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.

Oct E

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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From Rehab to Racing

8 weeks post-foot surgery, happy to be out of plaster and trying to stay positive...

8 weeks post-foot surgery, happy to be out of plaster and trying to stay positive…

I flew today.

Well, it felt like it. 6km run at good pace with minimal foot discomfort, able to find my rhythm for the first time since July 2013. Excited much?! I was smiling from ear to ear for the rest of the day!

It’s been a huge challenge, a very long 9 months, and the biggest mountain I’ve had to climb in my post-ED life. But I can finally see the light at the end of the tunnel. Today I entered two 5km fun runs, and an Olympic Distance Triathlon which I will do as a team (as my surgeon is not giving me the green light to run 10km at race pace just yet!).

Still a long road to another Ironman finish line but every day is a step forwards

Still a long road to another Ironman finish line but every day is a step forwards

So what have I learned along the way? Patience. Something I never had a lot of before. I’ve learned how to apply my discipline to my rehab like nobody’s business. That applied effort has allowed me to return to running 2 months ahead of the schedule my surgeon set out for me post-op. In fact, when my psychologist was warning me about the danger zone I am currently in (given my raging exercise addiction, it was a fair concern!) – I reassured him “don’t worry. I am treating my rehab program just like I once did Ana – I am aiming to be the “perfect” patient, which includes following the program to a tee, eating every nutritious food I can get my hands on, and doing every recovery strategy that is validated in the research – compression, ice, physio, you name it.” I’m not sure he 100% approved of my approach but was nonetheless impressed by my creativity and my insight into my personality characteristics (well, they weren’t going to go away just because my foot got cut in half and I couldn’t run for a while, let’s face it. May as well make use of them).

Full steam ahead: back on the bike and loving the training!

Full steam ahead: back on the bike and loving the training!

So, as my coach would tell me, it’s “onwards and upwards”. Every day is another opportunity to “practice perfection” – every stroke on the bike, arm turnover in the pool, step on the run, and weight in the gym, all tiny building blocks that will one day form the strongest Ironman body I’ve had yet. Every new day is another chance to be thankful for my health and my happiness. To breathe in the fresh air and feel alive.

I don’t believe in luck, but I do believe in Karma. And I am grateful for the chance to rebuild my body and to live life to the fullest.

Happy training everyone!

K xoxo

Sesamoid Fractures

D10 Post Op Review
Day 13 post-Op

“Your journey has moulded you for your greater good, and it was exactly what it needed to be. Don’t think that you’ve lost time. It took each and every situation you have encountered to bring you to the now. And now is right on time.”

So it will be two weeks tomorrow since my foot surgery, what a whirlwind of a fortnight. This is going to sound like stating the obvious but I just cannot wrap my head around how much it has taken out of me – I mean, I can do an Ironman and run 3 days later, but this surgery thing is in a whole different ball park! Even as a physio, I am constantly amazed at how exhausted I am and how little it takes to get fatigued or to swell up the foot…..but I am learning, often the hard way, and trying to be very patient with myself (doesn’t come easily!). I guess I figured that I was super fit going into the surgery and I had done so much “pre-hab” that I would just breeze through it – ah, close but no cigar! As promised, for the medical nerds out there I’ll go into the juicy details; if you’re not into it then feel free to let your eyes glaze over momentarily while you fast-forward past this section.

