I started 2023 on the top of Crater Lakes, toasting the beginning of what is going to be a great year. About 20 minutes later I was using my poles to walk 5h out of the Tongariro Crossing after a misstep resulted in skidding and landing heavily on my left leg, the result of which was a broken fibula and waving goodbye to the Tarawera Ultra 102k event and any running for a couple of months.
Alright then. Now what.
Here are a few things that I’ve spent the last week researching and implementing – as I post this it is Day 13. There’s a ton of stuff here and a ton of stuff not here. While I’m looking at this from a bone healing perspective, much of this is related to bone health in general. Osteoporosis and osteopenia are two bone-related conditions that would benefit from this. It is long and overwhelming and includes the basics along with the ‘nice to haves’ depending on your resources. Save it for later use. Note, where possible, this is based on human clinical trials. Where not, there are preclinical and/or mechanistic trials. And advice from practitioners. Everything is safe.
Nutrition and supplements
Calories. You need calories to fuel the healing, and with any trauma your basal metabolic rate (BMR) will increase in response to the repairing and rebuild after a slight decrease in expenditure in the hours post injury. Over time, this will level off to pre-trauma levels. Metabolic rate increases by around 20-25% and serum levels of nutrients decline as they are used to help in the healing process (a good debrief here).
We are all different, and for me, I have to make sure I’m not restricting too much because I’m suddenly doing 10h less exercise a week. Appetite naturally decreases, and I will say the attention has to be towards getting mostly really good foods to support a nutrient-dense diet. In addition, now is not the time for a 1200 Calorie diet because my deliberate energy expenditure has gone down. One of the biggest hurdles to recovery is lack of calories, the second is quality calories. It does matter how much and what you eat. (So it isn’t licence to go for gold on all of the foods you wouldn’t normally eat during your usual training cycle). Understanding that goes a long way to coming back stronger and in a good position to build up once the bone has healed. As a person who naturally (and easily) restricts, staying on top of my calories and nutrition is key, and I find tracking them is a good way to do this.
Protein is key. Your bones are ~30% protein and low protein intake is associated with poorer bone health. We need the substrate that creates bone. There are associations between high and low protein intake and bone mineral density. I never have a problem with getting in protein and currently I’m ensuring that I’m getting at least 3g/kg body weight protein. That is a LOT, however it does include collagen (low in the essential amino acids, but contains the glycine, proline and hydroxyproline amino acids that are key for our musculoskeletal health). I track using an app right now as I’m just doubling down on it, and it does mean I’ve added in an extra protein and collagen smoothie mid-afternoon I wouldn’t normally have. It’s just easy and I like it. This gives not only the aforementioned macronutrients, but calcium too. I go between the Balance Whey protein and the Nuzest Clean Lean Protein. Along with eggs, meat, chicken and fish, I am right now including 2-3 serves of protein powder. This is completely safe and will not ruin your kidneys.
I take my Good Green Vitality daily, with some essential amino acids added also. It contains adaptagenic herbs which support central nervous system activity, and that is important when lowering stress hormones. This is a dietary standard for me. It is also a good broad spectrum multi vitamin. The Curranz supplement I take daily (and the MitoQ) both help with reducing oxidative stress and inflammation, important for bone health and metabolism.
Creatine is basically a super supplement. It helps improve recovery, may have antioxidant and anti-inflammatory benefits, and may reduce bone breakdown A most recent line of research is looking at bone metabolism suggests that it may help influence bone modelling by increasing osteoblast cell activity and indirectly through increasing muscle mass and the pull of the muscles on the bone (thus, increasing homeostatic stress – a good thing). This is in the presence of resistance training, however. Any creatine monohydrate is a good supplement choice and is recommended, regardless.
Vitamin C helps with collagen synthesis and is a good addition to the supplemental mix. It may also help improve pain and inflammation with muscle and bone, though larger trials are yet to be conducted.
Silicon helps improve bone matrix quality and helps increase bone density and mineralisation, working potentially at the initiation phase of bone building. It is recommended as a supplement for people with osteoporosis and is often found in supplements specifically to support bone health. While bioavailability has been an issue that is raised, there are many supplements that have a bioavailable form of silica that can be absorbed. FWIW, beer is a source of silica, and a bioavailable one. This is research I love to find, as you know I love a craft beer. Boron is another trace element that actually has some pretty interesting physiological properties, including wound healing and bone regeneration – and is found in the multivitamin supplements for joint and bone. I have it in the collagen supplement (below) that I have been using.
