyway.

Happy training xo

April 20, 2014 by Ana To Athlete

Racing Weight

So yesterday I had a revelation. It’s only been, hhmmm, 18 years coming.

I was looking through some race results from a recent track meet and they had accompanying photos. One photo in particular really set me off – I felt a deep pang of ?yearning? to suddenly stop eating and to run a really long way. To look like that. ASAP.

I won’t put the triggering photo up for obvious reasons. Instead, here’s a bunch of awesome, fit healthy chicks at the New Balance Games.

Ever since I started restricting calories at age 12, I have always been very easily triggered by certain people – for me, mainly athletes of the very lean, tanned, blonde and hot description. I most definitely have a “type”. For the longest time it was Anna Kournikova. I remember as a 12 year old looking up her height (same as mine – I was tall at 12. Incidentally, I never grew after that….amazing what starvation can do to the human skeleton) and weight. That was ground zero. Only, once I got to her weight, of course the ED/Ana was in full flight and I couldn’t stop there. I may have had the long blonde hair, the sports trophies, the tan….but I didn’t look like Anna Kournikova, because, well….she looks healthy. She glows. I had some grey death staring out my eyes to match the grey shades under them, and a bony back to boot.

Anna Kournikova in full flight.

Over the years the role models have evolved, and as I’ve talked about in previous posts, I now tend to look up to healthier athletes as a matter of requirement. I am simply too easily set off by the former. And of course a swap to a sport that suits my genetic make-up to a tee has helped as well: as a distance runner, being lean and super light was always an uphill battle, whereas I build the endurance and strength needed for long course triathlon almost by mistake, it happens so easily.

Anyway back to the point. To give you some context, my body at the moment is not at racing fitness and after being “Ironman fit” for the preceding 3 years straight, that’s a hard thing to get used to. I was as fit as I’ve ever been going into my foot surgery in July last year. But 3 months in a cast and non-weight bearing on crutches, when all I could do was core and upper body gym work and then after that, swimming….well for someone who builds muscle easily, I suddenly developed upper body muscles. Throw into the mix a couple of pregnancies then miscarriages in that period and well, needless to say, my body has changed. So I’m in the prime target zone of being affected by such triggers and constantly fighting the urge to overexercise and undereat, when in reality my body needs to be loved in every way in order to repair right now.

Only yesterday, for the first time ever, a shocking thing happened. I’m not even sure it was my brain producing the thought process, so foreign was that thought process. I suspect perhaps my psychologist or dietician found a way of tapping into my brain waves and altering them. For when I saw the picture, I yearned to starve and go run 35km. But then the next thought that followed was astounding: “yeah, if you want to be skinny-fat and unhealthy. If you want to get back to that level of fitness, you know what you need to do. You need to commit to training hard, and eating. A lot. Of really high quality food.” Sigh. Wait – whoah!! What just happened?!!!! Was that my head talking?

New, healthier role models: Caroline Steffen aka “Xena”, 2nd fastest female Ironman athlete in the world. Machine.

After deep consideration, I’m fairly certain it was me. I’m impressed. And when I analyse it, it’s true – the only times in my life I have been super race-fit, lean, healthy and glowing (and incidentally injury-free) have been when I’ve been able to train well and at a high intensity, and when I’ve been able to eat a lot of food to support that. For many of the other times, I may have been clocking in at my desired “racing weight” – for distance running, not triathlon – but I was far from glowing, and the fake tan and smiles were barely hiding a very frail skeleton with 10+ stress fractures in their short history.

As we all know a little too well, it’s far easier for us to undereat and overexercise. It’s comfy, predictable, safe, not scary. Eating like an athlete is frightening, uncomfortable, requires planning, and a lot of mental strength – and not just for a day, but for months. But when all is said and done, it’s always more rewarding doing something challenging than sticking to the same well-worn path. I don’t want to be a skinny-fat distance runner anymore; I will stand proud as an athlete. Glowing, too.

Bring it.

xoxo

My hand-made Easter chocolates for the family. Happy Easter everyone! xoxo

January 6, 2014 by Ana To Athlete

The broken. A Survival Guide.

Part II:

So you’re fractured – body and brain. You want to scream at the world and pull your hair out and cry, simultaneously. I get it.

In the previous post I introduced the concept that perhaps it is essentially the mind that causes stress fractures in the large majority of athletes, moreso than just the body failing, as modern medicine would have us believe. Specifically, the sheer force of power that is that voice in your head that will not allow the body to stop, even when presented with increasing physical pain. We are a smart bunch; it’s not like we don’t know that something’s wrong and it’s getting worse. It’s just that stopping is infinitely harder than pushing through a little physical pain. Hell, sometimes the physical pain feels good – euphoric even – like you are fighting the beast in a different way. And yes, the pain of a stress fracture is “little” in comparison to running 35km after not eating much for a few days….there’s levels of relativity and most of you here have an abnormal sense of ‘perspective’ when it comes to matters of human suffering. I wish it wasn’t so, I really do.

