Episode 2The journey from injury back to activity.

Nick: 

Hello everyone, welcome to the second episode of the NK Active podcast. I really hope everyone enjoyed episode one. So today we’ve got some different guests with us. So we’ve got Natalie who was obviously here last time, but she’s not here speaking from her role at NK Active, she’s speaking here about actually what its like being a patient, because as you all remember, she did speak about the injury that she got six months ago, was it?

Natalie: 

December the 14th.

Nick: 

December the 14th. Sorry COVID has just massively thrown all my concept of time out of the window, and then we also have Chris who was also a patient of ours who had a plantar plate injury. Now the interesting thing is, is that they are actually both triathletes, but they actually live together as well, so we can sort of maybe ask them what it’s like living with someone who has got an injury, because I know it’s most probably not the most pleasant experience. So let’s get cracking. So Chris.

Chris

Hello.

Nick

Speak to us about the injury that you had, let’s just give everyone a flavour of what happened.

Chris: 

So I’m Chris, I’m a triathlete, I have been for about the last four or five years, and I started to up my run mileage probably about 18 months or so ago, and started to notice a little bit of a dull ache in my left foot, around the forefoot area, and sort of put it off, put it off, put it off. It would come and go and I could ignore it for a little bit. Sometimes it hurt during the run, sometimes it would go away, so I tended to ignore it. I noticed it a lot when I was cycling, it would aggravate it quite a lot, so Natalie and I talked about it for a little bit, all the different options that it might be, it seems to be that the world and his wife on the internet is an expert on foot injuries, they offer-

Nick:    

Oh Doctor Google.

Chris:

Absolutely, 1001 different explanations as to what it might be, but I ended up going around in circles really, trying all sorts of different things, ended up getting a steroid injection which made absolutely no difference, and then one run, doing the Gosport Half-Marathon, I had to pull up at 18 or 19K because I was in agony and just shuffled my way home, and that’s when I went to hospital to see if, because I had all the typical symptoms of a stress fracture, so I went in to see if I could get any sort of scan, they did an X-ray which obviously showed nothing, and then Natalie suggested that I introduce myself to you and we went forward from there and sorted me out really, and now I’m back to running now, so-

Nick:   

So thinking about the build-up to the injury, was there anything in particular, was there a pike in mileage, pace, or training load?

Chris:

It was difficult to put my finger on because it happened over a long period of time, it was difficult to say that this caused it, or this caused it. I messed around changing with shoes a little bit, but not to any great extent, I never deviated for too long or did any high mileage weeks with new shoes or anything like that, so it was difficult, but I was trying to increase my mileage at the time, and I run completely or I used to run completely on my forefoot, so right on the toes, no heel touching the ground at all, so obviously 100% of the impact going straight through the forefoot, so perhaps just overloaded at the time, had a weakness there that just was exacerbated and I’d been lucky not to have a flare up until then.

Nick:  

And obviously we diagnosed it as a plantar plate injury, and in the next episode actually myself, Charlie, and Natalie will be speaking about different problems in the ball of the foot and we will cover a plantar plate injury, but if you sort of just describe the symptoms you were getting?

Chris: 

Symptoms, difficult to pinpoint, but in my head I thought I had either a bursitis or a neuroma or something, because it felt like something was between my second and third metatarsal, it felt like it was swollen, there was no swelling on the surface, there was no bruising, it just felt like I had a stone in my shoe all the time regardless of the shoe I was wearing. If I walked around barefoot it would exacerbate the symptoms even more, it just ached all the time, every time I’d wake up in the morning and it’d be aching enormously, and then I could go a whole day and have no symptoms, take my shoes off at the end of the day and be aching again, so there was no real consistency other than the inconsistency was consistent, so it was constantly aggravating me but not!

Nick: 

Reliably unreliable.

Chris:  

Reliably unreliable, absolutely yeah.

Nick: 

And then, because when you get injured, people always think about the physical injury itself, but then actually how did it feel getting injured?

