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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When all else fails, Bake.

Hormones rule the World…ok I get it, I GET IT!

It’s been a pretty stressful last few months, which largely stems from the fact that I am once again faced with the ever-challenging issue of learning to trust my body.

After having a miscarriage 4 months ago, my body has decided that it’s going to do its own thing, regardless of whatever I am choosing to do. Despite zero change in my food or exercise, I have been battling an influx of hormones presumably stemming from the miscarriage. My previously flat stomach is now decidedly curved and my breasts have gone from a small B cup to a large C cup. Initially I thought that this would level off over time, but it seems they are here to stay – at least for the time being.

Tiffany's-inspired Chocolate Cupcakes.  I dare you not to feel uplifted!

Tiffany’s-inspired Chocolate Cupcakes. I dare you not to feel uplifted!

It’s brought all those recovery memories flooding back. The overwhelming feeling that you are drowning in a sea of change and you don’t know when the wave is going to stop pummelling your body against the floor of the ocean. It’s also a bitter pill to swallow: that I would not only lose my baby, but that I would lose control over my body as well. My doctor reassures me that it’s a good thing, that my body is trying to set itself up to become pregnant again (which is what I want more than the world). My psychologist says that I should focus on the positives, like having amazing breasts – my husband has certainly had less trouble than me focussing on this one – and that this will not last forever. But for me, it’s all been downright confusing. Just when you think you truly know your body, know what it likes, know where its set point is, have come to accept a certain size as being healthy for your frame….it all gets thrown to the wayside. I can almost hear God laughing.

Once again it has reminded me that hormones do, in fact, control the world. Or at least our sleep, mood, emotions, fat deposition, curves, weight, fatigue and ultimately, fertility…. So what to do? The only thing I know how to do: make sure I am taking the best possible care of my body and mind and trust that it will settle into itself, wherever it is supposed to be. Which means, for me, cutting out caffeine and alcohol, eating A LOT of fruit, vegetables, good quality protein, nuts, seeds, good fats, and of course steering clear of gluten (I have Coeliac disease, as an aside, which does put me at a higher risk of miscarriage along with a history of Anorexia. Oh the joys.). It also means focussing on nourishing my body with activity that brings me joy and relaxation, namely running, dance, Pilates, group rides and swim sessions with my husband. Not because I have to do a set session or hit a predetermined interval; simply because my body can and it makes me happy. That is an important distinction. It means getting at least 8 hours of good quality sleep a night, and actively trying to relax during the day – deep breaths at work, 5 minutes of meditation when I get the chance, and laughing a lot. And of course, when all else fails, it means baking – the cheapest and best therapy of all.

Death by Chocolate: Chocolate Mousse Layer Cake with Chocolate Ganache

Death by Chocolate: Chocolate Mousse Layer Cake with Chocolate Ganache

I’m not sure that I will ever be able to accept that I cannot control what is happening with my body. Ultimately, your body will change at various stages during your life, and there is very little that you can do to stop that – short of being unhealthy and falling back into eating disorders patterns, or conversely, saying “stuff it” and allowing yourself to become significantly overweight, which is not healthy either. It is well established in the research that your body has a “set point” – a range of about 5 kg, that it will defend at all odds. So just like in recovery, when you have to trust that you won’t keep gaining and gaining indefinitely; I too have to now trust that if I nourish my body and treat it well it will do what it needs to do to create the optimal environment for baby-making and health. I can’t change what that shape ends up looking like on me, but I can change how I react to it. I am faced with a choice – to reject the change and stick to everything I have known up to this point, or to embrace that I do not have control of what is happening and to learn to love my body, no matter what form it presents in. After all, I am still the same person inside.

It’s going to be a challenge, but I’m pretty good at overcoming those.
Keep on keeping on fighting the Good Fight. This one is going to be tough.

“When doubt seeps in, you got two roads, you can take either road. You can go to the left or you can go to the right and believe me, they’ll tell you failure is not an option. That is ridiculous. Failure is always an option. Failure is the most readily available option at all times, but it’s a choice. You can choose to fail or you can choose to succeed.” – Chael Sonnen

K xoxo

“When you come to a fork in the road, take it” – Warren Miller.

