MTSS or Stress Fracture? Does it Really Matter?

Deshea_Townsend_treated

Photo by Steel City Hobbies obtained from Wikimedia Commons

It feels so good to be able to progress from a red to green theraband and from couch surfing (+some suuuper easy stationary bike) to pool running last Monday. When I tried to actually swim a couple of strokes, my foot let me know that it wasn’t a good idea. But I was incredibly stoked about being able to pool run on Monday. I was also able to start walking barefoot with next to no pain (just going downstairs sparked some pain spontaneously) last weekend. Fast forward to this weekend, I am so thankful to have been able to attempt a 10x1min run/walk (with walking warm up). My left foot was a bit sore from riding to work with cycling shoes for the first time on Saturday in a couple of weeks. So after 8.5 minutes, I called it quits. BUT, I was able to get past the muscle guarding and fear, as I worked into my 5th rep and really felt like I was running smoothly again. I’m surely not out of the woods yet, but if it’s anything like my limited shuttle run workouts coming off my Lgr2+ hamstring strain, I think I’ll be back soon. (Fingers crossed.)

But while pool running for 30 minutes on Monday, I thought about what I learned at the running injuries course, as mentioned in my previous blog post. JF had talked about whether it was truly important to differentiate between MTSS (medial tibial stress syndrome) and a tibial stress fracture. If symptoms were the same, ie. same sort of stage in the injury, why would he need to send his patient for a bone scan, wasting money and increasing radiation sort of exposure, if his treatment would be identical regardless of the diagnosis? Most patients and competitive athletes might want to know anyway, just so they have something concrete that they can google and hopefully have a timeline for return to activity. However, I think JF has a point.

I for sure don’t have a stress fracture or MTSS. It’s likely just dysfunctional foot alignment and weakness in the structures. And my newest theory is that it’s glute amnesia, which was already sort of affecting my left glute in relation to my right shoulder dynamic instability near the end of my triathlon training last summer. The hours spent writing papers and then right into studying for finals might have just made it worse. And when I walked and ran especially, too much load and torque was put onto my left foot. But anyways, it kind of almost felt as if I had a stress fracture while I was pool running. It’s been about 4 weeks with this injury that came out of no where in the tail end of my finals before I even started to run, which obviously exacerbated it. Only last weekend was I been have to walk barefoot without much pain, after my fifth metatarsal was adjusted by the locum chiropractor I was working with. And my rehab has been kind of similar, as if I had a stress fracture, in trying to return to running.

I really wanted to try a walk run workout today to get my foot stimulated. This way, as JF really stressed, my foot can begin to adapt to the stress and the structures in my foot can receive stimulus to promote healing and strengthening. Similarly, as I mentioned, it’s probably why 2nd hamstring strain (also grade 2+ but opposite leg and ~6 months apart) recovered much faster than my 1st strain. I started a shuttle run protocol as soon as I could (as per the SFU varsity physiotherapist) and I recovered much, much faster even though when I initially started, I felt like I was running through maple syrup. My muscles weren’t firing as well as usual, so I felt like I was stuck in slow mo and my ROM (range of motion) was very limited. I felt insanely awkward like I wasn’t accomplishing much, but my body was very much fatigued after each workout. Thus the shuttle runs helped stimulate my hamstring to heal and got me back to running form quicker than when I didn’t do much of anything after my 1st strain.

Currently, even though my physiotherapist and I haven’t been able to pinpoint the exact “mechanism”  that led to this injury, what’s clear is that my left glute isn’t firing well in proportion to other muscles. And, the instability (and weakness) in my left foot is still present. So I’ve been patient and religiously working on my foot strength, proprioception and now glute strength. Nothing exciting, just trying to get my motor control and feet strength back.

It’s really all about getting back to the basics, especially after being affected by an injury for this long. I decided to test out my eccentric heel drops last week, and found that my left calf had ridiculously weak motor control that was nearly half of the control in my right calf. I’ve already been doing this for less than 7 days and today I could tell that the asymmetry has decreased. I’ve also been training a 2xMVA (motor vehicle accident) client at the gym for over 8 months now. Although her core and leg strength have gone up considerably, her neck and shoulder issues have been flaring up again the last while. As she is very aware of her own body, even she suggested to go back to basics. We’ve been working on a lot of scapular clocks lately for proprioception and motor control.