Chris:  

It’s really difficult, especially at the point where I was in my life, I was at university in my third year I think I was, and all the friends that I was training with were training hard and going on to bigger, better things, and I just couldn’t or I could for a couple of weeks and then it would flare up and so in my head I felt like I was missing out because of it, and it was really, really frustrating, but at least I had something to take my mind off it, university studies should be my priority, but it was a good distraction to take away from the injury itself, but sport is what I love, it’s what I want to do, so it was really, I don’t want to say the word depressing, because a lot of people use that word.

Chris:  

It wasn’t depressing, because I’m not a depressive person, but it could easily have been had I not had other things to distract me and motivate me down other avenues.

Nick: 

Okay. So then Natalie, we’ll come onto Chris’ treatment in a bit, but Natalie, if you remind everyone about the injury that you had back in December?

Natalie:  

Yeah so I had a navicular stress fracture, so the build up towards it, I couldn’t really like pinpoint anything because I hadn’t increased my mileage enormously, apart from I finished Uni at the end of July and I came back to live in the New Forest, and the people I trained with, I did an awful lot of running with them during the whole of August, so that was the only sort of time I could pinpoint my mileage being high. I then started training with a coach and I was doing a lot more sort of track work, and obviously track work you only go one way, so my left leg had all sort of the load going through it, and I wasn’t backing it up with the S&C that I needed to have, and yeah, I started to get pain on the outside of my ankle, and it got to the point where I’d be running, doing like a threshold set, and I’d get cramps all the way up the outside of my leg.

Natalie:  

And I’d stop, let it sort of settle, and then run again, and that went on for about three weeks, I didn’t really think anything of it, it was just like, “Oh well, it’s just me cramping, it’s nothing too major.” And then it wasn’t until I was doing a 5K time trial and I remember it because it was 2.32K in and I got this pain in my foot, and I’ve never experienced pain like it, and I immediately sort of like ran/limped, and I finished the race, didn’t get the time I wanted so I was annoyed at that, and then as soon as I crossed the finish line I couldn’t weight-bear at all.

Natalie:  

He refused to scan because he was convinced it was an ankle sprain, so I was like, “okay fine.” The whole of that night it was like a throbbing ache, and it just kept me awake the whole night, and I have previously had a stress fracture in my tibia, and it was the same sort of throbbing pain, it was like very sort of localised and I could pinpoint exactly where the pain was, so I actually texted you and I said, “By the way, I’m coming to work on crutches,” and you were like, “What have you done?” And I literally explained it and Charlie did a quick examination and she was like, “I think it’s a stress fracture.”

Natalie:  

And then I went for an MRI on the Thursday, which was about three days after, and yeah, it was confirmed, stress fracture of the navicular and then slight oedema as well on my cuboid.

Nick: 

And I’m going to ask you, I know the answer to this question, but how did it make you feel?

Natalie: 

I cried. I cried a lot.

Nick

There were a lot of tears in the clinic.

Natalie:   

Yeah I think it was because I’d literally just got my half-marathon PB, and I was on for my 5K PB, I was doing really well in running, because I hadn’t had a PB in my half-marathon since two years previously, so that was like a big step for me, and it was by about seven minutes, so it was like huge, and I think when I heard the words stress fracture I just panicked and it was everything I had with my tibia back again, and then I know that navicular isn’t a great one to do either, so yeah, it was just a whirlwind of emotions.

Nick:    

Yeah, because you had been setting a good number of PBs, because we have a rule in clinic, if Natalie sets a PB there’s cake.

Natalie:

Yes, lot’s of cake.

Nick:  

And then there was quite a bit of cake, and then the stress fracture sort of popped up. So then the question to both of you really is how did it feel living with someone, because both of you guys, you’re triathletes and you both compete at an age group level, so you’ve both done stuff for GB, so how does it feel then being told, “You can’t do what you want to do,” and then you two are like living together.

Natalie:

Yeah, I think it was frustrating because when Chris was injured, I wasn’t injured, so I was able to go and do all my sessions, and you were very frustrated because you were like, “I can’t do mine,” and you were trying to sort of take your mind off other stuff and you were working an awful lot to try and sort of compensate, and then vice versa when I was injured, Chris is at his peak running volume and he’s increasing it every week and I was sort of sat there like, “I literally can’t do anything.” I was like in a boot and yeah, I had nothing to do.

