The Importance of Rehabilitation

For any athlete – professionals or just weekend warriors – it can be very difficult to come back from a major injury.  I am learning this firsthand.  While out on a training run back in July, I tripped and broke my left big toe.  You might not think that breaking your big toe is any big deal (pardon the pun).  However, the big toes are among the most important parts of our body for running.  We need to be able to push-off using the big toes in our feet.  I am finding not only did I need to allow my broken toe to heal, I also needed rehabilitation to restore my flexibility, strength, and balance.

My doctor did not prescribe any physical therapy when I was released from wearing my boot.  I was told to start walking and building back up to running.  I wasn’t given any exercises to start limbering up all those joints in my foot that had gone on an unplanned vacation.

Without any guidance from my doctor, I did the best I could.  In Pilates the instructor had me doing various exercises that involved my foot.  I would do exercises on the Reformer where I would be raising up and down on my toes, balls of my feet, and on my heels.  I used the foot pedal on the Chair to push down using different parts of my foot.  The problem was my foot had been totally immobile for eight weeks.  Jumping back into intense foot work ended up causing me more problems.  Over the last several months, I developed a severe pain in my ankle as well as tendonitis in my lower leg.  It was increasingly difficult to run and we all know how much I like to run.  I was getting anxious as to whether I would be ready for my next marathon.  It is a biggie – the Boston Marathon in April.

I went to see my chiropractor.  Yes, my bones were a bit out of alignment but my foot lacked flexibility.  The joints weren’t fluid and moving as they should.  My big toe wasn’t bending as it should.  I needed to address this problem quickly.  After verifying that I didn’t have a stress fracture, my next stop was my physical therapist.

My physical therapist got me going on a set of exercises that are improving the strength in my ankle as well as improving the flexibility of my foot.  She also hooked me up with a personal trainer in the clinic who works with patients on more involved rehabilitation.  Both my physical therapist and personal trainer confirmed something that I already suspected.  My running (and walking) gait had changed as a result of my broken toe.  I wasn’t pushing off of my big toe on my left foot.  I was compensating by using other parts of my foot, resulting in an unnatural gait.  My body was totally out of balance.  I was on the road to more serious problems in my ankle, lower leg, hips and potentially also even in my right leg and foot.

The personal trainer used the GravityFit system with me.  The GravityFit system helps you to understand what muscles should be engaged to do things like stand, sit, and squat.  I put on each of the different pieces of GravityFit equipment that provide feedback on my form.  I understood instantly what correct form felt like, when my core was engaged.  Establishing that understanding (and muscle memory) helped me to identify when my form was right and when it was wrong.  With my new-found knowledge, my balance immediately improved.

Once I understood what correct form was, the personal trainer then worked on my gait.  I was putting my weight into my heels when I walked and ran, possibly from an unconscious fear of putting weight onto my big toe.   She showed me the proper way I should be walking and running.  I focused on shifting my weight onto the balls of my feet.  When I took a few running steps, I was able to push-off from my big toe.  There wasn’t pain in my ankle.  Granted the muscles in my foot, ankle and lower leg need to be strengthened but at least now I feel like I am working on getting back to where I was.  More importantly I will be rehabilitating my foot without causing myself more problems.

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This experience with my broken toe has taught me that I can’t go it alone.  I can’t just do things that I think will help me fully recover.  I don’t know much about recovery and rehabilitation.   I was relying on a disjointed patchwork of self-prescribed strategies – massage, Pilates, and chiropractic adjustments – I thought would help me get back to pre-July shape.  I was doomed to failure.

What I really needed was people with the expert knowledge of injuries and rehabilitation to get back to pre-injury condition.  I have that team in place now.  They are giving me exercises to improve my strength, flexibility and balance.  Massages supplement the work the physical therapist does and remain an important part of my recovery.   Everyone knows what is at stake for me.  They are confident that if I do my part, I will reach my goal.

My foot is responding very well to the physical therapy and personal training.  I can see improvements already.  Today I had no pain when I was running hill repeats.  To me that is a huge improvement.  I know my running form was better because I learned what correct form feels like.

My advice to anyone who gets a significant injury is to work with someone who is certified in rehabilitative fitness.  Don’t do what I did and self-prescribe a rehabilitation program that can backfire, causing more injuries.  If you care enough about training for a big event, don’t short change yourself by not getting the expert help you need for rehabilitation.  In the long run, you will bounce back faster and probably stronger.

How important is the big toe for running?  Here is an article that explains just how critical it is  http://www.kinetic-revolution.com/big-toe-extension-running-gait/

The GravityFit program was extremely informative for helping me find my core and use it to improve my balance and work on my gait.  

