This would be roughly the first 2 - 4 weeks of your recovery after you have reduced the level of activity you were performing.
Education
The aim of phase 2 is to reintroduce some strength work to the area. Strength exercises will still be loading the affected area because as the muscles contract, where they attach onto the bone will put a certain level of load on them. By reintroducing load slowly and progressively to the area will help with the healing process, and over time we can build up the level of exercise intensity to match the activity you wish to return to.
The biggest mistake made with stress reaction or stress fracture injuries, other than not initially stopping the aggravating activity and allowing the area to rest, is that someone has a short period of rest and then simply returns to the activity or sport that caused the issue in the first place without any build up. This phase is really important as your bone will still be undergoing the healing process as it repairs itself from the excessive load it struggled to deal with. We need to use this phase to build a really good level of base strength.
Stress reactions are normally caused by an increase in the type of activity we do, an introduction of new activity, or simply changing the type of surface we perform this activity on and even a change in footwear. Like most injuries without addressing the underlying cause which triggered the symptoms, if you simply return to activity after a period of rest there is a good chance that the painful symptoms will also return. It is important you try and correct any tightness or weakness in the area with some basic strength and stretching exercises, along with ensuring you have a structured and progressive build up back to activity. Simply returning to your level of activity after a short period of rest will most likely result in another stress reaction or worse a stress fracture. This injury was caused by a specific reason, so not addressing this cause will most likely lead to the same outcome.
We also need to consider that because of this period of reduced load throughout the entire lower leg as we rest the affected area, there will be general weakness of the muscles in that area which will need to be improved upon.
There are also a number of non-exercise treatment options which aim to offer support to the foot and ankle, to help reduce the workload on the tendons and muscles in the area, and also to help improve the blood flow. These treatment options can be helpful in the first few weeks if daily activities can cause irritation but these shouldn’t be relied upon to rush through your rehab. Don’t be disheartened if a treatment doesn’t work for you as they don’t work for everyone. Similarly, don’t be put off by a treatment option which doesn’t work on the first time you try it, it may be the case if you retry it in a few weeks time and it does offer some relief. The non-exercise treatment options can help to offer good symptom relief but generally won’t completely alleviate discomfort in the area. They work well alongside the exercises we have highlighted and make sure your return to running, walking or sport in a progressive way.
You can continue with the mobility exercises from phase 1, and apply some other treatment options which may alleviate your symptoms.
When returning from a stress reaction injury, having a flexible and patient approach is best.
Exercises
The aim of these exercises is to introduce some basic strength work and to add to the mobility exercises from Phase 1. You may want to use the exercises from Phase 1 as a warm up before moving onto these, and continuing the calf stretch will help make sure any calf tightness is not contributing to your symptoms. With these strength exercises start off easy and only increase the intensity each week once any symptoms have settled.
| Exercise |
|
Frequency |
| Double leg calf raise |
12-15 reps x 2 sets |
2 x daily |
| Single leg balance |
30 - 60 seconds x 2 sets |
2 x daily |
| Resisted inversion, dorsiflexion and eversion with a band |
30 - 60 seconds x 2 sets |
2 x daily |
Some things to consider with the exercises:
- Start with 30 seconds or 12 reps for the exercises before increasing the duration. Aim to complete at least 2 consecutive days at each duration before increasing the length of time, but weekly may be more appropriate. This will ensure you are slowly progressing the load instead of increasing it too quickly.
- You may find you can increase the calf raises from double leg to single leg also in this period.
- You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, and then restarting
- Remember that any day-to-day activity, such as walking, will use the lower leg muscles as well. So if you went for a particularly long walk and tried to do the exercises, it may be too irritable for the muscle group and tendons.
Pain levels and exercises: mild discomfort is ok during these exercises as long as the pain doesn’t spike above a 5-6/10 and as long as it does not linger for longer than 2-3 hours following the activity.
Cardiovascular exercise: it is also important here to try to maintain good levels of CV fitness in this phase for overall health without putting too much pressure on the affected body part, such as gentle swimming could be of benefit.
Strapping
Kinesiology strapping is very popular for many musculoskeletal injuries. The idea is that the tape helps support the muscles and tendons at the point of pain, and therefore causes less pain when doing exercises or general daily activities. The evidence for kinesiology strapping is mixed, and because of that some people find it’s really helpful whereas others find it doesn’t offer them much at all.
If you feel you are struggling to progress, or you feel your rehab is a little stagnant, or that general daily activities are still irritable, then it may be helpful to try this.
You can leave the tape on for up to 5-7 days but at any point if it feels hot and itchy take it off straight away. Have a day's rest of no tape before reapplying, and ideally test with a small strip before applying a big strip.