Vitamins D and K are fat soluble vitamins that are essential to bone. Definitely on the list, and I take this one at 5000 IU as a standard, so no change there. Vitamin K is needed as a cofactor in the production of proteins that aid in bone health (such as osteocalcin) and vitamin D promotes the production of these proteins. Vitamin D also increases the absorption of dietary calcium.
I take magnesium nightly, 300mg (more than one dose of this) and this mineral which is involved in over 250 cellular pathways is a cofactor in bone metabolism. While its role in bone health is well understood, there doesn’t appear to be a lot of studies looking at its role in fracture healing. This study, however, found that, when administered post-trauma for 9 days, fracture patients receiving a multi-mineral supplement had increased calcium and magnesium levels in their blood and had reduced inflammatory markers, suggesting a role for these minerals in recovery post-accident. The vitamin C I’m taking also has magnesium in it (it’s similar to this one).
Bovine colostrum supplementation has been compared against traditional osteoporosis meds in order to see its effectiveness at improving bone mineral content and bone metabolism, and it appears to exert a positive influence on bone. If nothing else, it certainly isn’t harmful and therefore it could be worth investigating. I have ordered this product in powdered form.
A good intake of fruit and vegetables is obviously important, with the antioxidants and phytochemicals that they provide to help dampen inflammation and scavenge free radicals. In addition, the antioxidant quercetin which is present in produce (highest amount in onion skin, actually) is thought to have an overall positive impact on bone metabolism, at least in preclinical trials. A supplement I’m taking from Thorne ResvereCel contains quercetin, at 250mg. Again, safe to take and no harm in doing so.
Lysine is an amino acid which helps bone metabolism by increasing both calcium absorption from the gut and collagen synthesis. Lysine can be found in meat, fish, eggs, cheese and is abundant in the diet, and is also a cheap supplement to take. I’m taking this one here, which also contains zinc. Zinc is absolutely essential for bone metabolism. Insufficient intake negatively impacts on bone quality, and zinc supplementation promotes the activity of cells that are involved in bone regeneration and mineralisation. A couple of the supplements I’m taking include it actually, as does this joint supplement from Nutralife, the main ingredients being chondroitin and glucosamine, which have been widely studied and recommended for osteoarthritis (clinically a lot of people really benefit from taking it). There is preclinical research to suggest it could also be beneficial for bone and, given that I have it at home already, I’ve also added that in to my daily supplements
Specifically, collagen could help bone metabolism – preclinical trials show that type 2 collagen fibres improved bone mineral density. It is the underlying structure of our musculoskeletal tissue and often recommended for gut, skin, bone and muscle and ligament health. I was using this one here, I ran out and picked up this from Chemist Warehouse as I wait for my order to be delivered. I’ve written about the injury protocol for collagen here, and another blog on whether collagen is worth the hype here (spoiler alert: yes). Check them out. In addition, this most recent preclinical trial found that bone loss was reduced with the administration of collagen in a mice-model of menopausal levels of oestrogen.
Lifestyle and Mindset
Importantly, reducing stress and cortisol levels is key to bone metabolism. Elevated cortisol and inflammation that is unresolved impacts negatively on bone health. So it is ensuring you can keep cortisol lower as much as possible. Sleep is our biggest recovery tool and at this stage it is unknown the direct cause of why a short sleep duration is linked to lower bone density and bone health. Growth hormone is involved in bone metabolism and is essential to bone, most of that is released when we sleep, though the older we get, the less this will be involved as levels decline as we age. Lower overall cortisol and sympathetic nervous system activation may also be involved, and with it, what is termed ‘complex’ interactions for overall hormone physiology. The flow on effect to feeling more fatigued and doing less physical activity (and choosing less optimal food choices) may also play a role. Needless to say, I am prioritising sleep right now, and the last couple of nights it has been much more comfortable and less painful. A great debrief on sleep and bone health can be found here.
Sauna is something that I’m definitely a fan of, and was happy to hear that sauna sessions are related to improved bone mineral density (BMD) in a human clinical trial over the course of several weeks. Sauna helps activate the production of heat shock proteins (HSP) which attach to degraded proteins, preventing their aggregation and help the delivery of proteins involved in repair. Other research suggests that HSP could help with bone regeneration. While I don’t doubt that infrared has its own special properties, this study implementing a dry sauna protocol found that after 12 sessions (10 min, 100 degrees Celcius) there was an improvement in BMD not seen in the group who weren’t in the sauna. So, that is quite hot and I’d be lucky to find a sauna to get to that level – but actually this week the sauna in my gym it was around 100.