I’m Back

It has been awhile since I last posted on my blog.  Recovering from my broken toe has taken longer and been more difficult than I expected.  The last 2 months have not been filled with adventure or running.  I have been on a detour along my running journey that I never want to take again.

When I broke my toe in early July, I expected after 5 or 6 weeks of rest I would be able to ride a bike or swim.  I was totally unprepared when, at my 4-week check-up, the doctor told me there were really two fractures in my toe, the second a lengthwise crack down the bone.  He was concerned that the bone would pull apart if I flexed my foot as I might while biking or swimming.  He told me that I had to continue resting my toe for 4 more weeks.

I needed some sort of physical activity for my physical and mental health.  I kept asking the doctor to suggest some activity that I could do, some way to keep moving.  My doctor just shook his head and said “sorry, I can’t let you do anything.”  I cried as he delivered the news.  After I left his office, I sat in the parking lot in my car and cried some more.  I had been a good patient for 4 weeks.  I had stayed off my foot.  I took extra calcium and Vitamin D.  I had done every thing I was told to do and it did not seem fair that I had to wait another 4 weeks until I could resume my active life.  I have to be honest.  I was depressed.

My enthusiasm for writing my blog took a big hit too.  I tried to rally and write about the 2016 Summer Olympics in Rio.  As is the case with every Olympics, there were stories that fascinated me and I had wanted to write about them.  Stories like Usain Bolt’s triple-triple (3 gold medals in 3 straight Olympic Games) and Mo Farah’s double-double.  Mo’s gold in the men’s 10,000 meter race was even more astounding considering he fell about halfway through the race.  (I wish I could learn his secret of falling and springing back up to finish a race.)   Or the collision of Abbey D’Agostino (USA) and Nikki Hamblin (New Zealand) half way through a qualifying heat for the women’s 5000 meter race and how Abbey and Nikki helped each other to get back up and finish the race – they personified true sportsmanship.  Or that among the competitors in the women’s marathon were two sets of twins and one set of triplets.  Or that the Belgium team in the Men’s 4×400 relay race included 3 brothers – Kevin, Jonathan, and Dylan Borlee.  (It was a family affair for the Borlee’s – their sister Olivia competed in the Women’s 200 meter race.)  No matter how many times I sat down to write I just couldn’t get motivated.  If I couldn’t run, I couldn’t write about it.

I tried to think of activities I could do that would not aggravate my broken toe.  I had spent the first 4 weeks of recuperation reading and finished 9 books.  I couldn’t imagine reading anymore. I didn’t want to watch movies. I wanted to be moving. I tried to think of any activity I could do to keep my body from turning into a blob.  The only activity that I could think of was Pilates.  I signed up for private lessons 3 times a week.  The instructor listened to me explain all my physical limitations from my arm with its limited range of motion to my healing toe.  She was confident despite these challenges, I could still get a work-out.  Since I started taking Pilates, I can tell that I have gotten stronger.  If there can be a silver lining to my broken toe, it is that I discovered how  Pilates can improve my running – a stronger core and more flexible hips.  Pilates classes saved me from total despair.

Last week I was finally given the ok to resume exercising.  I started riding my bike and walking on my treadmill.   I even pushed things a bit and did a short run this week.  After 8 weeks of inactivity, my body isn’t the same as it was before my fall.  I feel like I am starting all over from square one.   But the ability to get moving again has turned my frowny face into a smiling one.  I am a living example of the positive effects of exercise on one’s mental health.

I did learn a few things during this ordeal.  I got a deeper appreciation of how much I value the ability to move.  It is a gift.  While I was unable to run for only 8 weeks, there are people who are permanently unable to move including those with more serious cases of Transverse Myelitis, MS, ALS, or spinal cord injuries.  I am fortunate to be able to lace up my shoes again to run.

I also learned how important it is to have multiple hobbies or interests.  Running is my only hobby.  When I was unable to run, I had nothing other than reading to keep me occupied.  Reading is extremely important but it was not enough to sustain me.  I need to develop other interests so my life doesn’t come to a screeching halt when I can’t run.

Despite my latest injury, I still have my goals of completing each of the 6 Major Marathons (only 3 left to run) and a full or half marathon in each of the 50 states (17 states to go).   It just might take me a bit longer to finish them.  I learned that it is all part of my running journey.

Getting Up Again

You may have noticed that I haven’t written on my blog for the last couple weeks.  I was trying to come to terms with my latest injury.  I didn’t want to talk about it, write about it, or even think about it.   While running two and a half weeks ago, I tripped and broke my big toe.  My podiatrist told me no running, cycling, or even swimming for at least 4 weeks.  There is no way to speed things up.  I just have to rest my toe and hope for the best.

