Everything I Wish I Knew: My Stress Fracture Story

Kicka här för hela inlägget på svenska: En löpares bekännelser: min stressfraktur från start till mål

Maybe not the most fun topic of all at first glance, but hopefully one that can prove useful to some of you out there. When I first sustained my injury, I would have loved to read someone else’s description of their journey from diagnosis to return back to running, but couldn’t find much – so I figured I needed to write one myself!

In other words, my intention is to try to provide a little bit of guidance to those currently struggling by sharing what went down and how with regards to my stress fracture. Needless to say though, no story will be an exact copy of another so I urge you to keep that in mind when reading – don’t jump to any conclusions and don’t assume your road back will look exactly as mine did. A stress fracture is indeed an athlete’s nightmare, and it’s easy to get stuck in a very frustrated, hopeless type of mindset. Many of us try to seek as much information as we possibly can in order to cope and grasp what’s ahead of us, but maybe with stress fractures more than any other injury, the trajectory of each individual case can look rather different. There are those coming down with one that are back to running in five to six weeks, and then there are cases in which the recovery takes five to six months. In other words, educating yourself is always a good idea, but believing each and every thing you read is not. Trying to tune into you own body and stay calm in the initial stages – however difficult that is – will be your best bet.

Before I dive into the details of my own story, I wanted to straighten out exactly what a stress fracture is. Simply put, it all comes down to an imbalance between osteoclastic and osteoblastic activity. Osteoclasts are cells removing bone tissue, whereas osteoblasts are creating new. Bone is a dynamic tissue in the body which responds to stress (i.e. movement, activity etc.) by reshaping and being made stronger by the cooperation between osteoclasts and osteoblasts. In the case of a stress fracture, the osteoclastic activity has been outstripping the osteoblastic – in other words, there’s more removal of bone tissue than there is formation of new, and this is most often caused by too much stress on the bone compared to the amount of rest and recovery. Eventually, this imbalance results in microscopic cracks in the bone, and ouch – we have a stress fracture.

I’ve divided the rest of this post into five different parts, taking you through the whole process from start to finish. I sincerely hope you’ll find some useful information here, and – if you’re injured – I wish you the best recovery and return back to your sport. Alright? Let’s go.

Pre-Injury

I was very happy with my training year of 2019 up until the time of my injury. Mike and I had increased our mileage slightly from the previous year, but we felt as if we had done so mindfully and in a controlled fashion. For the most part, we logged about 100-120k per week, typically divided over six sessions, and we popped up to 140k one week in July. Most of our running had taken place on trails and gravel roads, and exposure to pavement running had been limited as per usual. Overall, I felt really good the entire season, performing well at races (my 8th place at Ultravasan 90, 3rd place at Höga Kusten Trail and 1st in Åre Trail Tour felt like the biggest accomplishments) and being able to recover fast after each all out-effort. Because of frequent racing and being in a constant cycle of taper mode and recovery during late summer and early fall, we ended our last big training block in late July and surfed on that wave throughout the coming months, only doing about 50-70k of running per week (excluding races). Basically, it was all good… until it wasn’t anymore. More about that in the next part.

Time of injury

Fast forward to mid-October, and I found myself out running on my own one day (Oct 14th). Mike had some minor hip pain so he was giving himself a few days off, and this particular day I was only going for an easy 12k run. About 8k into it – without any indications of pain/discomfort whatsoever prior – I felt a sharp and rather intense pain in my left foot, sort of where the the third and fourth toes blend with the rest of the foot. It subsided slightly and was nothing I gave much thought, so I continued onwards and returned back home without any particular worries on my mind. I still noticed a sensation in the area, but I wouldn’t go as far as saying it was painful. I thought some muscles were a little tight and made sure to stretch the top of my feet a lot that evening. The following day, I had a road biking session planned, and didn’t ponder my foot one bit. Sure, the sensation was still there, but that was all there was to it. On Oct 16th, however, things got juicy. I had planned on a 10k tempo run and left home in the early hours, only to start noticing the pain increasing more or less immediately. After about 1.5k, I stopped to walk a few steps. At this point, it was rather painful, but it got much better once I stopped running. It never crossed my mind that this was a stress fracture, so I told myself to just tough it out. I ran another kilometer or so, only to feel the pain intensifying by the step. Around here, I had started thinking that maybe I should cut the run short. When I had been out for about 4k, I turned around, and from this point and until I got back home, my “running” was more of a combined limping/jogging movement. Walking brought a slight relief, but the pain did no longer go away entirely.