The fracture to the medial sesamoid happened 8 months ago; because of the difficulty in diagnosing this injury and because it was literally Christmas time there was a 2 week delay in getting the MRI results and a definitive diagnosis, then getting into a boot to offload the bone. Sesamoids are well known for being very difficult to treat and even with 8-12 weeks in a boot, your chances of it healing are statistically about 50%. This is mainly due to the location of the bone (under the forefoot so it gets your full body weight with every single step), and the poor blood flow to it – which is usually only one small artery for supplying all the nutrients needed for healing. Often when it fractures, you either break the artery or the swelling compresses it, further limiting the blood flow. I’m sure the delay in diagnosis would not have helped nor – I’m sure in retrospect – would me working 40 hours a week on my feet while in the boot; lesson learnt and I would never let a patient of mine do that. (Got to love the benefit of hindsight) So long story short, 4 months after this I had another MRI that showed no healing through the bone despite the mandatory time the boot, and I found myself sitting in the very swish office of a well-known sports surgeon in a big city far away from home.
He explained that we had a few options, and after a lengthy chat and a lot of questions from me, we both decided that the best shot I had at competing in Ironmans in the long term was to operate. He planned to do a bone graft from the hip and screw it into the sesamoid, but also do a dorsiflexion osteotomy of the 1st metatarsal at the same time, which would effectively offload the sesamoid and hopefully prevent me from having this problem again in the future.
So far so good, but here’s the kicker: it was fairly major surgery. Two hours under the knife, overnight stay in hospital, 10 days in a backslab, 6 weeks in a cast non-weight-bearing, then a further 6-8 weeks in a boot partial weight-bearing and a grand total of 9-12 months before I start a return-to-run program. Gulp. I asked him how long we could put off the surgery – I needed time to think! – and he gave me a couple of months. I needed every bit of that time to process how I was going to handle the situation (mentally and physically, not to mention the logistics of work etc) and to most importantly psychologically prepare myself so that I would be able to maintain good nutrition for healing and not revert to old habits throughout this challenging time.

Which brings us to the now, 13 days post-op.

The surgery itself did not go to plan in that when he got in there, the fractured bone literally “fell apart like an eggshell” and so he set about salvaging what he could of it. No bone graft was done but he re-attached the ligaments to the new smoothed out bone and the outcome should remain as favourable as if the bone graft was done. The osteotomy went well, and when the backslab came off it felt like unwrapping a present to see two relatively big but very neat incision scars and everything coming along well. Surgeon’s happy means I’m happy. He didn’t let me leave without a 15 minute lecture on training and not overdoing it, but then he does work exclusively with athletes so I am thinking I was not alone on the receiving end of that spiel! My next review is in 5 weeks to get an XRay done and hopefully we can remove the cast and get into a boot shortly after. I am allowed to do upper body weights and Pilates as long as I do not put my right foot on the ground, but nothing else. I will hopefully get back into swimming and deep water running, plus cycling in the boot on the turbo trainer, once the cast is removed.

The things I have handled well include preparing work and home so that I can still be keeping my mind occupied – that is, running the business from home and still overseeing my junior staff treating my patients etc. That has been huge for me, because without running AND my work I go mad. Take away running – and Physio becomes my main crutch, excuse the pun. So the surgeon was happy to work with me on that one, I was upfront from the beginning and he has been brilliant with setting clear guidelines. As of next week I will go back to the clinic and see selected patients during half-days so that will be even better – the worst thing you can do in this situation is have only yourself to focus on! I was also lucky to have my closest friends around me throughout the whole process, as well as my husband’s family who I am closer to than my own. They all knew in advance that I would be in need of lots of laughs, some sense of “normality” and zero sympathy (I am NOT a good patient! Business as usual….well, as much as possible!). Anyone in my life that I thought would not be able to abide by those guidelines I haven’t spent much time with (yet). I need to make sure I have a strong support network around me and it has been worth its weight in gold; I would do the same for any of my friends. (Don’t be afraid to tell people what you need – your true friends will actually feel more comfortable as they will likely be upset seeing you so busted up as well! This was a lesson in life that took me a long time to learn but that has been invaluable). And of course, there has been plenty of baking coming from my kitchen (therapy for me and a great “thank you” gesture for said friends). Equally as important as anything else has been making sure I eat great quality food, regularly, and getting enough sleep – not as easy as it sounds with zero appetite after all that my body has been through. Of course, this is hard for me when I can’t train as the two remain inextricably linked for me (ironically I am healthiest food-wise when I am in full Ironman training mode), but having prepared mentally for it beforehand was very important. I have no intentions of gaining any weight during the next few months, but by the same token now is not the time to be depriving my body of any vital nutrients – the success of this surgery depends on it. My long-term running depends on it. And that, my friends, is non-negotiable!!
What I have found most challenging has been pacing myself – I am so used to going 100 miles an hour every waking moment of the day; obviously being in plaster non-weight bearing slows you down but having to stop and REST every hour or two is a HUGE ask for this little duck! The other complications couldn’t have really been predicted – I have low blood pressure normally (110/70) and a low resting HR (55) which I put down to being fit and possibly a bit of after-effects from the ED; but my body really struggled with the anaesthetic – the night after my BP went down to 70/40 and things got a bit hairy for a while there. But all is well now, onwards and upwards, time to rebuild this body!

