MUSINGS, ADVICE, RECIPES ETC!

Lesser trochanter ostectomy July 2021

Revision femoral osteotomy March 2022

Bruising following the revision femoral osteotomy

2022 Update!

As you are likely aware, I have had a number of hip surgeries to manage my left hip dysplasia and femoral anteversion. At my last big hip update in 2021, I was recovering from a Femoral Osteotomy and was planning to have a combined Periacetabular Osteotomy and Femoral Osteotomy on my right hip.

Unfortunately, the left Femoral Osteotomy did not yield the results I was looking for and left me with a host of new issues- ischiofemoral impingement, knee valgus and increased biomechanical loading leading to a bone stress reaction, weak hip abduction, painful and weak quadriceps, reduced hip external rotation and hip extension. 

I ended up seeking a a second opinion from a different surgeon and this resulted in me having a arthroscopic surgery called a lesser trochanter ostectomy in July 2021. This was to remove an overgrowth of bone on my left femur, which was causing ischiofemoral impingement (pinching of the sciatic nerve where it runs between the femur and pelvis). This surgery was successful in rectifying the painful pinching of my psoas muscle (causing groin and abdominal pain), reducing the pain in my buttock and increasing my hip extension. However the other symptoms remained (as we suspected would be the case) and my new surgeon informed me that I needed a revision of the femoral osteotomy. I was, unsurpisingly, very upset and disappointed to have to go through such a big and painful surgery yet again. Any revision surgery holds extra risks and a major surgery to the femur is not to be taken lightly so I consulted with 4 different surgeons who perform this surgery and thoroughly discussed my options, the risks and exact surgical approach and techniques that they would use.

After much discussion with my Melbourne surgeon and physio I opted to have a revision femoral osteotomy (derotational and valgising) performed by a surgeon in Brisbane. This was performed in March 2022. I am currently recovering from this, but it seems to have been a lot more successful at this stage, much to my relief!

After the problems with my left hip, I was understandably cautious about having surgery to my right hip. I consulted with my new surgeon and we decided that as my hip dysplasia and femoral anteversion is mild on the right hand side I could manage with a simple capsular plication- this is tightening the soft tissue that surrounds the hip to give more stability. This was performed in December 2021 and the recovery has been uncomplicated.

At the end of this year I will need the hardware from my left hip removed again and hopefully that should mark my last hip surgery for a very long time! I am hoping to be able to fully resume sporting activities next year and very much looking forward to the potential of running again. In the meantime, lots more rehab!

Guest post-the comeback from long term injury

A few months back, Lauren asked if I would like to write a guest blog for her website about my experience in coming back from long term injuries. Whilst I was keen to help, I never got around to writing my thoughts down as life got in the way - "life" being running/riding/swimming/walking during the week and adventuring, climbing mountains, socialising and hiking on weekends.

When Lauren bought up the idea of writing a blog, I was 15 months in after re-starting my exercise journey from scratch (again) and my priority was to make use of every spare minute I had to be outside, enjoying the weather and doing all the things I'd waited so long to do. I was at my peak running fitness, running near PB times after six years and loving every moment of my training. So at that time, whilst I was interested in writing a blog, I was at a point where it was difficult to remember exactly what it felt like to be in the middle of the comeback process.

But its quick how things can change - fast forward 10 weeks, and I am now living a constant reminder every minute of every day how much it sucks to be facing a long-term comeback to doing the things I enjoy most. And its shit - it really is just shit!

My long-term injury timeline is as follows:

  • 2019 - a full year of rehabbing an extruded disc at L5/S1 and associated discectomy where I had the piece of disc removed from sitting on my sciatic nerve - walking, hydrotherapy, clinical pilates, but no running as the body didn't like it
  • Early-Mid 2020 - six months of rehabbing a protruded disc also at L5/S1 from a bad kettlebell swing - walking, hydrotherapy, clinical pilates and I joined a physio-based gym that focuses on strength-based rehabilitation by isolating and strengthening the specific muscles surrounding the spine to take pressure off the discs.
  • May 2021 - Underwent a planned abdominal surgery that saw me unable to exercise for 6 weeks
  • Late October 2021 - had a mountain biking accident where I suffered a stroke, three significant lacerations to my face, a sprained wrist, deep bruising to my right quad and a jaw (cheekbone) fracture

That's a total of roughly 92 weeks of rehabbing out of the last 144 weeks.