The reason why I kept moving as fast as I could – even though it meant more pain – was that I was quickly getting very cold. We had a quite chilly October, and this particular day the temperature hovered only a few degrees above freezing – and it was drizzling from the sky. When I finally arrived back home, I was at a loss as far as what was going on. I’m a certified sports massage therapist with an additional degree in sports physiology, but I couldn’t wrap my head around what had happened. A stress fracture felt miles and miles away, as I was under the impression these typically come on gradually and often can be linked to a significant change/increase in training. I didn’t feel as if anything applied – all I knew was that my foot hurt so much I couldn’t put any weight on it at all (and I’m rather pain-tolerant, I should add). If I were to describe what the pain felt like, the word sharp comes to mind. It literally felt as if someone had dropped a 15 lbs kettle bell on top of my foot and crushed it. The rest of the day, I was starting to panic slightly, as I stayed still with my foot elevated most of the time. When palpating (i.e. touching) the foot, I could tell I was very tender close to the third and fourth toes, and when dorsiflexing (i.e. bending at the ankle so the toes move closer to the shin bone), the pain intensified. I could also tell it was slightly swollen, but nothing too severe at this point, and there was no obvious redness (however that would change). When we went to bed that night, I didn’t really know what to think of anything. We had our first ever Backyard Ultra coming up the following Saturday (this was a Wednesday) and even though I knew it was looking rather grim, I don’t think I had accepted my defeat just yet. That realization came on a few hours later, I believe, as I woke up around midnight from a foot so painful I couldn’t believe it. I went to the bathroom but I had to drag myself there as I couldn’t put any weight on it, which lead to Mike waking up and asking “why are you stomping so hard?” and we both started laughing. Ever since then, we refer to that night as the stomper night (and apparently, it’s very common for stress fractures/fractures to hurt more at night). I couldn’t fall back asleep for a few hours because the foot was throbbing so intensely, and I started thinking that maybe we should go to the emergency room the next day. In the back of my mind, I couldn’t help but to worry that it could be a blood clot, which of course was a result of me being ten weeks pregnant at the time. When morning finally arrived, that super intense pain had subsided slightly and I was back to where I was the previous evening. We concluded we should go to the hospital, and that will mark the end of this part.

Part I post-injury

We decided to go to our closest emergency room, which is at Norrtälje hospital. I really didn’t have to wait for too long before I got to see a doctor, but that was the end of the good part of this first encounter with the medical world. The doctor I got to see was a GP, and she basically took 30 sec to assess my foot, rolled her eyes at my training volume (so as to say well, darling, my foot would also hurt if I ran that much) and then sent me to get an X-ray. The films came back clean (which they more or less always do in the initial stage of stress fractures) and she sent me home with crutches and the advice to pop two paracetamol. I was not pleased when I hopped into the car to go home, to say the least. My status then remained about the same for the next few days, with the addition of two symptoms: my foot was getting increasingly cold (like, ice cold despite several layers of wool socks) and also turning some sort of purple-reddish hue. This freaked me out a bit, as I didn’t feel confident the GP had made sure I wasn’t suffering from a blood clot. Two days after the first hospital visit, we took to the road again and shot for the bigger Danderyd hospital instead. Here, I was so happy with the treatment! I got to see an orthopedist who assessed me properly, ruled out a blood clot (and explained the coldness was probably due to the immobilization) and basically concluded the only way to find out what the heck was going on with my foot was by doing an MRI. I got a referral for an MRI three days later, and an appointment back with the orthopedist was made for four days after that. I was also told to not put any weight on my foot whatsoever, and definitely urged to take that advice seriously. Said and done. Back to the car I jumped on my crutches, with my mind set on an MRI.