During the time that I was rehabbing my shoulder(s) (left was also a bit unstable), I was initially limited to glenohumeral centering and scapular control. I did this supine, then standing with therabands. -Next to people attempting to deadlift with good form, and with weight that was less than my warm up. I then came up with this phrase to help keep me patient and motivated: “Regress to Reinforce, Progress to Propel.” Following any injury, it’s wise to recheck your foundation. Is that transverse abdominis firing as it should? What about the big trouble maker, glutes? My good friend and former coworker, who is an RMT and fellow kinesiology student, came up with another good one in parallel: “Simple to Stabilize, Complex to Challenge. – Christin Sadler.

So I think no matter what injury you suffer from and no matter what the “true diagnosis” is, whether it’s MTSS vs. stress fracture, you have to start from the bottom and make sure that the foundation is there before you progress. This will lead to a more steady return to activity and less chance of re-injury. With that being said, no matter how long it takes, single leg box jumps, I’m comin’ for you!

Advertisements

Minimalism: 3rd Time’s the Charm

This weekend I was part of The Running Clinic’s Newest Trends in the Prevention of Running Injuries course led by Jean-François Esculier. It was fantastic and well evidence-based. Many things were discussed, but one of the big messages was how minimal/minimalism/minimalistic running can make a runner more efficient and alter characteristics that commonly lead to injury. This wasn’t the first time that I heard rallying for the minimalism approach aside from shoe companies and media. Let’s back things up to when I was first geniunely intrigued by minimalism running.

One of my highschool cross country and track coaches actually ran in Vibram FiveFingers when I was in highschool. I recall running with him as he ran in his “feet gloves” as the cross country team ran the golf course for easy runs. It was interesting at the time, as Vibram’s FiveFingers line really took off for both running and training in the gym. But I didn’t think that it was for me. My coach commented on how he found that his running gait changed to a forefoot strike when he wore his Vibrams. But as soon as he switched back to his regular runners, he switched back to his regular running style. In the middle of my highschool career, my other coach had us run strides and some drills barefoot on the infield of the track. His explanation behind the premise of this new coaching implementation made sense. When running barefoot, we become more efficient, as we shift our weight more foreward, ie. less heel  or rearfoot striking. Our cadence increases and our stride length decreases to a more efficient length. Plus, you strengthen muscles, especially in your feet, that get neglected when running with shoes. Following this introduction, 3 more people have convinced me about minimalism.

1. Born to Run by Christopher McDougall
After reading the book several years ago, I was so gung ho and swept away like a fan girl about running barefoot/minimalism. I was very intrigued by the Tarahumara runners. Going minimal sounded magical and I wanted to run like a swift gazelle too. I’m not 100% sure about this, but it may have been what convinced me to try out Saucony Kinvara’s, after having run in “motion control” type of shoes throughout my highschool career. I had always struggled with tight shins in highschool. It wasn’t exactly “shin splints” or “medial tibial stress syndrome”, but similar. And I was close to being diagnosed with compartment syndrome, but it was ruled out by a sports doctor at UBC’s Allan McGavin Sports Medicine Centre. Anyhow, to keep it nice and short, since I’ve switched to more “minimal” shoes, I’ve never had my shins as tight, where I get to the point that I can barely dorsiflex and must cease the workout. My hypothesis is that I altered my footstrike and resultant running gait (only solution for compartment syndrome as I learned today) and strengthened my feet by switching to Kinvara’s.

2. Dr. Irene Davis’ Evaluation and Treatment of the Injured Runner weekend course
I attended this course when she came to Vancouver, less than 2 years ago. Dr. Davis brought up that my Kinvara’s weren’t even true minimal shoes, as she considered shoes more like the Vibram FiveFingers with 0 toe to heel drop as true minimal footwear. But compared to everything I ran in previously, Kinvara’s were “minimal”, in my opinion anyway. After hearing Dr. Davis’ research and opinion, I was pretty close to looking into training minimal that winter. I forget what stopped me, but I decided to put that idea on the backburner, probably because I didn’t feel like investing in more shoes at the time.