So here I sit, with a sewn-up face (plastic surgeons are pretty good at what they do!), a blood clot still somewhere close to my brain and a very large amount of frustration about facing another long-term return to all the things I enjoy. And to be brutally honest - this time around has been the hardest of the lot of them and whilst I know that a positive attitude and patience is the key, I am struggling a lot to keep my mindset on track this time around.

My back rehabs were long, the first was twelve months and the second only six because of the lessons I'd learnt from the first time and the hard work I put in to find specialists who focused on active rehabilitation underpinned by strength work. A friend recently said to me that they didn't understand how I got through such long-term periods out from the things I enjoy - the answer is easy, there is no other choice. When my back as at its worst, I cried every afternoon and evening from the pain I was in, usually while pacing across the lounge room or doing laps around the dining room table. Often, I was most comfortable lying flat on the floor, but then it would take me the best part of 20 minutes to stand up again. The pain never went away, it was there 24/7 and it was exhausting.

When you are in constant pain or suffering from something that is chronic, the end feels like it will never come. I have so much admiration for people who experience chronic pain due to injury or illness and continue to get out there and do the things they enjoy and experience as much as they can. It is such a mind-game to understand what is happening, why your body is responding that way and then pivot your mindset to not let it constantly drag you down.

With each of my rehabs there has obviously been a turning point - but I can't actually explain exactly when any of them came or why. That's the unknown of long-term injuries and possibly the most frustrating part. There is so much trial and error, and so much risk in trying to do things and then falling back if the gamble doesn't pay off. But the biggest lesson I've learnt is that the small things most definitely do add up. Doing your physio exercises, turning up to do your classes or sessions your specialist has programmed, stretching or mobility work, journaling or chatting with your coach or specialist about exactly what is happening with your body and how it reacts to the things you're doing. These are the boring things - but they are the most important. Your physio or specialist doesn't prescribe your exercises to fill your time, they have a purpose, they build the base, they provide stability or mobility to your joints, they work the small muscles and ligaments and tendons. If you don't build your base, the bigger strength gains and improvements won't come.

This time however, my rehabilitation process from my biking accident is different to my back injuries - it's more frustrating, I'm annoyed and I am 1000x more emotional. So quite possibly, this is not an ideal time for me to be writing a blog on long-term comebacks. I think these reactions are driven mostly by my head trauma and the fact that the area of my brain that was affected was the emotional/behavioral center. I find each day difficult. I am constantly told that I am such a positive person, but right now I feel like the negative nelly of life and like I am always in a bit of an emotional ditch.

I am also finding this time so much more difficult because I have an unknown hanging over me - the unknown of what happens if my blood clot doesn't resolve itself soon?! If it decides to stay around for longer, that means I have to wait longer too or what if I can never go back to strenuous exercise or doing the things I want to?! I don't know when this process will end, whether my clot will resolve, when my energy levels will return and when I might stop being so tired all the time. All injuries carry an unknown, no matter what stage you're in - but we need to remind ourselves that nothing is forever. Every feeling and circumstance is temporary.

Like physical pain, the mental worrying and negative thoughts are exhausting and they're relentless. That has always been for me, the most difficult part of injury and long-term ones especially. That as well as the feeling of being left out, being left behind and like you don't really fit in while you can't do the things others can.

Unfortunately, there is no magic pill to make time away from the things you enjoy and coming back from long-term injury or illness, easier. Right now, I really wish there was! I wish I could just have all the answers to pass on or even better, rewind time 8 weeks for me personally and not get on my bike.