Chris: 

It was difficult. It was difficult at times. We helped each other an awful lot, I think we’re lucky to have each other, both doing sport and both understanding injuries now. We both appreciate the process of an injury a lot more having both been through some fairly serious ones, thankfully you know, touch wood we haven’t been through anything major, but they’ve been setbacks, and we both know now how each other reacts and how to look upon that from a third-party and see where the other one may be making mistakes in their rehab programme or is overlooking something or you know over analysing, the other way around, they’re being overly cautious and you need to just tell them – well we’ve both had conversations with you Nick, where the answer is just, “man up,” and that’s not being disrespectful, it’s just we’re both sometimes being overly cautious.

Natalie:

Yeah definitely.

Chris:

Because we don’t want it to happen again, and we don’t want to go all guns blazing straight back into training, and come back to you in eight weeks on crutches again crying again, so.

Nick:   

Yeah there is definitely an element of, I do believe, the fear of reinjury can be as bad as the injury itself.

Chris:

For sure.

Natalie:   

Oh I think so, definitely. I was so scared to come back to running, and I’m still doing it now, like I come home from running and I’ve said to Chris, “Oh I’ve got a bit of a niggle in my calf,” he’s like, “Stop overthinking about it.” And I’m like, I don’t know, I just get really sort of anxious, like any pain in my foot I’m like, “Oh my God it’s back.” I mean I think the first two weeks I came back to running, I was like, “Chris it’s back.”

Chris:  

She had a stress fracture every run she did.

Natalie:  

I was like, I kept hopping, because the hopping test is how you like prove you’ve got a stress fracture, and how many times did I hop?

Chris:  

I could hear her from upstairs, she’d be downstairs in the kitchen hopping, and I’d have to shout down, “You don’t have a stress fracture.”

Natalie:    

Literally it got so bad.

Chris:  

It was in your head, yeah.

Natalie:     

 It was almost like obsessive, I was like, “I need to check I haven’t got it still,” and I was just continuously hopping everywhere.

Nick: 

But you did still manage to keep active? Because who’s birthday was it when on Zwift, you both did 100 miles?

Chris:   

So for my birthday, we saw everyone doing these lockdown challenges and all these physical exercises, but we were still in lockdown and we wanted to go out for the day, we were only allowed out once a day at that point, so we wanted to go out, we wanted to do some form of exercise, a challenge, and I thought why not ride 100 miles on Zwift, because obviously I’m a nutter. So I thought why not get Natalie to do it as well? So we were up at half-past-five on my birthday, on the turbos and didn’t leave the turbo room until lunchtime, so it was great to do for both of us because no turbo will ever be a long turbo until we do that again, so it made everything else seem a lot easier mentally.

Nick: 

And you were done by lunchtime so you still had the rest of the day.

Chris:  

Exactly.

Natalie:

Yeah that’s true.

Chris:    

Yeah.

Natalie:  

But,

Nick: 

So for anyone that doesn’t know Zwift, you can get smart turbo trainers now so you can basically, as Zwift is almost like reality, you basically connect your bike to your turbo trainer, and you’ve got a community of cyclists that you can cycle with in real-time from across the world. I use it, and for me it’s the only way I can sit on a turbo and not get bored. I can sit on Zwift, not for 100 miles, but I can sit on Zwift for, well a short time compared to you guys, and not get bored, whereas before Zwift the thought of doing a turbo session was just like –

Chris:

It’s a great training tool, it’s a great motivator isn’t it? It really is, because as you said, anyone that you know that has Zwift you can just meet up and they’re on a different side of the world, different time zone, you can just meet up and do a ride, do a session, and with famous triathletes, with famous cyclists, a lot of them use it, so especially during lockdown. I know Geraint Thomas rode three lots of 12 hour days to replicate NHS nurses’ shifts, so you know, our 100 miles is nothing compared to riding on Zwift for 12 hours, three days in a row .

Natalie:   

No, it was enough.

Nick: 

He cycles for a living.

Chris: 

He does, that is his job, yeah.