3. The Running Clinic’s course this weekend led by Jean-François Esculier
As we come full circle, here I am. Still rocking the “minimal” style shoes (wearing Pearl Izumi Road N0 only because I didn’t hear good things about Kinvara 4; and wearing Saucony Type A6/Brooks T7 Racer racing flats). Interestingly, even Jean-François noted how he would consider the Saucony Kinvara line as more of a “light trainer” and not a true minimal shoe. His clinical and research experience determined that wearing minimal shoes vs. maximal shoes does not decrease the prevalence of injuries. Minimal shoes will change the locations of where the body is most loaded when running. Instead of maximalist shoes (not limited to Hoka’s beastly shoes, but the typical big motion control, bulky shoes) that load the body most at the low back, hips and knees, minimalist shoes will load more of the lower leg and feet, eg. calves, Achilles tendon, metatarsals. Injury is just caused by maladaptation and too fast of a transition eg. between shoes, training volume/intensity, etc. However, literature agrees that minimal shoes will stimulate more protective biomechanics, such as less impact force and better dynamic alignment of the lower limb. As a result, running efficiency and feet strength will increase, which sound highly attractive to me. Jean-François does encourage running in minimal shoes like Dr. Irene Davis, but like everything, it depends on your goals and your current health status. He has this pdf that is a flow chart to help people discern what types of shoes are suitable for them.

One of the large themes from this weekend is that the body adapts to its stresses. This will include running in minimal shoes, when introduced slowly and progressively. I don’t think that I’ll train to become specifically minimal for this summer, since I plan to race Squamish 23 in a pair of Salomon Speedcross 3. But I’ll surely add in the barefoot strides and drills again, in addition to a slew of foot strengthening exercises. However, in the fall, I plan to try introducing minimalism into my training. Jean-François mentioned how proper adaptation and periodization for the transition into minimal running can take about a year. It starts from say, running 29 minutes in your usual trainers and 1 minute in the minimal shoes. Then, 28 minutes in usual trainers and 2 minutes in minimal shoes. Etc. If that’s the way to safely do it without risk of injuring myself, I think I’m game to try it. Why wouldn’t you want to feel like a smooth, floating gazelle?

“Every morning in Africa, a gazelle wakes up, it knows it must outrun the fastest lion or it will be killed. Every morning in Africa, a lion wakes up. It knows it must run faster than the slowest gazelle, or it will starve. It doesn’t matter whether you’re the lion or a gazelle-when the sun comes up, you’d better be running.” – Abe Gubegna 

How to Maximize Your Recovery Post-Treatment

“Sometimes serious injury is a great thing for an athlete. It provides the chance to rebuild everything they never had in the first place.” – Charlie Weingroff

I wish I could say that this was me right now 

but as it stands, or rather, as I sit, this is more like me. 

It’s not a serious injury, such as a stress fracture, but it’s a mysterious “chicken or the egg” injury. The only thing that’s clear is that I never rebuilt the foundation in my left foot that I’ve needed to, likely within the last 2 years. In January 2014, I had the most glorious, close to “runner’s high” 16K long run (on sidewalks). I felt good going out for 8K, then coming back I started to feel an ache in my left arch. No biggy, I kept running and I felt good despite that growing ache. I felt fantastic after I got home, all except for the fact that my foot was now swollen and I could barely bear weight on my foot. What happened? Well, I sprained structures within my medial longitudinal arch, without acute trauma, just from the magnitude of foot falls on pavement. Once my foot healed I didn’t end up running much in that spring semester due to other reasons. In the summer, I found myself riding and swimming more than running while training for my first triathlon. And here I am. I lacked stability then, and I lack it now. I’m unfortunately not hitting the roads or trails, training for Squamish 23K at the end of August. I’ve got a lax subtalar joint and lack of ligamentous strength that would reaaaallly be needed on the trails. So in one sense, I’m thankful that this is happening now, as opposed to a few weeks out from the race. In another sense, the bang to start my summer semester was to soak up the sun and train hard. Well, if you’re forced to couch surf like me, and desperate to get back to good health and action, here are some ways to maximize your recovery post-treatment.

If you want to get the most bang for your buck after seeing any therapist, be it an RMT (registered massage therapist), physiotherapist, etc., what you do immediately following your appointment matters. Think about this. If you’re seeking treatment due to chronic injury, you’ve most likely built muscular/fascial compensation patterns leading to your dysfunction. It takes adjustments, needles, massage, etc., to try to break that pattern and reset the nervous system so you can lay down new, better patterns to lead you to improved health. (Cue active rehabilitation exercises).

So how can you maximize your recovery post-treatment?