But the main things I have learnt through my experiences are:

  • A positive mindset is the most important - trust me, I know it's not easy and right now me as miss negative nelly is hating writing that as much as you are possibly are reading it - but it is most definitely #1. I'm not suggesting putting your head in the sand and pretending everything is rosey, but instead approaching each step of your recovery with a smile, with excitement, celebrating the small wins and the next achievement no matter how much you think your circumstances suck right now. After my bike crash, I had a friend (a neurology nurse) from my Masters course a few years back (ironically a Positive Psychology course) reach out to me. She told me that the #1 factor in successful recovery from a stroke was a positive attitude. But that goes for everything not just brain trauma injuries.
  • Patience is key - I find this one most difficult and I actually have 3-5 friends message me this on a daily basis and whilst they all mean well, it can get tiring after a while. Patience wears thin easily especially when you've been dealing with something for a long time, but it really is important. We need to keep perspective. As a very special friend always tells me "we do what we need to now, to still be running when we are 70", so be patient!
  • The boring stuff makes a big difference - consistent physio/rehab exercises and strength training really does help - not many of us can just run or do our chosen activity without any cross-training. I am at the point with my back where if I don't do any strength work, I get achy at the three-week mark. Accountability in this area is important to maintain the gains you've made in your recovery but also to bullet-proof yourself from future injuries.
  • Slow and steady wins the race - I am often jealous watching others return from injury with a bang and doing 10/20+kms out of nowhere while I start with 2 mins of running broken up with walking and take a full month to get back to 30 mins of continuous running - But it's worked twice before and it will most definitely work again. So, take the time to build the base back, be smart in your return and even better yet, find someone who can help hold the reins and keep you accountable to a smart return (like Lauren does for me).
  • Reach out to others experiencing similar - there is always strength in numbers. And its always helpful to have people around you to talk things through with. Recovery from injury, chronic pain or being unable to do the things you want to can be a real mental rollercoaster. There is so much benefit to having other people around you to listen to your current thoughts, provide perspective and also to share their experiences and lessons. I have friends who are years into rehabbing injuries and others who are still in the process of trying to identify what the problem actually is. We talk daily usually and they are such a big support to me and I know they value being able to share with someone who understands the frustration and exhaustion of what they are going through.
  • Learn from your experiences - there is no greater asset in your recovery than the lessons that you will learn. Take the time to listen to your body, understand what it tells you, why things hurt, write stuff down and take note. It will help you next time and the time after that and it will help you help others too. It will also most probably help you to avoid being in a similar situation again.
  • Surround yourself with professionals and specialists that work for you and provide them feedback often - every qualified medical professional or coach has done the study to get where they are or the title that they hold. But do your specialists and coaches listen to you? Do they follow up on programming they've set for you, do they take the time to understand how you operate, what's important to you and what you're trying to achieve? Having a support network of professionals that you trust and that work cohesively to help get you back on track can be one of your biggest assets in recovery.
  • What you're going through and feeling is temporary - It often doesn't feel temporary, but it is and one day you won't be able to remember exactly how things felt right now. We usually don't really have a choice but to suck up our current situation, grit our teeth and get on with it. Easier said than done, as most things are, but on really bad days, reminding yourself of that can be the one positive you can find at that moment.
  • The comeback is always greater than the setback - this one I can vouch for wholeheartedly. I haven't been in a better place physically and mentally in a long time than where I was three months ago. There is no better feeling than ticking off a goal and enjoying the success of achieving something you've worked your butt off for. And when you have come from a long long long way back, it is always that much sweeter. That is a feeling I now crave and I can't wait for the day when it comes.

Injury, rehabbing and missing out on the things you enjoy is unbelievably tough. I've had my experiences with it as have millions of others and even Lauren herself also. It's exhausting, it's frustrating and often it's lonely. But it's not forever - keep hanging in and I promise the effort will be worth the reward. And when your rewards come, I'd love to hear all about it x

Kelly Thomas

The effect of Oestrogen on the musculoskeletal system

  • There are three main sex hormones: oestrogen, progesterone and testosterone.
  • Healthy men have a consistent high level of testosterone and low levels of oestrogen and progesterone.
  • Healthy premenopausal women have low levels of testosterone and cycling high levels of oestrogen and of progesterone.
  • Oestrogen is highest in the seven days after menstruation (leading into ovulation)

When Oestrogen is high:

  •  improved: bone density, muscle mass and strength, and increased collagen content of connective tissues
  • decreased stiffness in ligaments and tendons
  • due to increased ligament laxity, power and performance decreased and ligament rupture increased
  • Tendon and muscle injury risk is decreased due to increased tendon compliance and force absorption

The oral contraceptive pill:

  • holds oestrogen at a stable low level
  • decreases the rate of collagen synthesis post exercise
  • increases the risk of muscle and tendon injury
  • decreases ligament laxity and ligament injury risk

When oestrogen levels drop to very low levels:

  • Usually due to relative energy deficiency
  • amenorrhea (absence of menstruation)
  • loss of bone mass
  • increased rate of musculoskeletal injury

Conclusions:

  • Healthy oestrogen levels are vital for female health
  • There may be a role for the oral contraceptive pill in athletes at high risk of ligament rupture
  • Normal oestrogen cycling protective against muscle, bone and tendon injury
  • Precautions could be taken when oestrogen levels are high to protect against ligament injury eg. taping
  • More research is needed!