Natalie:  

I found Zwift quite useful coming back from my injury because I wasn’t allowed to cycle outside for the first eight to ten weeks, so for me, Zwift was all I could do, and it just made a huge amount of difference.

Nick:  

Yeah and the only reason for that is because you obviously ride clipped in with your SPDs, and if you needed to come to a sudden emergency stop, could you do that?

Natalie: 

Yeah and I do actually unclip with my left foot, which I didn’t realise.

Nick: 

Could you do that? We sort of came to the conclusion that you couldn’t do that, so we thought let us just get your mileage up indoors because

Chris:

She struggles to unclip when she’s not injured sometimes when we’re coming up to a red light so

Nick:  

Is she the cyclist that you see that comes up ….

Natalie:  

I panic and you’re like, “Quickly, quickly, quickly.”

Nick:   

……and just falls over.

Chris:    

So now it’s a case of we’re sort of half a mile away from a junction and she’s already unclipped and freewheeling although there’s no traffic coming.

Nick:    

Oh dear. So then Chris, let’s go through the sort of treatment side of things, talk me through what we did to get you back to running and whatnot.

Chris:

So we did, relatively, not an enormous amount, but everything that we did worked, so it started out I had some orthotics that I’d had made previously about a year ago when I thought it was something else, and when I showed them to you, I didn’t know whether to laugh or cry, because you looked at them and said, “Well that’s in the wrong place, this is wrong, this won’t be helping you.” So I, you know, put my trust in your hands and you got me some new orthotics.

Natalie:  

 I think as well, the first time you did it, we were away, and Nick you were on the phone to me and you were like, “Mark it with some lipstick,” so we were like trying to mark these things in the different places so then he could send them to you, because you guys hadn’t actually met at that point.

Nick:       

No. The whole thing, and this is the irony of it, this was actually before coronavirus, so we were doing like a virtual consultation before.

Chris:         

We were practicing for lockdown.

Nick:         

Yeah, exactly that.

Nick:     

There we go

Chris:         

Yeah absolutely. Yeah.

Nick:        

It was all meant to be.

Chris:

Yeah it was. Yeah. So I got the orthotics with a cut out on my third metatarsal, and as I said, that was in the wrong place, and you put a met dome underneath it as well to offload, and advised I get some of my now constant running shoes, I wear Hoka Carbon X’s for absolutely everything because it totally alleviates the pain with the rocker sole and the carbon insole. It totally supports my foot, doesn’t cause any pain at all, so the orthotics in those shoes are perfect, and I could begin running, slowly albeit, and I took it very sensibly with my running, and cycling, so I was wearing those orthotics all the time. I had a pretty rigorous strength routine programme outlined by Natalie, so my legs were in pieces daily, and you know my feet, I seemed to live with a TheraBand around my feet.

 Chris:

So I did that for a long, long time, and gradually it just started to become less noticeable, and when someone would ask, “How’s you foot?” I wouldn’t be saying, you know, the same old, “Yeah no better. No change.” I’d sort of well, it would remind me that I actually had a foot injury at all and I could go sort of two, three days before I’d remember it, which for me was huge, it was sort of – if I could go half an hour without thinking about it, that was good in the past, and it gradually got less and less noticeable, and I still run in the same shoes now, because they’re still well, it’s still niggly every so often and I just avoid exacerbating it, so barefoot walking and stuff is well, if I can avoid it then I wear some sliders or something around the house just to not make it worse.

Chris:  

And then I came and did the 3D gait analysis and some strength testing, and I was told that I need to work on just about everything, so yeah, another strength programme introduced, which I’ve been doing ever since really, and-

Nick: 

No, and that was interesting because we had done the fatigue stuff with you, so we basically hooked you up with a heart rate strap, tested your baseline, then ran you for 30 minutes to look at the difference, and obviously the initial rehab stuff we were doing was focusing on getting the pain, the plantar plate injury, but then we were also able to show you that actually there was some stuff, there was other work to be done, shall we say.

Chris:

Absolutely, absolutely and classically I can probably say, not to offend all triathletes, but weak soleus and weak glutes are a typical symptom of a triathlete because they run, swim, and cycle all the time and tend to neglect the fourth discipline of strength and conditioning.

