Anatomy
A quick google search and I learned this was not a typical stress fracture. The talus highly specialized under-appreciated part of our anatomy. It’s like one of those things we don’t know about until something happens to it and then we can’t imagine ourselves without it.
Deeply embedded in the structure of the ankle – nested between the calcaneus, navicular, tarsals, tibia and fibula – the talus serves as the linchpin of the lower extremity, responsible for the mobility of the ankle and load transfer from lower leg to foot. Not directly connected to anything, it’s held in place by a network of thick ligaments and tendons that do a lot of the work to protect it and keep the ankle stable.
Like a river rock that’s been formed by water over millennia, the talus’s complex geometry is so specific to its function that it is has five distinct sides, each acting like a mortise for the adjoining bones. I broke the lateral portion of the posterior process, which in layman’s terms means, the outside of the back part.
More common for dancers and snowboarders than runners, fractures to the talus usually happen with sudden force on-point or in lateral torsion. My doctors suspected mine must have been caused by a traumatic incident, like a severe sprain or misstep. Truth, I had seriously sprained the same ankle trail running on Mount Tam six years prior but couldn’t recall anything traumatic recently. The sprain was severe enough to do damage to the ligaments. It put me on crutches and in a boot for a couple weeks and the inflammation stuck around for another two years or so. In hindsight, it makes sense that the reduced elasticity of the injured ligaments put more stress on the bone and increased the risk for injury.
Fractures of the talus are uncommon and they comprise 3.4% of foot and ankle fractures and 0.32% of all fractures in the human body
Talar process fractures: An overview and update of the literature
Haroon Majeed and Donald J. McBride2
For all its strengths, the talus’s greatest weakness is its deficient supply of oxygenated blood. Gravity and the web of tendons and ligaments surrounding it reduce the circulation of blood in and keep inflammation around longer. As one of my doctor’s put it, “it’s a slow healer in a high impact area.” Clinical and personal accounts confirmed as much. At least four to five months non-impact, i.e. no running.
Prognosis
One specialist suggested surgery was the only alternative for a full recovery. Another encouraged me to turn to other activities and put ideas of running aside for the foreseeable future. Being in the early stages of the injury, I optimistically chose neither and I opted to heal the “natural way”.
I was 100% non-weight bearing and immobilization for the first four weeks. The pain persisted, even in the boot. The ankle joint was filled with so much inflammation with nowhere for it to go. Partial weight-bearing in the boot (walking in my apartment) but otherwise on crutches for another two weeks after that. The 5:30a masters swim group at the Y got used to seeing me crutch up to the poolside, deposit my crutches at the edge of the deck and lower myself into the pool, only to vigorously tread water for an hour and get out.
Still in the boot, I was cleared to start introducing walking without crutches at six weeks. Spin biking a little after that. I was allowed out of the boot at eight weeks, which in hindsight was probably premature. Unable to walk or stand for periods longer than fifteen minutes without feeling a dull ache in the ankle, I couldn’t bring myself to return to the boot. At nine weeks I got a follow-up MRI. “Minor improvement, if any” was the radiologist’s finding. Doctors told me this was not necessarily a bad sign as MRI’s don’t pick up the subtleties of bone growth, so I continued to progress with cross training as if on the path to running, like any other stress fracture. Elliptical around ten weeks, road bike soon after that, and Alter-G at fifteen weeks (starting at 55% and increasing as tolerated).
Five and a half months after the initial diagnosis, the pain was only marginally improved. The pain was different than stress fracture I had before. It moved around. Eight weeks before my first MRI the pain started in my shin – posterior tibial tendon perhaps. It dissipated there and suddenly manifested itself my heel – or so I thought. It wasn’t until another three weeks of running that it finally migrated to what seemed like my ankle – throbbing at times.
My theory is that there is a huge codependency between lower extremity stability mechanics. By the time the pain became fully apparent in the talus, the surrounding support network had sent out smoke signals of overcompensation to protect the stressed bone.
I remember thinking “I just wanted to pull my foot off” the pain was so deep in the joint. Some of the most intense pain I’ve suffered with any injury, triggered by clenching my toes and arching my foot to its max. It wasn’t the clenching but the release that hurt the most. In running, this translates to the moment immediately after push-off. The moment of release just after the ankle is 100% loaded. It threw me off track. I’ve always known stress fractures hurt on impact. I tested running on land for a few paces before realizing that was out of the question. Third MRI report:
Mild sclerosis posterior process talus with subtle smooth lucency involving the inferior lateral cortex. Findings reflect a nondisplaced stress fracture with differential also including vascular channel.
This news came as a blow. By all reports, five months was the longest possible time-frame I had rallied myself around. What’s more, the rate of improvement, if any, was unknown. Vitamin D tests revealed low counts, too low to help supply calcium to the bones. But this was just part of it. With feelings of desperation, I signed up for elecro-magnetic shockwave therapy upon the recommendation of Amol Saxena, MD, a respected podiatrist in the professional running community. He dubbed my injury a “non-healing stress fracture”, recommending surgery from the beginning: a treatment plan I felt was too aggressive and risky. Three sessions of shock-wave therapy over a period of six weeks; the findings were unsuccessful. The improvement, nil. The pain persisted. I was confounded. I started wondering if it was all in my head.
That was the breaking point. Forced to back off everything; cut out the Alter-G; limit cycling to the indoor bike, seated only; no walking longer than twenty minutes. Regression. After hanging my hopes on each new specialist and every optimistic personal account, I started coming to grips with the reality that I may not compete again. A paradox perhaps, but my hope was obstructing my happiness. It amplified the disappointment that came with each follow-up MRI and got in the way of my acceptance that running was not mine to keep.
Tapped of whatever motivation I had left, the drive to hold on to whatever connection I had with running and fitness drained from me. The battle was a psychological one. Depression? I needed to turn my energy to something else.
In endurance sport there is a critical difference between letting go and giving up. “Letting go” is abandoning your idea of a good outcome. “Giving up” is forsaking your purpose. The talus injury delivered this lesson to me over and over, though it took me months to comprehend it. I had to learn how to let go without giving up.
To be continued…