Anyone wanting more info about sesamoids and stress fractures can head to this brilliant site:
and of course I am happy to answer any questions on this tricky topic or with coping with injuries.
Happy training!
K xo

(Un)lucky Number 13

So they say the number 13 is unlucky – I don’t consider myself a particularly superstitious person but perhaps that will change after this!  I would like to turn my bad luck into fortune so here is my best spin on the current predicament I am in.

In just under 24 hours I will have surgery on my foot to bone graft and fixate a stress fracture which I somehow managed to get some time around Busselton Ironman last year (almost 8 months ago).  How it all came about is a story for another day but the gist of it is, this will be stress fracture number 13 for me.

13 sounds like a lot but I will qualify it by putting things into some kind of context: the first 10 were all sustained during “the Ana years”, so when you work it out that’s averaging one a year during a period where I was running competitively as a distance runner (50-120km/week from age 12-22) and not eating much at all.

The last 3 stress fractures have been more “normal” athlete injuries, for one of a better description.  That is, they have occurred predominantly due to training errors on my part, and have occurred over the last 7 years of being a healthy-weight competitive Ironman athlete.  I have to add that with my personality type (ie a “Pleaser” and Type-A overachiever), being a Physio doesn’t really help with coaching errors – what the coach writes, I do, no questions asked.  That part of my brain that analyses injures for a living doesn’t really factor in much when I am training (that isn’t work time, that’s my fun time!) and unfortunately it’s something I still need to work on in the future to prevent more injuries.  While those down times have never been easy – time away from my love, running is always trying – in the past I have always managed to heal pretty well and been able to cross train through them.

Not this time.

Unfortunately this time the fracture was in a tiny bone under your foot called the sesamoid; it has terrible blood flow and so is notorious for being a slow healer.  So, despite the 8 mandatory weeks in a boot, the use of bone stim, good nutrition and now over 7 months away from running, it hasn’t healed.

This left me calling for a little help from my friends, who fortunately include a couple of top Sports Physicians and Orthopaedic surgeons.  At this point we were left with 3 options: 1) Remove the bone and hope for the best, which would likely include not a lot of running in my future; 2) Go back in the boot for 12 weeks, then operate after if it hadn’t healed – avoids surgery but not a great long-term outcome; or 3) to graft some healthy bone into my sesamoid and stick a screw in there to fix it in place.  This would give me a 90% chance of being back to running in 9 months, and back to Ironman training in 12, and the best long-term outcome regarding risk of re-injury.  For the medical nerds out there, the surgeon will also do a 1st metatarsal dorsiflexion osteotomy at the same time to unload the joint permanently.

So, this leads us to the now.  Granted, a week before major orthopaedic surgery would seem a strange time to start up a blog but for this little black duck, the timing couldn’t be better.  Over the coming weeks I will have forced “down time”, allowing me to get some writing done, but more importantly the next few months are going to be quite challenging.  What better opportunity to write about how to best handle it using strategies I have learnt over the last 7 years.  My hope is that in the process I can help a lot of people out there – because while I am certain my predicament is unique, I’m just as certain many of you have been through similar challenges (or may face them in the future).  I do know that one thing athletes are great at is talking a lot when things are going well, then going into a black shadow when they aren’t racing or training well.  There have been many times in the past when I wish that I could have had some advice about how to cope with injuries – mentally, not physically – from the athletes out there, and so I am going to start a trend: talking about it.  You can help by joining in the conversation and firing away with any questions or topics you might like covered.  I will do my best to entertain and enlighten!

So, wish me luck, and see you on the other side!  Hoping I can make 13 into my lucky number – I thoroughly believe everything happens for a reason.

Any questions or comments fire away.

Happy training!

K xo