Like many people, Jeanette Pallister was keen to step up her
exercise routine during lockdown. The 49-year-old had regularly gone to fitness
classes at a gym in the two years before the pandemic struck, but when they had
to close again last December, she decided to start jogging.
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Beginning with a run-walk program — where you alternate
between running and walking — she gradually built up and within four weeks she
was jogging for 20 minutes at a time, covering 3km, three days a week. She’d
also started doing 45-minute HIIT (high-intensity interval training) online
workouts at home every other day, with plenty of lunges, stretches and jumps.
This all came to a grinding halt less than two months after
starting, as Jeanette, from Mayfair in London, developed a stress fracture in
her right ankle — caused by repetitive pressure. Jeanette is just one of many
to suffer this type of injury in the past year, say health professionals.
Typically because they’re new to exercise, increasing in intensity in a short
space of time, with a lack of expertise at hand — a fitness instructor would
gradually ease someone new into exercise — they’ve been pushing their bodies
too much and too soon.
There’s been “a significant increase in the number of stress
fractures in clinic in the past year,” says Kumar Kunasingam, a consultant
orthopedic surgeon specializing in ankle and foot surgery at
Croydon NHS University Hospital and at the Schoen Clinic in Marylebone, London. And where
previously it was something he treated in elite athletes, “I am now seeing
members of the public with stress fractures,” he says.
Ziad Harb, a consultant orthopedic surgeon who specializes
in foot and ankle surgery at
Ashford and St Peter’s Hospital, Surrey, says he’s
seen about a fourfold rise in stress fractures starting in the first lockdown.
“It’s one of the most noticeable trends I’ve seen over the past year,” he told
Good Health.
A recurring theme is that patients have taken on a virtual
“challenge” — often inspired by a charity, to help with fundraising — such as
running or walking 160km in a month. For many this is a drastic increase in
regular and intense exercise. With others it’s challenges inspired by
TikTok —
“people injure themselves trying to replicate intense bursts of exercise such
as dances,” says Kunasingam.
A stress fracture is caused by overuse or “overloading” the
bone — the bone is weakened because it is not used to the demand being placed
on it. This overloading has a cumulative, damaging effect. “I’m now seeing
patients who are literally breaking their bones to stay fit,” says Kunasingam.
“It’s like flexing a ruler over the side of a desk; gradually cracks will appear
and if you carry on doing it, it will snap.”
He adds: “Stress fractures are not caused by one incident
but an accumulation of forces over weeks or months which build up in the bone.
“Often the person can suffer a low grumbling pain during and after exercise for
a period before they do anything about it, by which time it will get worse as
they continue to run on it.”
Jeanette’s stress fracture was in her fibula, one of three
bones that make up the ankle joint — a common site for stress fractures. A US
study in the Journal of Sports Medicine in 2015 found that 80 percent of stress
fractures occur in the lower limbs. The five long bones, the metatarsals, which
make up each of our toes, and the bones in the middle of the foot, are
particularly vulnerable — perhaps not surprisingly, given that a force of up to
three times our bodyweight can be exerted on the foot when running. Stress
fractures can also occasionally occur in the hip, too.
More seasoned exercisers are also at risk if they increase
their activity too rapidly or change where they run — moving from running on
grass to hard pavements, for example. Stress fractures are more common in women
aged between 30 and 50, possibly due to hormonal changes and the effect on bone
density — or a diet that lacks oily fish, red meat, and fortified cereals,
which contain vitamin D — essential to bone health.
Harb, who also works at the Princess Margaret Hospital,
Windsor, says the underlying weakness is multifactorial but often there is also
a lack of vitamin D. External factors also play a part, he says — these include
poor footwear, i.e. wearing fashion-style trainers rather than proper running
shoes, running on unsuitable terrain (e.g. hard surfaces such as pavements),
and running without warming up (which allows the muscles and tendons to prepare
for exercise, improve their range of motion, and prevent tightness).
Mother-of-two Jeanette, who runs a pub with her husband
Dave, 50, says she only took up jogging during lockdown “to get out more”. On
the day of her injury she’d gone out for her usual 20-minute run, then at
lunchtime she went for a three-hour walk. “After returning home at about 5pm,
my right ankle felt sore and quickly became red and swollen, and the front of
it was in agony,” she says. “Within about an hour it had doubled in size and it
was too painful to walk on.”
“Luckily, Dave still had some crutches from when he had a
knee operation previously, so I used them to move. But that evening my ankle
was so puffed up, I could no longer see the ankle joint.”
It is important to get a stress fracture treated promptly,
because if you continue to exercise on it, pain and swelling will worsen. That
means it will not heal and it can potentially lead to requiring surgery if the
fracture widens. The only way for the bone to heal is to rest it and immobilize
it. Fortunately, Jeanette already had an appointment with her physiotherapist
two days later about an unrelated shoulder injury.
Worried her ankle was a stress fracture, he carried out the
classic tests, including pressing over the tender area — which caused extreme
pain. As well as tenderness when touching the bone, other clues Harb looks for
include “swelling, warmth, difficulty weight-bearing, and a thickening of skin
on the fat pad close to the toes — this can be an indication that an extra load
is being put through metatarsals, for example,” he explains. “A tightness of the
calf muscles can start bells ringing about a stress fracture, especially if
they are also suffering swelling and pain in the foot,” he adds.
Stress fractures often can’t be seen on X-rays but show up
on an MRI. “It is extremely important to identify the intrinsic and extrinsic
causes, because without correcting these, stress fractures can get missed, take
longer than average to heal, or most worryingly recur in the future,” says
Harb. “If a stress fracture is spotted early, it would usually take around six
weeks to heal.
“But some bones have a poor blood supply so may take longer
to heal, so the boot would have to be worn for longer.” Physiotherapist Gary
Jones of Physio 206 in Bromsgrove, Worcestershire, who has also seen more
patients with stress fractures, says that coming out of an aircast boot is not
the end of the story.
“It can be a long rehabilitation,” he says. “For a stress
fracture of the tibia — the shin bone — it can be up to four months before you
can fully exercise on it again. “At first it will be very stiff and other parts
of the body — such as the calf and foot muscles — will become weaker, as they
are not being used in the normal way, which can start after only 48 hours of
wearing the boot. It will require a phased return of stretching followed by
building back up.”
At the end of March, Jeanette went back to see Kunasingam.
As well as taking a rest from jogging, she has done daily stretches of her
ankle and begun using an exercise bike for 10 minutes every other day. With her
fibula now healed sufficiently, she’s been allowed to go back to gentle
jogging, working up to 10-minute jogs twice a week. “But I will be a bit wary
of overdoing it and will stop if I feel any pain,” she says. “I’m going to be
very cautious about how I exercise in the future.”
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