Resources:

  • https://pubmed.ncbi.nlm.nih.gov/8648477/

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993893/

    https://pubmed.ncbi.nlm.nih.gov/998180/

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341375/

    https://pubmed.ncbi.nlm.nih.gov/15377967

Ischiofemoral Impingement

A less common cause of hip and gluteal pain

Lesser trochanter ostectomy surgery

What is it?

  • narrowing of the ischiofemoral space (<20mm)
  • impingement of the sciatic nerve, quadratus femoris muscle and sometimes other structures


Symptoms:

  • deep gluteal pain, particularly with sitting or hip flexion
  • sciatic nerve pain and sometimes numbness, tingling, weakness
  • groin pain
  • sometimes pain and weakness of psoas muscle
  • sometimes internal snapping hip
  • may cause limping and difficulty with sport/recreational activities


How is it diagnosed?

  • clinical assessment
  • MRI showing decreased IF space and odema of QF
  • XRAY of pelvis showing decreased IF space


Treatment:

  • Physiotherapy: exercises to activate and strengthen QF and other external rotators and hip abductors to help open up IF space
  • Corticosteroid injection into QF muscle to reduce odema and also lessen inflammation of sciatic nerve
  • Surgery - lesser trochanter ostectomy (removal of lesser trochanter to increase IF space)
  • In extreme cases, Proximal femoral osteotomy (realignment of femur to increase IF space)

Blood Flow Restriction Training

What, How, Why?!

What is it: Low load blood flow restriction (LL-BFR) training entails applying a tourniquet-style cuff on the proximal aspect of a limb just prior to exercise eg. at the top of the thigh or at the top of the calf. The cuff is manually tightened or pneumatically inflated to a pressure that occludes venous flow yet allows arterial inflow. Muscular strength and hypertrophy can be improved with LL resistance training if combined with blood flow restriction (BFR) as opposed to resistance training without BFR, which requires loads of >70% of one rep max to induce gains in muscle strength or hypertrophy.


How does it work: Published studies hypothesize that blood flow restriction training induces skeletal muscle hypertrophy through a variety of mechanisms however, a definitive mechanism has yet to be elucidated. Proposed mechanisms include increased fiber type recruitment, metabolic accumulation, stimulation of muscle protein synthesis, and cell swelling, although it is likely that many of the aforementioned mechanisms work together.

Safety: A recent review looking at potential safety issues of this type of training concluded that it offered no greater risk of clot formation, muscle damage and increases in blood pressure than traditional exercise.

If you are post-operative you should consult with your surgeon before beginning this type of training.

If you have any medical conditions you should consult with your GP before beginning this type of training.

You should use a pneumatic cuff in your size for safest and most effective BFR training to ensure that the correct occlusion pressure is obtained. 

BFR training should be carried out under the guidance of a health care professional initially to ensure safe tourniquet application and pressure, exercise load and technique.


Application: LL- BFR training is great for people with an injury, post-surgery or with a medical condition where high-intensity training is contraindicated.

A metaanalysis of studies showed that 2-3 days per week for at least 10weeks had the best effect on strength and hypertrophy (more sessions per week actually decreased strength gains and strength improvements did not begin until 10 weeks). However, >4 session/week had a significant increase in muscle endurance. 30sec rest between exercises was found to be the most effective.

High volume is ideal; a standard structure for LL-BFR training is 75 repetitions over 4 sets (i.e., 30/15/15/15) with 30-second rest periods between sets.

Load as low as 20% of 1 rep max (RM) has been shown to be effective.

Cuff pressure around 150mmHg was effective, with higher pressures not having any increase in effect.