The next day, I received a phone call from the X-ray department at the hospital, informing me that unfortunately, an MRI isn’t permitted while pregnant in the first trimester (some even recommend staying away from it during the entire length of pregnancy). This is a medical stance taken due to lack of evidence it is not posing a risk, as opposed due to evidence that it does, but I sure wasn’t going to argue. Prior to them calling, I didn’t think it was going to be a problem because I would come for a foot (compared to, let’s say, a lower back issue), but as soon as I was informed about the contraindication, I tried to let go. It was annoying, I’ll admit that, since I knew an MRI would by far be my best bet to find out exactly what was going on. I was well aware of how stress fractures typically don’t show up on a regular X-ray films until they have started to heal (normally after six to eight weeks), so I was struggling to keep my mood up, thinking I could end up “waiting” to get a diagnosis for so long. I mean, what do you do in the meantime? What kind of rehab do you assign yourself, when you can’t be sure what’s wrong? Add to this the worst nausea-phase of pregnancy, and you’ll understand the end of October wasn’t the best time of my life.

So in the absence of an MRI, the orthopedist wanted to do another regular X-ray, just to be sure. Nov 4th, it was time again – and the films again showed nothing (which was disappointing but not one bit surprising). At this point, almost three weeks post the time of injury, I had seen absolutely zero improvement. My pain was the same, the swelling the same, the purple/redness the same. I was diligent with my crutches, but I was definitely a little edgy towards Mike. Upon injuring myself, I had thought ok, worst case scenario is that it’s a stress fracture, and in that case, I’m looking at a six to eight week long recovery time (because that’s what the internet will tell you). When seeing zero improvement after three weeks, I started to realize my journey would be a lot longer. It was difficult not getting stressed about this, I’ll happily admit that. I was in the (running) form of my life at the end of this season, with a great training year behind me. Given that I was pregnant and eventually would have to take a step back in the later stages of pregnancy and in conjunction with labor, I had really set my mind on training ambitiously all of the fall, to prepare myself as best as I could for the “slower” months to come. I had days where I thought life was unbelievably unfair – who gets pregnant and breaks their foot at the same time? – and wasn’t always the nicest to be around. 

Now, you would think that learning that nothing showed on the Nov 4th X-ray would have sent me further down that dark hole, but fact of the matter is that the opposite happened. First, the orthopedist said that we would just go ahead and treat this as a stress fracture, as they couldn’t think of any likely differential diagnoses and parts of my anamnesis did indeed line up with the concept (i.e. I’m an ultra runner). This meant I was equipped with an orthotic boot, and I really can’t speak more highly of this lifesaver of a tool. To begin with, as opposed to a regular cast, you can take this thing on and off as you please (meaning you can sleep without it), you won’t have to put up with that awful itching, and I believe it also benefits retaining both muscle mass and flexibility in the entire body part in question, as it’s a little more forgiving. But the glorious part is that my foot did not hurt in the boot. Right from the beginning. I was strapped up by an orthopedic technician (lovely woman) and was just unbelievably happy to be able to “walk” with my foot in a correct position and not experience any pain. What I had done up until this point was “rolling” on the outside of my foot, so as to prevent the sole from touching the ground. This, of course, made my foot take on some sort of “claw-look” and I could tell how quickly you can get into bad habits and how difficult it would be to re-learn how to walk normally again. Like I said, I loved my boot from the beginning. I was told to wear it morning until night for five weeks, and another re-visit was scheduled for me on Dec 11th. I wasn’t explicitly told to continue with my crutches now that I had the boot, but I took the approach of “it can’t hurt” and continued using those for all my walks even though I was in the boot. I figured the lesser the pressure, the better – plus those crutches made my arms strong, and crutch-walking can be a pretty intense form of exercise, I’ll tell you.

The other thing that happened that day, which helped keeping my head straight, was an encounter I had with an older man on the bus on my way home. A gentleman in his early 80’s asked if the seat next to me was free (which it obviously was, I just had to get my crutches out of the way), and it didn’t take him many seconds before he had asked what had happened to me. I told him, and his next question was what my sport was. This was the start of a 30 min long fun, in-depth and totally nerdy conversation about endurance sports – this man had run a sub-2 hr Lidingöloppet back in the day, done 30+ Vasalopp, played soccer competitively and knew SO much about training I was in awe. Sadly, he had been diagnosed with a rare bone-related disease many years ago, and then prostate cancer following that, which had unfortunately kept him away from the world of sports – which he loved so much – for 20+ years. I can’t even tell you how much this conversation meant to me. Besides the obvious fact that I had so much fun chatting with him, he brought me perspective as strong and clear as a slap in the face. Who was I to be sulking and complaining day in and day out over a few months away from running, when he had been forced away from sports entirely? Who was I to portray my injury as the end of the world, when he gladly would have taken my diagnosis instead of his, had he had the opportunity? I owe him my sanity, and I feel endless gratitude towards life and the universe for sending him my way that day. And of course, I wish him all the best in the future. He had gotten himself a cabin out here on the islands a few years ago, to give himself something to do, and I certainly hope we’ll cross paths again. Mike and I have been joking around about trying to track him down and ask him to become our coach. I’ve never talked to anyone possessing such a wealth of knowledge regarding training.