Drink Up
Most practitioners will advise you to drink plenty of water following a treatment and in the days after. Why? Well the body is made up mostly of water and it’s widely used as a transport mechanism to flush out the metabolites and toxins that hopefully got released when you were getting worked on. My wording may not be scientifically accurate, but essentially, we want to flush out the bad waste and replenish tissues with water and help bring in nutrients. It follows the same principles of why you would want to rehydrate following a workout. When you exercise you stress the body. When you are receiving thumbs, needles, metal Graston tools into sore tissues, that’s stress too. So in the same way, hydrating after treatments is just as important.

Get Sleep
This would make most sense but it’s also something we easily ignore. Sleep is when the body can optimally repair. I remember reading about this on the internet in highschool when I was desperate to get better from my injury. Some article stated the importance of sleep under “Treatment”, so I immediately told my friends that I couldn’t keep talking on MSN and I slept super early. When your body is weaker than usual, trying to heal tissues, your overall body could use some extra ZzZs. The body always has healing to do from every day stresses, but with an injury, there’s additional damage control that it must deal with. Thus if you want to get reap the most benefits and get better faster following a treatment, it would make sense to get a good night’s rest and in the following days.

Nutrition
Now you must think we’re talking about recovering from a workout, not a treatment where it should have made you already better in the first place. But if you’ve suffered a muscle strain or tear, would it not make sense to also have good nutrients to create new tissue? Even if you’ve sustained a stress fracture, the body needs the proper balance of minerals and vitamins to build new bone. Most, if not all, of the vital nutrients that we need come from our diet. My former teammate in first year told me how if he felt slight muscle twinges (preluding to a blown-out strain) during practice, he’d make sure to eat extra protein and carbohydrates. And somehow, it would seem to help and he’d be good as new. Obviously it doesn’t really work, but when I was super desperate to bounce back from my grade 2+ hamstring strain, I was willing to try anything. Nevertheless, the concept is still important; if you want your body to heal, you need to provide it with a steady amount of good nutrients.

Keep Your Cool
If you let your stress levels peak after a treatment, it won’t help the healing process. Obviously this is a difficult thing for people that need to return to work, to taking care of the family, etc. But ideally you would try to keep things on the down low so your nervous system can hone in on your physical ailments and let the healing take place. If your mental state affects your exertion levels in a workout, then it will also do the same for your recovery. I’ve experienced first hand how mental stress can really put a damper on physical recovery. In addition, I get many questions from people asking if they can crosstrain or do other strenuous activity so long as it doesn’t flare their injury up. It depends on what stage of their injury they are at. Generally if it’s acute or they just received a huge treatment, then my two cents is this: in the immediate days, relax and let your body absorb the good changes elicited from the treatment. I always thought if you worked your other body parts really hard, then you’d be taking your nervous system’s attention away from the injured location. It would panic and be confused about which body part to focus its recovery on. Steve Magness found that having his athletes relax in a social environment immediately after workouts improved their recovery.

All of this is just about optimizing your healing and recovery to get you back to feeling better sooner. These minute details aside from making an appointment, attending the appointment and working with your therapist to solve your issue(s), and following their directions eg. ice/heat, exercises, are just things you might want to think about when trying to reap the most benefit from your treatments. It might also help you feel active in your rehab when you’re supposed to just couch surf and be passive. Most of the time, you get sore the day(s) after a treatment, just as you would from a workout. So why not take care of yourself in the same way as you would after a hard workout?Currently, I’m making sure that all of those are on point, doing banded rearfoot eversions religiously among other things that I can do without pain, and looking to rebuild the foundation that’s been missing in my left foot.


If you’ve made it this far, thanks so much for stopping by and giving up your generous time to read. I’m influenced by great blogs by strength coaches, such as Tony Gentilcore, Eric Cressey, Jon Goodman and Dean Somerset, just to name a few. They are able to elegantly present evidence-based facts, while sharing their opinion and humor, which make it really enjoyable to read. I hope I can mimic that to some degree, where my blogs are insightful, helpful and enjoyable to read at the same time. The main content here will likely just be some reviews and my thoughts about things. Examples of what you can expect from me in the next while are: reviews and my 2 cents on my arsenal of recovery tools such as MobilityWod’s Supernova or the R8 Roller; Why I Came to Love CrossFit, But Will Likely Never Crossfit Myself and 6 Things that CrossFit Games Athletes Taught Me.