Low intensity (LI) BFR aerobic training results in significant improvements in cardiorespiratory endurance (i.e., VO2 peak). These changes have been observed with walk and cycle training at intensities as low as 30% of heart rate reserve, durations of 10-15 minutes at a frequency of 2-3 times a week for 6 weeks. 


Loenneke, J.P., Wilson, J.M., Marín, P.J. et al. Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol 112, 1849-1859 (2012). https://doi.org/10.1007/s00421-011-2167-x

Vanwye, W. R., Weatherholt, A. M., & Mikesky, A. E. (2017). Blood Flow Restriction Training: Implementation into Clinical Practice. International journal of exercise science, 10(5), 649-654.


My stance on sustainability


I am very passionate about the environment- I have been for as long as I can remember...at age 11 I wrote to the Japanese Prime Minister imploring him to stop their annual cull of dolphins. In my early teens I was vegetarian for ethical reasons, I ultimately returned to eating meat, but have always looked for the most sustainable and ethically produced food- kangaroo, local grass fed meat and poultry, home grown eggs and veg, local organic produce etc.

In 2006, on completion of my A Levels in England, I went to South Africa to do a month-long nature conservation immersion experience on a game reserve. I loved it so much that I ended up returning in 2007 to study nature conservation at a university there and stayed for 2 years studying and working on a game reserve.

Over the years I have discovered more and more the variety of ways in which humans have a devastating impact on our planet and I try my best to reduce my impact as much as possible- avoiding palm oil, avoiding plastic packaging, bottles and products, using recycled paper products and plastic alternative products, supporting environmental charities such as the Wilderness Society, shopping locally where possible and avoiding big corporations such as Nestle, Coca-Cola etc, growing and sourcing my food locally and organically from small producers etc, supporting ethical brands such as Patagonia and avoiding excessive consumption of material items and unsustainable fabrics (polyester etc). In the modern world though it is virtually impossible to not have an environmental impact, especially if you are trying to actively participate in society.

Three major areas that I struggle to reduce my impact are- transport, working in the healthcare industry and being an athlete.

As I live rurally, there is next to no public transport out here and couple that with having spent most of the last year on crutches, unfortunately, driving is the only option.

Healthcare uses a huge amount of material resources- in order to be sterile things come individually wrapped in plastic and must be discarded after each use.

As a runner, I wear through running shoes in two to three months and all the sweaty workouts mean lots of showers and lots of laundry.

As an individual and a business I want to have integrity that I am acting inline with my ethics and doing my utmost to minimise my impact, despite sometimes incurring extra cost and/or effort.

So here is how I am doing my best to make Evolve as environmentally friendly as possible:

  • I use earth friendly cleaning products and reusable/washable cloths for cleaning

  • I use towels (not paper) for face hygiene on the treatment table, that I wash after use

  • My uniform and branded apparel is all made from environmentally friendly fabrics

  • Programs and communication is all digital- no paper wastage

  • I offer a fully online, telehealth service, which cuts out travel emissions

  • My custom made pilates reformer is made from pine, which is a quick growing sustainable wood

Buckini body slices

Vegan, gluten free, healthy and delicious!

I've been making these slices for a few years and they are a crowd favourite! We have affectionately named them buckini body slices due to the "buckinis" (buckwheat kernals) in them!

These are sweetened only with dates and are high in fibre, complex carbs and healthy fats. They're great as an energy boost for morning or afternoon tea and could also work well for snacks on a long hike or endurance activity.

First place 300g of pitted dates into a bowl or container and just about cover with boiling water. Leave to soak for at least 30mins until soft and gooey.

In a food processor combine:

Soaked dates (reserve soaking water)

100g melted coconut oil

100g almond meal

200g buckwheat or rice flour

2 tablespoons any nut butter or tahini 

5 tablespoons cacoa

pinch of salt

splash of date water to combine

Once processed into a smooth paste then add 150g buckwheat kernals and process until just combined.

Spread this out into a lined slice tray- mixture will be very sticky!

Cool in the fridge and then slice up

These are best kept in the fridge and consumed within 5 days 

My hip journey!

symptoms, diagnosis, tests, surgery and recovery

After first hip surgery

After second hip surgery

Femoral retroversion, normal femur, femoral anteversion

Normal and dysplastic hip and mechanism of PAO surgery

Swelling after my second hip surgery

Continuous passive motion machine day 1 post PAO

Day 1 post PAO surgery- first steps

Hiking with one crutch four months post second hip surgery

Diagnosis:

At the age of 30 I was diagnosed with bilateral developmental hip dysplasia and femoral anteversion. This was something I was born with, however it took 30 years to receive an accurate diagnosis!