To wrap up this Part I of post-injury, I spent another three weeks (until around Nov 25th) in a state of no change. Same pain, same swelling, same purple-red color. In an attempt to get a proper diagnosis, I made an appointment with a physical therapist for an ultrasound examination. This showed nothing either, but I knew beforehand chances were slim (ultrasound only detects stress fractures if they’re right on the surface and/or massive, I was told upon making the appointment). However, I just wanted to feel that I had explored all the options on hand. I maintained a pretty regular strength training routine (one hr sessions at least three to four times a week) and took long crutch-walks every day during this time, and we also got ourselves a spinning bike. I didn’t start to use this until the beginning of December though, since I simply experienced a decent amount of pain when attempting to earlier. I was told by the physical therapist that essentially, I should stay away from all activity causing pain at this point, but everything pain free was all mine to do. I would have gone swimming hadn’t we lived so far away from the closest aquatic center. Anyway, now we’re around Nov 25th, and it’s time for Part II.

Part II post-injury

A few days before Thanksgiving, I suddenly felt something had shifted. Nothing big (think more microscopic) but still – I felt something had moved in a positive direction. Maybe the pain was just a little less intense? Maybe I could flatten out the foot against the floor (e.g. when standing in the shower or at some other time when not wearing the boot) a little more? Maybe it was a tiny bit less swollen? It’s hard to say what I actually noticed those first few days of what finally started to feel like recovery, but it worked wonders as far as my mind. By far the hardest part of my whole process was those first ~six weeks of nothing happening. So if this is you, now – hang in there. The static state doesn’t mean you’ll need to amputate your foot or that the doctors missed a tumor or that you were misdiagnosed in some other destructive kind of way – it just means that some stress fractures are like this. It’s a big pain in the behind, but bear with it: there’s light in the tunnel, eventually. Just give it time. So for me, I feel like a turned a corner after six weeks. I kept my boot on just as diligently whenever leaving home, but I started to leave it off for some time here and there when just pottering about around the house. I felt as if my foot enjoyed some “fresh air” and sensed the swelling was a little less obvious at night when I had kept the boot off for a while. I let a week go by, and then started hopping on the spinning bike. My foot felt stiff, sure, but I didn’t experience any of that sharp pain at all. I wore a pair of old road running shoes and made sure to tie them quite tightly, and I have no words to describe the pleasure of the first few sweaty sessions. It was magical!

So with these improvements under my belt, I hopped my way to the X-ray department for what I hoped for would be the third and last time. At this point, all I wanted was for the films to show the fracture, which would mean that healing was underway. What the radiologist is looking for is called callus, which refers to the cartilaginous formation that appears at the site of a fracture as the bone heals itself. Eventually, this will dissipate and the completely healed bone will be the only thing remaining. When callus shows on X-ray, it means you’ve come far in your healing process, albeit not all the way. As I was in the X-ray room, I overheard some mumbling from the office and thought I could make out the words “callus” and “third metatarsal” and my hopes immediately shot through the roof. Could this be it? The moment I’d been waiting for? Well, an hour or so later, when I met with the orthopedist again, it turned out it was. I could have kissed her as she showed me my much longed for callus and handed me a printout of the X-ray film. After nine weeks of waiting, I finally got my diagnosis! I never could have imagined I’d feel so happy when hearing someone tell me “Stress fracture of the third metatarsal”. The doctor advised me to retire the orthotic boot, but to make sure I only wore really sturdy shoes for the next few weeks. She also recommended staying away from running until the new year, just to be extra careful, but that I could kick my spinning sessions up a notch and basically do whatever else didn’t cause me any pain. This was such a joyous day for me! I was all smiles as I returned to the waiting room, waving my printout at Mike and telling him all about it. I finally felt that I could see the end of everything.

