Sesamoid Update – 1 year on

oct c 2014

“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….!!).

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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.

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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

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The Broken: A Survival Guide Part III

Right now, I am at the point where my foot is essentially 95% healed, and I’m ramping my running back up.

Cue music: “Highway to the Danger Zone”……

You see, this is the magical moment where the bones are healed enough to need adequate loading in order to reach full strength and function. This means running every other day (yippee!!), but crucially it also means having the discipline to not overdo it. And to listen to my body. And put my pride and perfectionism to the side.

This is, in many ways, the hardest part. It’s the part where I have to test my growth over the past 9 months. Have I really become more patient? Stronger? Less perfectionistic? More realistic? Hell, will my body even remember how to run, let alone with decent pace or technique?! And then the toxic seeds of doubt creep in: what will my fellow runners think of me now? What if I’m not good enough? What if I never get back to where I was before I broke my foot? Will I ever beat my husband in an Ironman again?

Of course, it’s highly likely I will come back stronger than before, will continue to kick my husband’s butt in many an Ironman to come, will have learnt a boatload about myself and my body and most importantly, learnt how to train more efficiently and with less risk (cue Britney Spears: Stronger. Yep, I went there). This is my “logical voice” talking. But we all know, that illogical voice is the one that dominates when we have been out of the loop for some time.

Hiking in NZ with my better half

Hiking in NZ with my better half

Two weeks ago, I readied myself to go to running squad for the first time in over a year. It’s a super friendly bunch of runners who I have trained with throughout all my Ironmans in the last 5 years. Saturday mornings are usually a sociable 8-12km group run, with coffee afterwards. There is a front pack, of which I’m usually a member, and then there’s everything back to a 5km jog/walk group. In all, we have about 50 people turn up, so it’s not like I would be lonely.

Only I chickened out. Why? Because according to my return to run program from my Ortho, I still have to walk 2 minutes for every 8 minutes of running. And, I knew I wouldn’t be able to stop and have the discipline to walk when everyone else was still running. And my pride didn’t want the slower runners to catch up (there I said it. I may be the world’s most competitive person). A week later and I decided to try again. I took off at decent pace with a largish pack, and I did manage to stop and walk when I was supposed to. It was harder than getting through an airport on crutches, I’ll tell you that much. My heart and soul just wanted to keep on running!!

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Whether you are getting back into training after an injury or after an eating disorder (or both), the hardest part is often sticking to the plan. I know from coaching beginner run groups that the three aspects of training that “normal” people struggle with most are 1) motivation; 2) fitness; and 3) being able to mentally push themselves. This is not the case for athletes or those of us with the ED birdy on our shoulder. These are some strategies that have helped me over the last couple of months:

1) Front and Centre: How Far You’ve Come (and how quickly it could go wrong). Its human nature to compare yourself to others, and even moreso for uber-competitive athletes like myself. There’s a bunch of people you used to be faster than lapping you around the park. But that’s OK, because they don’t have a metal plate in their reconstructed foot. They haven’t walked every step of that hard road to recovery. When the temptation to push yourself overwhelms you, it’s important to remember how broken you were and how quickly you could return there (ie another stress fracture or overuse injury). Sometimes fear can be a very good motivator! Write it on your hand, stick a photo in your wallet – whatever it takes, a not-so-subtle reminder is key.

2) Plan Ahead: The Insecurity Factor. As a flip side to point 1, remember that we are all humans and we do all have our own story and our own journey. When that little evil voice starts sprouting doubts in your mind, squash the insecurity by fighting back with basic logic. Those runners know what you’ve been through, know what kind of an athlete you are, and really couldn’t care less that you are running slower than you used to. They’re more than likely impressed by your motivation and determination, not judging you for your pace. They’re likely happy just to see you back at squad. Or they may not have even noticed that you’re not as fit as you were (you’d be surprised how remarkably un-observative “normal” people can be, really….you’d be shocked….not everyone can recite what the whole table ate at lunchtime and what times they ran on the track for the last 4 years….that’s a very unique trait!).

3) No Negotiations. Even if you feel like Paula Radcliffe today. Any changes to the plan MUST be pre-approved by your Physio/sports doc ahead of time. As with any rehab program, you have days where you just float like a butterfly….and days you feel like an elephant. Just enjoy the fact that you feel great, cherish every step, and know that if you stick to the plan, it’ll be that much sooner before you get to have another great training session. If that fails, revert to point 1.

4) Focus on how Amazing Your Achievements Are. And celebrate them. Who cares if your old training buddies smashed out 10km in sub-40min pace? YOU just did 36 minutes of quality running, and you had the discipline to stop and walk, and your technique was great, and you are coming back from major foot surgery, and you get to be outdoors in the fresh air running…you get the picture. Gratitude is the best emotion on the planet. Use it to your advantage. Write it in your training diary. You’re doing awesome. Repeat.

5) Enlist a Training Buddy who is on board. Does not have to be of the human breed. If you are going to squad, suss out who is about your pace at the moment or perhaps also coming back from injury. Or grab a friend who is willing to do walk breaks with you. My favourites for this are my husband and my dogs, the three of them are always whinging that I run too fast normally so they are happy for the walk breaks – much happier than I am!

6) Nutrition: ensure that you are adjusting your eating plan for the increased exercise load. You need to be eating for training, recovery AND healing – the triple threat. Bones have a lag time of about 3-4 weeks with increased load, so when increasing run kilometres it is best to have a training week that is about 50% of your normal current load for that week, to let your bones catch up and get stronger. Push over that and you may find another stress fracture. So if you are up to running say 40km a week, on the fourth week, stick to 20km and you can add some walking or cross training. It’s an annoying but foolproof investment, and any running coach on the planet worth their salt will stick to this plan for injury prevention. You’ll actually come out the other side feeling fitter, as your body will have “absorbed” your training up to that point and feel fresh again. Bonus!

7) Get a Hero or Two. Professional Triathlete Jesse Thomas actually broke his foot during Wildflower triathlon 2013 and subsequently had surgery about a month before I did the exact same thing. He has blogged about his rehab, the highs and lows, and I have found it hugely helpful following his progress along the way. His wife Lauren Fleshman is also a great role model and her blogs are highly entertaining for any athlete who has faced injury or childbirth and beyond. As a side note – be wary of Ironman athletes claiming to be recovered from their eating disorders. There are a lot of them around who hide behind “Ironman/triathlon” as their excuse to continue with disordered eating patterns. Chrissie Wellington’s book “A Life Without Limits” is probably one of the worst so don’t go there if you are still recovering. Same goes for any running or ultraendurance bio if you are recovering from a running injury – it’s like motivation on steroids to go do something really stupid!

I hope that helps! The journey back to health can be a long and lonely one, especially once you get towards the end and on the surface everything looks fine. Stay strong and remember how far you have come. Most importantly, reward your body for the amazing job it has done by nourishing it and letting it bloom into its full potential. It will serve you very well if you treat it right.

Happy Training xo