Hip dysplasia is a condition where the hip socket (acetabulam) is too small and often misaligned so the head of the femur is not fully encased. This is present at birth and can often be corrected through bracing as an infant if detected early.

Femoral anteversion is a developmental condition where the femur rotates inwards.

In my case both of my femurs were anteverted 30° (normal is 10°-15°) and my acetabulae were small and angled so that the front of my hip had very little support causing my femurs to sublux out of the front of my hip joint with any hip extension (part of the gait cycle and many normal movements).

Compounded with this I also had bilateral ischiofemoral impingement due to the shape of my pelvis and hip joints. This meant that the gap between my femurs and bottom of my pelvis was too narrow causing my sciatic nerves to get pinched.


Symptoms:

Normal symptoms of hip dysplasia are hip pain- including into the groin and front of the hip and into the glute- and often a feeling of instability in the hip. Sometimes lower back or knee pain are also present. Generally the range of motion of the hip joint is larger than normal (unless restricted by pain).

Normal symptoms of femoral anteversion are visually that the knees turn inwards. The person will have a large range of hip internal rotation and often feel comfortable sitting in the W position and they may walk or run with a flaring out of their legs behind. They often will have increased quadriceps bulk and strength compared to the glutes and hamstrings.

Hip dysplasia and femoral anteversion are commonly missed and often take many years to be diagnosed.


My symptoms were less obvious. I was always very quad dominant and had several episodes of anterior knee pain through my teens and twenties. My left leg in particular always flared out when I ran. In my mid twenties I started to get sciatic tension in my legs during and after running. This progressed to the point where my calves "seized up" after a mountain race and I had a long break from running and a back procedure performed (due to a misdiagnosis- we logically attributed my symptoms to the prolapsed discs in my lumbar spine). Afterwards the sciatic tension still would come and go, particularly with uphill running, and I started to get a deep ache through my legs at times. I then also began to get feelings of weakness, where I struggled to lift my legs up properly, particularly uphill. Then my left quad started getting incredibly tense and tight whenever I ran too. My times started getting slower and my athletics club coach noticed that I was limping at the end of races and workouts. I then started getting classic hip pain symptoms in my left hip and my left leg started to give way when I was running downhill. As my symptoms progressed I would be affected in walking as well as running.

Throughout this time I saw countless different health practitioners and specialists (as well as doing a lot of my own assessment and rehab and speaking to colleagues), had numerous scans and tests and did daily rehab and glute activation exercises! My condition was somewhat of a mystery and I was advised to continue running- my sports doctor even thought it was psychological, which I did question myself for quite some time. Eventually when I started getting true hip pain and my leg giving way in the left I requested a left hip MRI, which showed the dysplasia. Frustratingly I'd had a right hip MRI over a year previous and the dysplasia had been missed.


Tests:

Clinical tests for hip dysplasia are hip range of motion and strength tests checking for pain, clicking and excessive range or movement of the femur within the hip. Gait and posture will also be analysed. Clinical tests for femoral anteversion are similar and will also include the Craig's test- where the patient lies face down, the femoral head is found and then tracked with the hand whilst the hip is internally and externally rotated by the practitioner to determine the bony limits of range.

A plain xray of the hips and pelvis in standing and in an angled stance are needed to diagnose hip dysplasia. After this, many other tests may be taken- I had bilateral hip CT scans to determine the angles of my acetabulae and my femurs. I also had D-Gemeric MRI's of both my hips where you consume a radioactive solution prior to the MRI and the integrity of the joint cartilage is assessed.


Next steps:

My sports doctor took my scans to a meeting of hip surgeons and presented my case and was advised that I should first seek rehab from a highly regarded specialist hip dysplasia physio in Melbourne. I saw this physio for 3 months and did all the rehab he prescribed. Whilst this did help slightly, it was not enough and it was determined that I would need surgery.

I met with two good hip surgeons and decided to go with a surgeon who specialises in hip dysplasia. Unfortunately though, as he is so well regarded, he is also very busy and I had to wait for four months after my appointment until I could have surgery!