Sometimes the beast wins, and you find yourself in the doctor’s or physio’s office with a full-blown stress fracture or major overuse injury, which essentially you did to yourself. Yet another kick in the guts. Facing down the barrel of 6-12 weeks off your beloved sport, you feel the red rush of hot panic bubbling up from the fracture site and seeping into your heart. Staring at the image of a clear break on a clear scan, suddenly the pain feels so much worse.

What now?

There are hundreds of well researched and accessible texts on gold standard treatment protocols for stress fractures, ranging from stopping running right through to the extreme of surgery, depending on the site and severity of your injury. But there are very few resources written on coping with the emotional and psychological backlash of injuries, much less if you also have an eating disorder or disordered eating and you are now faced with the removal of one crutch – running (emotional) and the replacement by another crutch (literal).

1) Take time to digest the news and go through the stages of grieving, so that you can recognise what you are dealing with. If possible, have a close friend or loved one with you to help with the support and to remember information. The average patient only retains 30% of what is said to them during a medical consultation. Even better – write it down. The doc won’t mind.

2) Embrace the “Athlete Mindset”. The fact that you are in this situation means that you are dedicated enough to your pursuit of excellence that you are already in the top minority of athletes. BUT….you need to learn when that line is approaching and how to not cross it in the future. Allow yourself to recognise your best traits (discipline, commitment, passion), but also to define what you would like to work on in the future (the strategies in part I – prevention; listening to your body; allowing yourself to rest and letting go of some of that perfectionism….). Your “training” now is recovery. That is no.1.

3) Get some Sun. It’ll help with the bone healing thanks to its Vitamin-D inducing properties. It will also assist with depression, appetite and most importantly it will get you outside into the fresh air.

4) Ensure Social Contacts. It’s more important now than ever to make sure that you stay involved somehow – whether that be with group catch-ups after training, going to training or dance class and assisting the coach or teacher, keeping up with dance or running magazines. While it seems counterintuitive, this can actually help you to keep the “athlete mindset” and to help with staying on track in order to achieve bigger goals in the future.

5) Create a different outlet. Use your emotions as a guide. Do what makes you feel good; steer away from things or people that make you feel more down or frustrated. Be aware of being pulled towards bad habits – they can be strong and start sneakily. Tune into your emotional radar early when it’s slightly easier to resist.

6) Develop a nutrition plan. And stick to it. Most notably:

a. Avoid regular and diet sodas due to the bone-leeching phosphoric acid contained in these liquids.

b. Reduce caffeine intake, ideally to less than 2 cups a day. Caffeine also leeches the skeleton of calcium, critical when the bones are in healing mode.

c. Avoid alcohol, which can induce a pro-inflammatory environment and affect absorption of important nutrients in your food. Aside from this, it is a depressant so probably not helpful on the brain given the current situation.

d. Maximise sleep, as this is where your largest surge of growth hormone occurs – crucial for healing and mental health as well. Talk to your doctor about this if you are struggling, which is common when you are used to expending so much energy on a daily basis.

e. Most challenging of all….keep the focus on nourishing the body with high quality foods, now is not the time to diet or restrict food groups. Keep in mind that healing takes up a huge amount of energy. Accredited Sports Dieticians are very experienced in this field thanks to the high injury rate in elite athletes – and yes, you can totally book an appointment and request a meal plan to maintain your current weight while injured, whatever that weight may be. Even if they suspect you have a phobia of certain foods or a controlling personality, they will respect that and all information shared is legally confidential.

7) Most importantly, give yourself permission to rest and heal. If you cannot give it to yourself, ask your health professional – whether it be your dietician, psychologist, physio, doctor or even a friend or loved one. The most weighted words you can hear are “you are not allowed to exercise with this”. You have permission, to just heal. That is your number 1 job. There will be plenty of time once you’re back on your feet to concentrate on training; for now, the more you rest, the faster you will heal.

Of course, it all sounds so practical and easy when it’s neatly typed out on a page. It won’t be – it’s going to be hard, much harder than the physical pain of the initial injury or the discipline of full training. But if there’s one thing that’s certain, it’s that with no plan at all, things will likely slip downhill fast on the sliperyslope to ED-land. You will have a much harder fight on your hands in the mental department during your down time, but it is worth fighting for and you will come through the other side a stronger, better, more passionate athlete. In my younger (Ana) darker days I had a tibia stress fracture which I couldn’t (mentally) stop running on, eventually I ended up in a cast. When the repeat XRays were done at 8 weeks there was zero evidence of healing, mainly because I had been stressing and severely restricting food during that time and had consequently lost a significant amount of weight. Yes, that can happen. Don’t muck around with it – the psychological setback is so much worse the longer it goes on.

Stay strong, fight the good fight, and learn from your experience so that you can come out fighting.

K xo

January 1, 2014 by Ana To Athlete

Stress Fractures – Dealing with the Emotional Backlash of Injury

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.

Sometimes fear of the impending “worst case scenario” can help you to protect your body before the worst happens….stick it somewhere you see it often

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.