Screen Shot 2016-07-19 at 6.57.46 PMMy emotions went the whole gamut.  First I was frustrated.  I blurted out “Why me?” to my husband.  I immediately realized the absurdity of the comment.  I sounded like Nancy Kerrigan, the Olympic ice skater, after she was attacked prior to the 1994 Winter Olympics.  That curb I tripped over didn’t have it in for me.  Things just happen and they are out of our control.

Then I was angry. I threw my running shoes into the back of my closet.  I thought about giving up on this whole running thing, quitting my 50-State goal and no longer writing this blog.  I never broke a bone while I sat working at a desk.  Maybe I needed to get a job and go back to a sedentary life style.

Finally I became very depressed.  It took me a long time to discover running.  Now I was unable to do the very thing I loved the most. There were races that I was going to have to miss.  My half marathon in Maine in July was scratched and another one in August is questionable.   When I had mentioned the Chicago Marathon in October to my podiatrist, he was doubtful that I would be ready.  I was devastated at the thought of missing that race.   I may claim to be the funatical runner but I was neither running nor having fun.

I couldn’t think of any way to fill my days if I could not run.  When I broke my arm almost 2 years ago, I gained 5 pounds that I struggled to lose.  I feared that I was going to be reunited with those 5 pounds and maybe more.  I could only sit and read.  Let’s face it – reading is not an aerobic activity.  I was doomed.

One day the song “Tubthumping” by Chumbawamba popped in my head:

I get knocked down
But I get up again
You're never gonna keep me down

I had tried to get up again.  I tried to have a positive attitude.  I decided to stay as fit as I could by doing floor exercises like Pilates that wouldn’t require me to stand and put weight on my foot (and therefore my toe).  My running coach sent me encouraging emails.  But it was all an act.  I just couldn’t get up again.

This week I read excerpts of an interview with Meb Keflezghi where he pointed out “everybody gets hurt.”  Over the course of his marathon career, Meb has ruptured both quads, experienced Achilles tendonitis, a soleus tear, and a pelvic stress fracture.  Getting injured is “part of the sport” according to Meb but “it’s how you deal with it that matters.”  Compared to Meb’s injuries, my broken toe was nothing.

Meb’s words resonated with me.  I needed to change how I was dealing with this injury – starting with my attitude.  I could be “down-in-the-dumps, oh-woe-is-me” but that response would just be wrong.  I have a friend whose husband is battling cancer for the third time.  I have no business feeling sorry for myself because a broken toe was keeping me from running.  I am going to be out there pounding the pavement again soon enough.  I may be inconvenienced by my injury but people who are battling life-threatening illnesses like cancer have a questionable future.

It was time for me to get up again.  I started by deferring my Chicago Marathon entry until 2017.  I looked at the calendar and realized I could probably be ready for the New York City Marathon.  I secured a bib through a charity and will be running through New York City’s five boroughs in November.  I won’t be very fast but I will be able to finish the race. I got more serious about my Pilates training and started increasing the number of workouts I do each week.  When I get approval from my podiatrist to start running, swimming, and cycling, I will work with my running coach to get back into aerobic shape.  I am fortunate that I was in very good physical condition when I fell.  I should be able to bounce back quickly.

So far I have not gained any weight.  I am eating much better thanks to the wide variety of healthy vegetables and fruits available at the local farmers’ market this time of year.  I plan to add more exercises to my workout routine to help maintain my flexibility as well as strengthen my core.  From a broken toe will emerge a stronger and more grateful runner.

The Importance of Moving

I don’t claim to be an expert in anything.  I have dogs but after raising six dogs, I would not be so presumptuous to advise others on how to train their dogs.  I still rely on my go-to resource, Auntie C., with any dog-training questions.  I have run 11 marathons and 35 half marathons but I would not coach someone else.  I know what works for me but everyone is different.  I sure wouldn’t want to steer someone down the wrong path.  The one thing I do know is that you have to keep moving.  I am a firm believer in this.  It is a “use-it-or-lose it” world.  That is something I learned the hard way.

About 18 months ago, I fell during a training run and broke my upper arm in four places.  I was fortunate it did not require surgery to repair.  The only treatment was to immobilize my arm by putting it in a sling.  The doctor encouraged me to bend over, dangle my arm and move it in circles.  It would have been equivalent to raising my arm to shoulder height.  As much as I tried, I couldn’t do it.  It was excruciatingly painful just to dangle my arm.