It’s likely that used alongside some of the other treatment methods it may offer some relief, but realistically on its own will not help completely alleviate your pain.
Footwear and Orthotics
A topic which you will want to start being aware of is the impact footwear and potentially orthotics can have.
If your stress reaction was triggered by an increase in intensity of your chosen activity, or by a change of training surface, then you may benefit from a review in your footwear. It is unlikely that repeating the same intensity of exercise that led to the stress reaction but this time with different shoes will change the outcome, but it can offer some benefit used alongside the other information in this programme.
Generally speaking if you have more supportive and cushioned footwear your tendons and muscles in your foot and ankle will have less demand placed on them, and therefore absorb shock more effectively. Both of these elements will help with your return to your chosen activity, and perhaps reduce the likelihood of a stress reaction occurring in the future. Remember that a change in footwear does not give you free reign to return to sport and activity as you did prior to the injury, and that the most important aspect of this rehab programme is to re-introduce load slowly and progressively.
In a similar fashion the use of inserting certain orthotics into your shoe can help support your foot and reduce excessive load on certain muscle groups. Using orthotics offers a cheaper option than buying a new pair of shoes and can have similar benefits.
The evidence and correlation between footwear causing stress reactions is poor as the overriding cause in general is an increase in activity, however for some people this is an important aspect to correct which can have good improvements. Equally the evidence to suggest that if you use orthotics your pain will reduce simply does not exist, however similar to footwear there are some people where using orthotics can be helpful, and alongside some of the other treatment options used it can help reduce symptoms further.
This is a challenging area to tackle on your own and our advice here would be to speak to your local running shop, podiatrist or physiotherapist. They will be able to tailor advice on which product may be suitable to your specific foot type and your specific activity.
Something else to consider here is the idea of ‘barefoot’ movements. This concept is that we shouldn’t be using excessively supportive footwear or orthotics long term, and we should instead train our bodies to move around in a more natural barefoot manner. This is so we do not become reliant on shoes or orthotics for our wellbeing. In theory this makes sense. The downfall people generally have when they start adopting this lifestyle is they try to make the change too quickly and cause irritation in their lower leg muscles. Going down this rabbit hole of the discussion of barefoot versus non-barefoot is huge, and most likely the solution that will work for you is probably somewhere in the middle. Similar to a number of the treatment options in this programme there may be a case of trial and error of what is appropriate for you as an individual, and a general sweeping statement of what will work for everyone simply does not exist. Again, speaking with a podiatrist or physiotherapist will be able to tailor the information specifically for you.
For a simple plan, if you normally have a neutral shoe moving to one with more cushion may be helpful, but a cheaper option could be to trial using a supportive orthotic inside your neutral shoe to see if this alleviates symptoms. If the orthotic does reduce pain it then gives you confidence to purchase some shoes which have more support, rather than buying the shoes first not knowing what effect they may have.
Acupuncture
The use of Western acupuncture in stress reaction aims at improving the blood flow to the affected area and therefore increase the speed of healing. Unfortunately the evidence is poor for the use of acupuncture on improving the outcome of stress reactions. You can simply get a similar benefit of blood flow to the area by doing basic non-strenuous exercises. There is some evidence on acupuncture as a general treatment modality for reducing pain, so there may be some benefit to you for that.
Similar to the other non-exercise based treatments, it is unlikely going to resolve your stress reaction by using acupuncture, but it may offer some short term relief, and used alongside other treatments help you on your rehab journey.
Medication
You should expect to see the usage of medication reduced as you move through this phase. If you always require medication after you perform your exercises or throughout the day it may be the case that the intensity of the exercises and activity is too much and may need to be reduced.
Symptoms
During this phase you should start noticing more times in the day when you are pain free, however it is not uncommon for there to be sharp spikes in pain if you are doing a specific activity. This will improve and the activities which cause irritation should become less. If you continue to perform activities which consistently aggravate your ankle or foot, it will continue to cause you pain and perhaps be affecting the healing. You may need to alter the activities in some manner that are causing irritation until you have moved further along in your healing.
Lifestyle Choices
In this phase you need to also consider other contributing factors which may have led to you developing a stress reaction. If you are overweight this will increase the load through your bones and put you more at risk. Reducing your weight will reduce the likelihood in the future of this occurring again. If you smoke, this will delay the healing time and cause your return to activity to be slower on average than those who do not smoke. Finally, a generally poor diet will also impact your body's ability to heal and repair. Making sure you have a balanced and healthy selection of food will improve the overall ability to repair itself and keep the body strong. Ensuring you get adequate good quality sleep will also improve your body's ability to repair during this period as well.