And cold water immersion (CWI)? A favourite of mine, though actually really hard to do right now in Auckland in normal conditions. Cold water doesn’t get cold enough in the shower, and the ocean is like 2 degrees warmer than normal. Another reason to get a freezer and fill that up with water like loads of people I know do! This preclinical trial found a positive impact of CWI on bone markers, and this observational study revealed lower bone turnover markers for people who typically do CWI (watch the cardiovascular risks though…). This option is less available to me right now.
Strength training is key to any training programme, and I am definitely continuing to do this (not in a way that will give me a shoulder or upper body injury because that would NOT be ideal!) Lower body on the left hand side is out right now, though can do some R side single legged work as long as I maintain stability without relying on my L side. Lifting to stimulate a load is super helpful for bone AND muscle, and promotes the release of anabolic hormones that aid in bone health.
Swimming and using the ski erg (from a seated position, and not in a way that I have seen others do it crunching their body in a ball – i.e., the way you should lol) are two ways to help get some sort of cardiovascular response. To be honest, if it’s not running, I’m not great at pushing myself on any other form of cardio equipment. And I find even if on an exercise bike or elliptical trainer (out of the picture at this stage) I might sweat and breathe heavier, but it’s nothing compared to running. I would say I get a solid high zone 1-low zone 2 response here. I did do a few minutes on the ski erg staying upright and standing (after 20 minutes of sitting) and it wasn’t too much load on my leg so that was awesome, and did a full session later this week, and felt fine. With swimming, it is using a pull buoy while I swim, and that is totally fine. I find swimming also quite meditative and, even if I try to swim faster, I don’t actually move that move quicker lol. Moreover, both of these are great for blood flow, and moving nutrients around the body and removing waste products, all of which are important for healing. I have heard of others who broke their fibula using a bike or a rowing machine and I have no idea how they have done that. There’s no way that I could do that at this stage.
Microcurrent electrical stimulus (using Nurokor) – there is evidence that the increase in blood flow can help with healing from a bone fracture in preclinical trials (Dr Cliff Harvey did a great article on the use of it), so am doing this multiple times per day in 20 min sessions.
I’m still enjoying a drink or two. I would say ‘call it medicinal’ lol but actually it’s more than that. I naturally have a restrictive personality and have in the past spent many years avoiding things, like alcohol, for the calories or similar that it adds to the diet. Now, this isn’t for everyone I know, however if I were to stop all of the things I enjoy doing (and I enjoy a wine/beer/etc) then I think the overall negative impact of restricting it would offset any benefit from abstaining. It’s a rabbit hole I don’t need to go down again in my mid 40s, so I am happy to continue to include it in moderation. This, yes, is related to diet, but also it is related to mindset and lifestyle, so it’s in here.
And, on mindset. This is big. Breaking my fibula has meant I can’t walk, run, move freely and that is so hard. I was at the pinnacle of my fitness after having a successful marathon campaign and some excellent long, slow hike/runs for the Tarawera. Now that is off the table. As is the Milford track run that we’ve organised for this coming week. I’m not going to say I wasn’t gutted about that (and still am). I do feel FOMO that I can’t get out amongst it right now with Baz and my trail and road running friends. However, my mindset is strangely okay. Better than okay. I’m surprised by how ‘okay’ I feel about it. But, then, I have written before of the work that I have done on mindset over the last couple of years and I think that I underestimated how transferrable that work is to all areas of my life. I quickly shifted from my pity party to my action plan. And you can see that I’m throwing everything at it. Every day that passes is another day that I’ve done multiple things to aid in my bone recovery.
With Tarawera off the calendar, and the next event I’m interested in is seven months away, I feel there is no urgency with this. And I think that is a big reason for feeling as relaxed as I do. I’m sure I’ll have my moments. I’m not under the illusion that I’m totally sweet (!) and will be until I start running again. However I’m both realistic and optimistic. Losing fitness was always going to happen. Instead of trying desperately to hold onto it post an event (and feeling sluggish and awful, as often happens), it will be sliding away quietly and I won’t even notice it at the time. Only when I get back to running will I then turn my attention to getting fit again. And that in itself is always an exciting prospect, especially in light of results I had this year which I was just so happy about.
Hopefully this is helpful. Sorry for the length.
2 thoughts on “Ran up a mountain, broke a bone, here’s what I’m doing (TL;DR the kitchen sink)”
Very helpful article Mikki! I broke my ankle this weekend on a hike and I’m working hard to stay out of the pity party and make a plan for recovery. Hawkes Bay marathon is out, executing your advice to is in! Wishing you a speedy recovery.
Pete! Gah, what a drama, I am so sorry to hear that. This looks like a lot but trust me it is worth hit – and the exercise piece, if you can do something similar to what I’m doing, I think that could be really helpful.