Nick:   

I think we can safely assume that applies for runners and actually the majority of sports people.

Chris: 

I think it probably does. I think you’re probably right.

Nick:

Because you can ask any sports person what would they rather do, would they rather sit there and do some strengthening work or would they rather get out and do the thing they love to do.

Chris: 

Absolutely, yeah.

Nick:

And it’s always do the thing they love doing.

Chris:   

Yeah, because that’s the thing about it, it’s a behind-the-scenes process, so you don’t see gains immediately, so you go out and do a run session, you’re not going to be running your 400 meter reps faster because you’ve done some calf raises the day before, but eight to ten weeks down the line you’ll be able to do that session, whereas previously you’ll have had something flare up and not be able to do it at all, so no, it’s become invaluable to both of us really.

Nick:  

Well you have been good, because even before sort of filming this today, you came in early just to use the gym in the clinic just to get a quick S&C session.

Chris:  

 Yeah, Natalie’s been really on me to get it at least twice a week, and I’m trying to spread it around so I don’t have to do S&C the day before my run session or a bike session or something, and also so that I don’t end up doing them, you know, Monday and Wednesday and then nothing again until Monday, I’m trying to spread it out as well, so it was, no, it was good to just get it done and it’s best to just – if I say I’m going to do it, then I’m more likely to, you know, come in early and get it done and otherwise I’d finish here, go back and do my run, and then it’s, you know, 6 o’clock in the evening, it’s nearly dark, and I think, “Oh I can’t be bothered to go to the gym,” and that’s it, yeah. The excuses come tumbling out so.

Nick: 

And then where are you now? What are you doing, like where are you at running-wise and cycling?

Chris:         

So running-wise I’m running more than I’ve ever run, weekly mileage. I just hit, to runners it’s going to sound childish, but I’ve just hit 70KM last week, which for a triathlete is probably more than a lot do anyway because it’s what I want to focus on this lockdown period. I run completely pain-free, I do two sessions a week, and I’m hitting 14 miles on my long runs now, and yeah, I’m absolutely loving it.

Nick:     

And you’re back to some okay pace as well?

Chris: 

Yeah I mean I want to hit a 10K time trial soon, just because I feel like it’s a distance that I enjoy, it’s that comfortably uncomfortable distance where it’s long enough to really hurt, and needs some pacing, but it’s short enough that it’s over within just over half an hour, so well, that’s the aim.

Nick: 

Yeah.

Chris:

Yeah. So no I’m really learning to take my training easy as well, big fan of the 80/20 rule whereby 80% of my training is truly easy, I do all my training off my heart rate, so just making sure that it is easy, because 160 beats could feel easy one day and the next day 130 could feel hard, so it’s all about getting some consistency and yeah, I love it. I absolutely love it.

Nick:

Good, good, good. So Natalie, talk us through your treatment journey and what was done over the course of time since that December until we got you back running?

Natalie:        

So I was put in the boot immediately, and originally it was six to eight weeks I was told.

Nick:      

There were a few tears when you got the boot as well.

Natalie: 

Oh my God, it was horrible. It was awful, and people would stare at me when I was walking down the street because I had this thing on my leg, and then I had an MRI at eight weeks, eight or nine weeks, and Dr Marsland saw me and said that it was healing but it hadn’t completely healed, so I did have to stay in the boot for, I think it was another two weeks after that, and then I started, as soon as I could come out of the boot I was able to start cycling very lightly indoors. I also then went to the Southampton University and did the antigravity treadmill, so I think you set me out, I think it was….

Nick:          

 Yes, I set you a plan for that didn’t I?

Natalie:         

Yeah I think it was 20% of my body weight, and then we increased it. I think I only got about 6 weeks out of that, because then COVID hit, so by that time I was nearly like 80% of my body weight, and then I sort of spoke to you and said, you know, what can I do, what’s the plan going forward? And you were like, “Well I’m happy for you to go on the treadmill.” So we were lucky enough to actually pick up a treadmill before everything got shut down.