Update to the original post:
For further information on the latest research into bone bruising this paper was released in October 2020: Read the Article.
Those close to me will be totally fed up of hearing about this ‘Tibial Bone Bruising’ (Tibia = big bone at the bottom of your leg) I’ve sustained and to be fair I probably have talked about it more than any other topic right now but mainly because:
a) I’m fed up with it.
b) I would just like it to go away so I can get back on track with my training.
c) It has stopped me doing everything I love doing.
d) I’ve had to cancel all race plans!
However, putting all that aside I am slowly moving on and looking at what is next. I have decided to write an informative piece about the topic for anyone else out there going through similar and to provide some insight in to the topic and the rehab process following it. I have tried to keep it simple for ease of understanding but if you have any questions please feel free to email me via the blog.
This is by no means extensive but will hopefully enlighten anyone remotely interested!
So, What is it?
- 1 step before breaking your bone. (This scared me!!)
- Bones are made up of fibrous tissue called Trabeculae which are like interconnected fibres in the bones cortex. If a bone is fractured all these fibres are broken, if it is bruised just a few of the fibres are broken.
- There are 3 types:
- Subperiosteal Bruising – this is bleeding under the Periosteum which is a tough, fibrous membrane surrounding the bone. Common in the lower half of the body and usually often the result of direct, high impact trauma.
- Interosseous Bruising – This is bleeding in the middle of the bone where the marrow is. This usually results from high compressive forces which are repeated and from shearing forces which are rotational such as twisting.
- Subchondral Bruising – This is bleeding between the cartilage and the bone beneath it.
- A bone bruise can be very painful, more so than a soft tissue injury. This is because soft tissues are able to expand and dissipate the increased pressure by swelling. Bones cant swell, so as a result you experience this horrible deep achy feeling.
‘it is like having toothache in your knee!’
- Finally, it is very common in all knee and ankle injuries and is often associated with soft tissue injuries. In Approximately 80% of ACL (anterior cruciate ligament) injuries there will be some element of bone bruising.
Whilst away in Norway, on our first day, we decided to go ski touring. In my stupidity I decided that I would be fine skiing, I hadn’t skied for some time but thought it would be like riding a bike and it would soon come back to me. What maybe I hadn’t considered was my sincere lack of experience doing anything off piste….well I had none. I genuinely thought I’d be alright.
On the ascent, which, I thoroughly enjoyed, I started to realise the extent of the situation I had got myself in to, but again I just thought I’ll be fine, it can’t be that hard surely. I personally felt I did very well considering my lack of experience and I didn’t actually fall that often. The fall that caused the injury I would like to say was something spectacular however it wasn’t, it all happened relatively slowly as I was turning and I went one way whilst my leg/knee stayed planted to the ground. I knew straight away I had done something and sat there for a little while to try and figure out the severity of the injury. I soon established I could stand up but it was painful and it just didn’t quite feel right. I managed to ski the rest of the way down relatively well despite the injury. I reckon I was just really unlucky.
Fortunately, being in Norway, we were surrounded by snow so ice was applied instantly and was continued for the rest of the day, night and the days that followed…I stuck to the R.I.C.E principles (Rest, Ice, Compression and Elevation) more than I think I have ever conformed to anything remotely sensible. Rest was difficult, but for the rest of the holiday we found ways and means to get me from A to B!
R.I.C.E., R.I.C.E., and more R.I.C.E.!!!!
Once home I tried to go back to work, I think I was in denial about the injury. It will settle down soon and I will be back training in no time. However, it became apparent this wasn’t the case as I was really struggling. I took myself to Accident and Emrgency where I was assessed and had an X-ray which thankfully confirmed no break. I then went to see a consultant who immediately pin pointed the painful area and immediately diagnosed it as bone bruising of my tibia. He also thought I had strained my ACL (anterior cruciate ligament) and there was a possibility of a tear in my cartilage. A MRI scan confirmed the diagnosis of extensive bone bruising. There was some discussion about a possible menisci injury (cartilage) however the radiographer felt this may just be an anomaly. There was some confusion as to how I had managed to cause such extensive bruising with out tearing anything but, maybe due to all the fell running I do my ligaments are strong and it all just recoiled and impacted during the injury!
Rehabilitation – What are the options?
As a Physiotherapist, following the diagnosis I immediately started exploring what my rehab would be to find that actually there is literally very little good evidence out there for what works and what doesn’t. I searched for anything remotely to do with bone bruising but found little of any use. There is some information in relation to soft tissue injuries, particularly related to ACL injuries but the rehab is pretty much all about the rehab for ACL repairs and not for what can be done about the bone bruising. I emailed via the Chartered Society of Physiotherapy (CSP) website as this is a really good resource for information and to obtain feedback from other clinicians to see what others had found but again, it was all pretty vague.
This is what I have found so far:
- Recovery can take any time from 2 weeks to 2 years according to the literature but I suppose this is dependent on the extent of brusing and which of the 3 types of bone bruising has been sustained.
‘2 years recovery? You must be joking?!!’