I now stand here just under a week out from the Hawaii Ironman World Championships. I should be on a plane, on my way to the enlightened place that is like the Garden of Eden for triathletes – Kona. The sacred lava fields and the magical place that is the finish line, able to immerse every blessed athlete in a drug-like serenity more addictive than heroin.
Instead, I’m back home, 10 weeks post major foot surgery (and still in a boot), preparing to do a presentation for a medical conference this Saturday. I’ll be speaking in front of 150 doctors, physios and health professionals about one of my specialty areas, which is an opportunity I never thought I would be granted this early in my Physio career. I am truly humbled by it.

So what would I choose, if I had the choice, of Kona or this conference? Kona, in a heartbeat. Not even a question. But as it turns out, not being able to race has given me this opportunity, which will in the long run build my career to a place of more freedom, which will allow me to train and compete as a more focused, well-rounded Ironman athlete in the decades to come. It’s all a big circle, this merry-go-round called life that we are on. And the important thing to remember is this: just don’t stand still.

Growing up as a child of the 80’s with snow-obsessed parents, Warren Miller movies were entitled to cult status in our household. And I never really got that famous Warren Miller musing: “when you come to a fork in the road, take it”. Now, I finally get it. When life throws a spanner at you, don’t stand there blinded to the rest of the world. Don’t kick and scream and fight it. Look around at all the other open doors that this (knockback) opportunity has allowed you. Pick one – any one – just do anything other than stand there fighting something that you now have absolutely no control over. What’s done is done, been and gone. Take a deep breath, look outside your current sandstorm and take a step in a direction that looks sunnier than where you are now.

Feel the immense relief and lightness of being in not having to fight any more. Just let go, and allow yourself to be uplifted by something bigger than yourself.

You just never know what lies ahead on the road up ahead.

xo

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Learning to “Hurry Slowly”

Nothing like Melbourne's best espresso to help one hurry slowly.  Brunetti's, amaze.....

Nothing like Melbourne’s best espresso to help one hurry slowly. Brunetti’s, amaze…..

“You can’t calm the storm, so stop trying. What you can do is calm yourself; the storm will pass” – Timber Hawkeye

Hurrying Slowly

This phrase has always immensely annoyed me as I find it very hard to get my head around the concept that sometimes, less is more. I am an intelligent and logical person and I can see how the concept is supposed to work; indeed I spend large proportion of my waking hours explaining its importance to my injured athletes (patients) so that their bodies can heal in due course. However, as with a lot of things in life, applying it to oneself has remained a challenge for me.

The first time I encountered it was from the man who moulded most of my triathlon ‘career’ to date, my coach. He used to annoy the hell out of me by responding to my long rants about how impatient or fatigued I was at any given time with the simple response: “we hurry slowly”. “I don’t do anything slowly!”, I would retort, and as it turns out this was to be my ultimate “fail” as I sit here recovering from foot surgery essentially because of my inability to stop when needed and not push the boundaries of the amazing human body (combined with a large proportion of congenital biomechanical predisposition to developing a sesamoid dysfunction). Lesson learned.

So the way I see it, the Universe has given me another shot at learning to “hurry slowly” and this time, I am listening up. It’s been a huge challenge for me, but it helps that the human body is pretty clear about things in a post-operative state: you do too much, you get pain. You get too busy, the foot swells. It’s not rocket science. But it is a great chance to practice the concept of listening to one’s body and pacing oneself. And I am hoping that by developing these skills, I will have a more successful shot at applying the ‘hurry slowly’ concept to my life when I am back in full swing – working full time and training full time. This is when the real challenge surfaces, as the vague rumblings of a body that is overstressed can be easier to ignore – the churning stomach, the over-racing mind, the lack of appetite, the niggles that pop up with routine training, the fatigue that slowly creeps up over days or weeks, the loss of patience for life’s little annoyances. These are all important signs to look out for and they should be respected even more than the clear-cut objectivity of post-operative pain and swelling.

Because, ultimately, a foot will heal as the amazing human body turns over its bone cells in a cycle roughly every 6-8 weeks.

But our health – mind and body? That is forever. We only have one body, and one life. And we can’t do a simple operation to “fix” it. So instead, we must take great care of it; listen to it, treasure it, and learn to go with its natural flow.

Hurrying Slowly.

K xo