I could tell that the doctor was disappointed each time I came into his office and showed him my progress in moving my arm (or rather my lack of progress).   I started losing muscle because I wasn’t using it.  I was at risk of developing frozen shoulder, if I did not get my arm moving.  It was clear that just a few months of immobility had reduced range of motion in my arm to next to nothing.    When I was discharged from physical therapy, I could barely lift my arm to shoulder height.

Since then I have tried acupuncture, cupping, dry needling, massage, additional physical therapy, stretching, and various therapies by my chiropractor.  At this point, I estimate my range of motion (which should be 180 degrees) is at best about 155.  I continue to get weekly 90-minute massages.   My massage therapist has made restoring my range of motion her life’s mission.

My experience with my broken arm leads me to consider the bigger picture.  All this sitting that the modern office worker does, hunched over a keyboard, is not healthy either.  There isn’t much movement involved.   The longer you don’t move something then the less your body begins to think it needs to do.  If you don’t straighten up your back, then eventually your back will probably start saying “don’t have to do that anymore.”   Evolution probably started that way.

I mentioned this to my massage therapist today.  She agreed.  She said when a new client comes in, she can tell what kind of work they do from the areas of their body that are giving them problems.  Shoulders and back pain are typical in people who have desk jobs.

According to her, for every repetitive movement, you need to do the counter movement to ensure that you are maintaining range of motion.  It is another way of saying we need to stretch more to maintain flexibility.  Runners, for example, don’t take big steps so we end up with tight hips and quads.   We need to stretch our muscles to ensure when we need to take a big step, we can still do it.

Maintaining movement is especially important in people with arthritis.  It can be painful but the consequences of not moving joints is they will lock up even more.  It is a downward spiral from there.

I am just as guilty as everyone else of not stretching enough.  I have once again resolved to start stretching every night.  In the past, when I made stretching a priority, I found that I had fewer injuries and no sore muscles.  I started getting more flexible.   If I am successful this time, a few minutes of stretching will save me from spending hours on the massage table.

So take it from me – the person whose right arm use to be as useful as the front leg of a T-Rex – keep moving!  You will be glad that you did.

Rolling, Rolling, Rolling

Every once in a while I have to ask myself why I chose a hobby that involves so much physical pain.  In marathon running there is frequently pain while you are running, pain when you are done, and if things are really bad, pain the next day.  I never hear people who paint or quilt complain about pain from their hobby.  But then I can’t see myself sitting still for long periods of time to paint or quilt.  I have to move.

Saturday was one of those days.  I ran my longest training run – 20 miles – in preparation for the Berlin Marathon.  I started my run early, hoping to beat the heat.  My running spouse was off working a race for a charity so I was running solo.  I arranged for my husband to meet me around Mile 10 with water, ice, and a banana.  The last 6 miles were tough because there wasn’t any shade.  My Transverse Myelitis doesn’t like the heat and I was starting to drag.  Except for being hot, I didn’t feel that bad while I was running.  Some dull aches but nothing extreme.  When I finished my run, I had a few spots – lower back mostly – that reminded me that I had just run 20 miles.  The next day was when I really felt the pain.

I asked Jessica, my physical therapist, to explain why it hurts the day after a long run or race.  She started talking about actin, myosin, trigger points and fascia, and my head started to spin.  From what I could gather, movement comes from the interaction of the actin and myosin.  When you do something like run for 20 miles, you can end up with trigger points where the muscles go into a spasm (a contraction) from all the repetitive motion.  Normal movement becomes painful or maybe not even possible, in the case of injury.

According to Jessica, massage is great for recovery and working out the trigger points that result from a long run.  My hero, Meb Keflezighi, uses massage as a key part of his recovery.  Unfortunately for me, my massage therapist, Jennifer, is not on call 24/7.   When I can’t see Jennifer, I have to resort to Plan B – self-massage.

There are lots of self-massaging tools on the market.  After my run on Saturday, I pulled out all the ones that I have in my closets.  It was astonishing to see all the things that I have bought over the years to keep my muscles moving.  Some were things I picked up at my local running stores but others were impulsive purchases made at race Expos.  In my self-massage arsenal I have two different kinds of foam rollers that you can sit or lay on (both in multiple sizes); three different massage sticks; a massage ball; and one hand massage roller.

