Today we welcome a guest post from personal trainer Natalie Salter. The article below addresses how to recover from an ankle stress fracture. Natalie does a great job on going over what a stress fracture is and explaining how to fix it.
REVIEW OF INJURY: ANKLE STRESS FRACTURE
Lisa experienced an ankle stress fracture, an overuse injury that creates a small crack in the bone.
What is a stress fracture?
When the muscles of an area are overtired and continue to be worked, the support of the muscle itself on its attaching bones is lessened. The stress of the muscle from overuse is actually then transferred to the bone, which can result in a crack or what we call “stress fracture”.
What exactly causes a stress fracture?
There are a lot of factors that come into play when discussing what causes an injury including gender, frequency combined with duration and intensity, conditioning, equipment and environment, and technique. Women are generally more susceptible to this type of injury than men are due to decreased bone density as we get older and especially in female athletes that lack regular menstrual cycles. When exercising, it is important to challenge yourself but there is always a limit that is created by the stage of training that you are in, whether you are a novice or an advanced exerciser/trainee. This can be determined by strength, mobility, endurance, etc. It’s imperative to stay within your means of training in order to improve quality of life. As a trainer, I am not going to instruct someone that can barely run a mile to include 20 minutes of 1min:1min sprints on the treadmill in their workout routine. Your body must slowly condition through a continuous cycle of stress, rest, and adaptation. But we must also be aware of our surroundings and that injury cannot just come from external forces by internal means but equipment and environment as well.
What is affected by a stress fracture?
Your body is a single entity encompassing thousands of little and big parts that all work together in unison to keep the organism alive. It’s one of the most beautiful aspects of life if you really look into how the body works. As we know, what happens to one part of the body can affect another. People that have strokes will often experience some sort of paralysis in portions of the body. When the brain is damaged from the actual stroke itself it can affect the transport of messages that occur between brain and skeletal muscle instructing the body on what movement to perform. Let us apply this theory of connection to the feet, knees and hips in association with equipment. Think of your feet as the mattresses to the rest of your body. For example, if you have flat feet, or overpronation, the alignment of your knees are now affected. If not treated, soon it can lead to hip pain or conditions that may be irreversible if left overlooked and untreated long enough. You alter the natural rhythm and position of the body in one area, and you almost certainly influence another. Wearing appropriate footwear and exercising on surfaces that create less of an impact on the body (i.e. wood floors of a group fitness room, as opposed to concrete slabs of outdoor sidewalks and driveways) can assist in making our joints long lasting as well as its supporting muscles and bones. Maintaining proper support can be a key influence in your feet, ankles, knees, hips and spine. But the connection can go both ways.
A stress fracture of the ankle that is overlooked can actually have a bigger impact than you think. Every skeletal structure in the body is connected in some way. What will affect the lower body will affect the more proximal structures when it comes to the skeletal portion of the legs because the feet and ankle support the rest of the body. Ignoring a stress fracture can increase chance in the bone breaking completely. It can cause Plantar Fasciitis, sprains and strains. If left untreated it can cause localized pain that will last forever, disable the person and limit range of motions. You also have now increased the risk the likeliness to reinjure the area.
Breakdown of Injury.
In Lisa’s injury, it was brought to the attention that her hip abductors and external rotators were weak. These muscles are known as biarticular, in that they cross two joints, being that of the hip and knee. Because of this weakness, Lisa experienced a lack of stabilization in the knee which led to a misalignment in her run. This contributed to a fallen arch that continued to be used, resulting in an ankle stress fracture. It is also very likely that Lisa’s shoes put in a great deal to the equation as well, with little support to make up for lack in strength in those muscles. However, even if Lisa was wearing shoes to support the issue, it must be understood that if possible we cannot compensate for a problem that is sustained within the body using outside tools and equipment such as ankle wraps, orthotics, etc.