- Study by Davies et al (2004) ‘Magnetic Resonance Imaging of bone bruising in the acutely injured knee – short term outcome’ found that from a study of 30 participants (a bit small to be relevant but evidence is limited) that despite there being a soft tissue injury or not, bone bruising is still prevalent 12 – 14 weeks after the injury. It had reduced in most cases by 50% but was very much still evident.
- Systematic Review by BOKS et al 2006 report full healing can take up to 12 months.
- Finally Nakame et al 2006 ‘Natural history of bone bruises after acute knee injuries:clinical outcome and histopathological findings’ highlight the conflict in the discrepancy of time for recovery but I do believe it is because bone bruising in isolation hasn’t been fully explored.This article does try and identify the differences between the recovery for each type of bone bruise but in no detail other than bruising with an osteochondral injury (injury between cartilage and the bone underneath it) will take longer but no time has been provided.
This not an extensive list of research but like I explained earlier, it was difficult to find anything that just related to bone bruising and rehabilitation. I guess in conclusion from a recovery perspective it is like anything else and is probably very dependent on the individual with mechanism of injury and age all having some sort of contribution.
- Rehab is guided by symptoms and pain!!
- There is some evidence to suggest Pulsed Short Wave Therapy (a machine that uses electric and magnetic fields) can help by stimulating bone healing and increasing the rate at which the bleeding is absorbed back in to the body.
- Interferential Therapy – This is low frequency nerve stimulation used to decrease pain, increase blood flow and therefore promote healing and decrease oedema. There is some evidence to suggest using low intensities and frequencies can help enhance fracture healing but evidence is mixed.
- Exogen Therapy – This is low intensity, pulsed ultrasound waves which can help with bone healing by stimulating the production of growth factors and proteins and can increase the rate at which the fibrous matrix that forms at a fracture site for healing is turned in to mineralised bone. It is however very expensive and I was directed to its use from CSP (Chartered Society Of Physiotherapy) colleagues. In NICE (National Institute of Clinical Excellence) guidelines (2013) they talk about and support its use in increasing the rate of fracture healing in long bone fractures that aren’t uniting (not healing!) but they don’t mention bone bruising, perhaps this is an area that needs more exploring. Theoretically it sounds like it might have some benefit.
- Comfrey Oil – This is a herbal oil with something called knitbone in it (yes this is exactly what it says!) which you massage in to the affected area and is supposed to aid bone healing.
So…What Have I done?
Due to such conflicting evidence I have been doing what I think feels right and paying close attention to any signs or symptoms of aggravation.
- R.I.C.E. plus ice, ice and more ice!!
- Rest was hard as I was on holiday but resorted to walking with a ski pole to off load my knee, being pushed around whenever possible and piggy backs when I could persuade someone to give me them.
- Ibuprofen – to help decrease any inflammation
- Paracetamol – Pain relief
- Brief encounter with a brace but this seemed to aggravate it more than ever.
As acute symptoms started to settle –
- I focused on restoring range of movement of my knee as I couldn’t straighten it initially.
- I started some really basic strengthening work.
- Gentle swimming and I made it up to the mile mark again which helped my psychological well being! Care had to be taken initially not to push off from the pool side though! This hurt!
- I really turned a corner following a session of hydrotherapy. I have continued the hydrotherapy weekly and I can’t tell you how much it has helped!
- I tried some yoga at this time too but initially found it really irritated me so had to stop.
- Static cycling – I was kindly lent some rollers for my road bike and tried them out for 40 minutes of easy spinning.
- Climbing – This doesn’t appear to affect it at all. I wouldn’t dare attempt bouldering (free climbing) right now due to fear of falling and landing on my knee….that would not be good, so sticking to rope climbing. Being injured has allowed me to really devote some time in to building my strength and improve my climbing ability.
- Lots of core work and upper body work….
Now, 9 weeks post injury this is what I am up to –
- Squats and lunges focusing on technique and control. Lunging on to an unstable base.
- Running on a trampoline. A trampoline absorbs up to 80% of the impact/force!
- Jumping squats on a trampoline.
- Dynamic work – hopping, high knees, working on changing direction, ladder work.
- Back at the yoga and I use yoga specific to running.
- I am now back hill training as the up is absolutely fine. Up until last week I had been walking down but now I can manage a gentle jog.
I am back outside on the bike and loving the opportunity I now have to work on my bike strength. Trying to push up big hills almost makes me feel the way I feel when I am out on the fells…free and happy!
- I still continue with the massage with Comfrey oil and the ice after doing anything just to try and manage symptoms as best I can.
There is a light at the end of that tunnel. It’s been a long few months and although I have struggled I know it could have been a whole lot worse. It has allowed me to have the time to think and make plans which otherwise I wouldn’t have done.
I hope this has been some help to anyone going through similar. It can be a tough time when you are active and love being outdoors but what this injury has taught me most is that there are other things you can do. It is an OPPORTUNITY to work on those areas you always put off doing as you know you prefer to be out running, such as the yoga and the strengthening work. It is also offers you the chance to give something back, go marshal an event, get involved in any other way you can and most importantly, a little reminder that it is NOT the end of the world and you WILL run again.
You never know…you may come back stronger than ever!