I drafted my husband for a fun product evaluation experiment.  We tested the self-massage tools by using each of them on the same 6 areas of the body: calf, IT band, hamstrings, quads, glutes, and back.  We used the tools on each area and then gave it a score, using a scale of 1 to 10.  Here are our observations on each of the products (Disclaimer: these are our observations; your mileage may vary.) :

(top to bottom) Pro-Tech Foam Roller (full and travel sizes), the Grid (full and travel sizes)

(top to bottom) Pro-Tech Foam Roller (full and travel sizes), the Grid (full and travel sizes)

Pro-Tech Foam Roller:  This roller is long and smooth.   I have used this one to do some my PT exercises for my arm but not too much for self-massage because it is pretty hard.  It is like rolling on a hard floor.  Not very comfortable.  Neither of us found that it helped much with any of the 6 areas because it didn’t seem to get too deep.  Overall score: 2.17

The Grid:  The Grid is another foam roller but with raised areas, or bumps, of different sizes.  The bumps can get much deeper than the plain foam roller.  You have to get into some unusual positions to use the Grid on some muscles so you have to have balance and some upper body strength.  Both of us thought the Grid did a great job, though my husband felt it was uncomfortable on his back.  Overall score: 8.50

(left to right) the Marathon Stick, the Hybrid Stick, the RangeRoller Pro, the Orb Massage Ball, Addaday Marble Massage Roller

(left to right) the Marathon Stick, the Hybrid Stick with red trigger wheel, the RangeRoller Pro with four black Trigger Treads, the Orb Massage Ball, Addaday Marble Massage Roller

The Marathon Stick:  I think this was one of the first self-massage tools that I ever bought.  It is a stick about 20 inches long with beads that move independently of each other.  You can roll the stick over muscles to work out sore areas.  Because it is flexible, it contours to areas of the body.  The Marathon Stick doesn’t provide a deep massage like the Grid and, in my opinion, is only good for lightly massaging the legs.  I saw videos on the Internet that show how to use the Stick on other parts of the body like the neck and back.  I don’t have the flexibility with my right arm to use it that way.  Compared to some of the other tools, my husband and I didn’t rate this one too high.  Over all score:  4.0

The Hybrid Stick:  The Hybrid Stick is very similar to the Marathon Stick except it has a single trigger wheel in the center that can reach deeper into a muscle.   The trigger wheel made this tool score higher in our review.  Overall score: 5.0

The RangeRoller Pro: This 16” stick is firmer than the other stick rollers that I have.  It has 4 Trigger Treads ™ (similar to the trigger wheel on the Hybrid Stick) that can reach deeper into the muscles.  Like the other stick rollers, I had difficulty using this on some spots due to my arm and we both found that it isn’t as helpful on the glutes.   Both my husband and I gave the RangeRoller high marks for working our legs.  Overall score: 6.5

The Orb Massage Ball:  The Orb Massage Ball is a 5” nubby ball made by ProTec.  I bought the Orb at an Expo this year.  It appealed to me because of its small size.  It fits into my carry-on.  It works like the foam rollers.  You can roll along the sore areas of your legs and even into your glutes.  I thought it was a bit difficult to use on the outside of my calves but otherwise it was pretty effective.  Overall score: 7.0

Addaday Marble Massage Roller:  I bought this at an Expo last Spring.  The 3 marbles can get deep without sharp pain.  The Addaday roller fits easily in the palm of my hand so I can massage any place that I can reach.  While it is not very helpful for massaging hamstrings or glutes, I think it works great on calves, quads, and the IT Band.  Plus I can massage my neck and arms, areas that are still recovering from my broken arm.  The small size makes this one very portable.  I can toss it into my carry-on bag or even my purse for a quick leg massage when I am flying on the plane.   I liked this one more than my husband did.  Overall score: 6.0 (I would give it 7 just because of how portable it is.)

We summarized our observations:

  1. The more bumps or raised areas on the self-massage tool, the better the tool.  The smooth foam roller just doesn’t give the same relief.
  2. Foam rollers that you can sit or lay on are better.  You get the added benefit of your body weight to get deeper into the muscles.
  3. Portability is important when traveling.  You can buy some of the foam rollers in smaller travel sizes but they still take up a good bit of valuable space in your suitcase or carry-on.  I think the RangeRoller Pro, the Orb and the Addaday Marble Massage Roller are the best for trips.  [Note:  The Stick might be considered a potential weapon so when flying, put it in your checked baggage.]
  4. Different tools work better on different areas.  In his book, Meb for Mortals, Meb mentioned that he uses a foam roller on his IT band and a ball on his glutes.  We found that some tools worked better on some areas than others.  Experimenting with different tools will tell you what works best for you.
  5. I don’t need to spend any more money on self-massage tools.  I have enough.  I just need to use them.

None of the self-massage tools we tested is a replacement for my massage therapist, Jennifer.  She can make just about any ache or pain disappear with a 60-minute massage.  Plus I enjoy chatting with her while she works the kinks out of my muscles.

Not sure how all this foam rolling works?  Jenny Hadfield made this terrific video on how to use a foam roller.  Check it out!