I stayed true to all the advice given by the doctor, and I’m so proud that I did. I think this whole experience has taught me patience like nothing else, and if there was one thing I didn’t want, it was making things worse and prolonging my “misery” even more. What was another few weeks away from running, if I had already done nine of them?

Return to running

My foot felt rather stiff and not completely pain-free until about Christmas, when I started to feel as if I could walk properly without a limp (albeit no power walking, that still felt risky). With this in mind, I postponed my return to running even more. Playing it safe actually felt fairly easy, and with the spinning bike, I could still get in 10+ hours of rather demanding training per week without a problem. I also started using our balance board, which I highly recommend. We had a week of cross-country skiing planned Jan 12th-19th, so I ended up holding off until we were back from that, and I hadn’t felt any negative effects at all during that week, despite skiing at a quite intense pace for three+ hrs every day. The first day I could tell my foot was not used to that much of extension (i.e. when the top of the foot moves closer to the shin bone) and I got a little nervous that I had jumped the gun despite my patience, but it turned out to be totally cool. When we came back home, I went for my first run. I did 10k on Jan 22nd, and it was amazing. I’m a runner at heart, I truly am. The light movement, the freedom feeling, the navigating past roots and rocks along the trails… it’s where I feel like myself more than anywhere else. With that said, I don’t recommend anyone doing a full 10k without any intermittent walking as their first run back from a stress fracture. I just couldn’t stop myself, and I naively assumed everything was properly healed at this point, given the fact that I had given it an extra three weeks compared to what the doctor told me. I ended up feeling quite tender at the fracture site for a week afterwards, and felt slight hesitation in my step when walking (in the pushing off-phase), so I had to give it some time (~two weeks) to return to the pain-free state it was in prior to that run. I trust that you all understand exactly how angry I was with myself at this point, so there’s no need for me to explain that here. Now, I’ve done around ten “run-walks” of about 10-17k each, and I can happily tell you that I’ve had absolutely no backlashes whatsoever. I basically just run for maybe 500-800 m, and then I walk for about 100-200 m, and keep repeating that. Easing back into it seems to be the key for me, and I’ll simply just increase the running sections as I go forward. The discoloration of my foot is about 90% gone, and more or less all the swelling has subsided (it took so long for these two to disappear, which I’m thinking could be useful for others to know).

Needless to say, running feels quite differently now from when I last ran. I’m 30 weeks pregnant, feel a lot less light on my feet and need to pee about every 15 min. Yet, I have loved every minute of my “runs” so far. I intend to continue for as long as it feels good, and then be respectful towards my body and take a step back when it doesn’t anymore. I hope to feel fine using the spinning bike until the very end, and thank goodness for long walks!

All in all, it took me about 17 weeks from sustaining my stress fracture to being able to run pain-free and without feeling anything afterwards.

So that’s my journey. I’m not 100% back just yet, but there’s also a pregnancy to take into consideration. All in all, it took me about 17 weeks from sustaining my stress fracture to being able to run pain-free and without feeling anything afterwards. Mine might have been the mother of all stress fractures, or maybe pregnancy prolonged the recovery process – or maybe this was just the nature of this particular one. Either way, I’m here now, and I’ve learned so much along the way. Maybe most importantly that I never want to have to go through it again… but on the other hand, one part of sports and wanting to become better is constantly pushing boundaries and exploring where your personal limits are. Falling over on the wrong side of that precious line from time to time is part of the process, after all. I think my biggest question mark is why I did, actually. I didn’t go from low to high mileage quickly or do any of those things typically associated with the development of stress fractures, which was part of the reason why I found it so difficult to not receive a diagnosis for all those weeks in the beginning. It didn’t seem logical. But, it’s what happened. I can’t help to think it’s somehow related to me becoming pregnant, but there’s no way I’ll ever learn so I’m just letting go and looking forward. With that said, I’m happy to answer any questions and wish you all the best wherever you are on the spectrum – purely interested in the topic, suspecting injury, in the midst of it all or coming out of it. One thing remains clear: the risk of injury will never keep me away from sports. I love it way too much. Cheers to running and pushing your individual boundaries!

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