It is very important to understand that immediately following injury, the muscles, tendons, and ligaments will be at their weakest and initially need extra support. But to continue support without strengthening the area through rehabilitation will only induce weakening of the joint in the long run. As stated earlier our bodies become conditioned through stress, rest and adaptation. We wouldn’t survive without adaptation; and such a large concept breaks down to even the smallest level of an ankle sprain for example. The muscles and ligaments of the ankle that have continued to be supported by an ankle brace long after the initial sprain will sooner or later become accustomed to the wrap. The joint will now rely on the support of the brace rather than its natural internal support system (muscles, tendons and ligaments). Consequently, the area that once supported the joint will become inhibited and over time without proper strength and stabilization exercises will progressively become weaker. In order to successfully recover from any injury an action plan that includes awareness, treatment and prevention must take place and be taken seriously.
As a result of the injury, Lisa attended physical therapy. Our goals as a team were redirected towards her injury. Our routine completely shifted focus to rehab of the injury and designing new exercises that still provided Lisa with an effective training routine. Initially, I avoided any weight bearing exercises that were directly loaded over the feet. When she began physical therapy, we focused a lot on another area she had been concerned with which was core. As a trainer you have to stay within your boundaries, as you are a Personal Trainer and her Physical Therapist is her Physical Therapist. But we all have one thing in common: Lisa. We are all a team. As she progressed through physical therapy, her Physical Therapist brought me notes to let me know exactly what Lisa and I needed to focus on to ensure a quick recovery. We wanted to avoid exercises that involved impact. And include exercises that strengthened those weak muscles in the upper leg, strengthened the ankle joint and to build the arches in her feet. We would have days that focused specifically on the posterior chain, and days that focused on balance and stabilization of the ankle using the Bosu Ball. To help slowly strengthen her arches (and ankle as well) we performed the ABC’s with her foot exaggerating each end point of each letter. We also did towel resistance stretches to manipulate the movements of the foot and ankle including: dorsiflexion, plantar flexion, eversion, inversion, pronation and supination.
It would be ignorant of us to say that we didn’t risk injury while exercising even with a trainer. It happens; there are things going on in the body that neither of us are aware of at times and can sometimes be overlooked as a minute problem. Injuries that are initially misdiagnosed by doctors as Lisa’s was will result in further damage to the area that could have very well been prevented. Lisa sustained an ankle stress fracture through overuse. Her lack in strength in certain muscles such as her hip abductors and hip external rotators contributed to an unstable knee. Any part of the body that is experiencing changes in any way will almost always have an effect on distal structures of the body. In Lisa’s case, the issues that were proximal to the ankle left a pathway susceptible for injury to lower portions of the leg and foot. After a clear diagnosis Lisa was instructed to attend therapy to strengthen the areas that led to her injury as well as rehabilitate the ankle to normal strength, function and range of motion. To prevent reoccurrence of the injury, proper footwear was recommended and purchased. When starting new activities, we will start slow and condition the neuromuscular junctions to the movement first before applying significant stress to the area. Being certain that kinesthetic awareness is present through an efficient message-pathway from the brain to the muscles. With this said, we will continue to alternate activities of the lower leg to keep the body “on its toes” and to make sure that the body does not become used to a single direction in ROM, to maintain constant challenge and recovery of stabilizing muscles of joints.
As a Personal Trainer, events like this can be very humbling. We don’t know the answer to everything but we certainly learn a lot through experience. As unexciting as it is to find out your client has an injury, to have the opportunity to learn is exciting alone. When you are able to come together as a team with other health-related professionals to successfully ensure the health of another human being, it really brings meaning to what exactly you do as a Personal Trainer. Lisa is now just passed the functional phase of rehabilitation and has returned to lifting. I took this video of her today doing RDL’s on an upside down Bosu Ball, pain and discomfort free, that is disregarding the burn of course. She may not understand the achievement, but the feeling you get when watching someone succeed in a specialized way knowing you were a part of it is the most rewarding feeling in the whole world.