Surgery and recovery 1 (Jan 2020):

My first surgery was a left Peri Acetabular Osteotomy, whereby several cuts are made around the left side of the pelvis so that the acetabulum can be rotated and screwed into a position that covers the femur better and gives more hip stability.

As expected this procedure is quite painful! However, luckily I only had pain with movement and certain positions and if I was at rest on my back I was ok. I spent 6 weeks on two crutches and two weeks on one crutch. Throughout this time I was doing progressive daily rehab under the direction of my hip physio. I recovered very quickly and felt very strong initially, however I started to encounter problems from about 10 weeks post op. I started to get seat bone pain, pain and impingement in my anterior hip and then weakness through my left leg, pain to weight bear or put pressure through my left leg and an inwards giving way of the leg. We determined that by correcting the hip dysplasia, my hip was now fixed into an impinging position due to the femoral anteversion and my bony anatomy also causing ischiofemoral impingement. My surgeon had initially thought that I would get away with just the PAO and not need my femoral anteversion corrected, but unfortunately more surgery was now required.


Surgery and recovery 2 (Sep 2020):

I had to wait until August for my second left hip surgery so that I would be covered by my private health insurance (I had paid for the first surgery out of pocket). My initial surgery date then got postponed due to Covid- being dependent on the health system and requiring major surgeries during a pandemic is not ideal!

This surgery was a derotational femoral osteotomy (to correct the femoral anteversion), varus osteotomy (to correct the ischiofemoral impingement), femur shortening (my left leg was 16mm longer than the right), labral tear repair (labral tears are very common in hip dysplasia due to the extra load put on the labrum to stabilise the hip) and PAO screw removal. My femur was cut and the head rotated into a normal alignment in the hip joint and pulled outwards (varus) and 5mm of bone was removed to shorten the femur. A plate was put on the outside of my femur and six screws were drilled through my femur to hold it in place. The labrum was stitched where it was torn and a PRP (platelet rich plasma) was injected into the labrum to encourage healing. The 5 screws through my pelvis from the first surgery were removed as it had now healed.

This surgery took longer to perform and was a lot lengthier and more painful recovery than the first. I was in a lot of pain, even at rest for the first month and was exhausted. I had considerable pain with moving and sitting for about three months and the plate and screws caused a lot of irritation to my surrounding soft tissues making it hard for me to do my rehab and come off the crutches. I was supposed to use 2 crutches for 6 weeks and then 1 crutch for 2 weeks. But, despite my bone healing very fast, I was in too much pain from the plate and remained on two crutches for about 10 weeks and on one crutch until the hardware removal.


Surgery 3 (Feb 2021):

The plate and screws in my left femur are being removed tomorrow (23rd Feb)! I cannot wait! They have been causing me a lot of pain and irritation and I can't wait to ditch the crutch and get on with my rehab and start getting strong. There will be a bit of downtime after this surgery as I will be inflamed through the soft tissue disruption to get to the plate and screws and the holes left in my bone that will need to heal.


Right hip:

My right hip has deteriorated a lot in the last nine months whilst it has been compensating for my left hip. I need the same surgeries done on my right hip as my left, although I am hoping that they can be done all at once. I meet with my surgeon in March to discuss this and have surgery later this year.


Looking forward:

Both my surgeon and my physio are confident that I will be able to get back to running and a full and active life. I am hoping to begin my return to running in 2022.

My hip cartilage is in very good condition, however my surgeon warned that I have a much higher chance of needing hip replacements later in life than the general population.


Am I ready to return to running?

So you've had an injury and it no longer hurts now, how do you know if you're ready to begin your return to running? Ideally this should all be in consult with a health professional as every body is unique and there are no recipes with injuries. However, a general guideline:


Range of motion- is the range of motion of the injured side equal to the non-injured side or if it's the spine, for example, is range of motion back to a normal range for you?

In some cases this won't hold true- for example if you are recovering from a surgery on a joint or ligaments then you might not expect the range of motion to be equal to the non affected side, but you would still need to meet minimum healthy values.


Power- can the injured body part output as much force as the other side? Ideally this will be measured quantitatively through a max strength test using weights or a dynamometer.


Endurance- can the injured body part create low-moderate level force for an elongated time period without fatiguing? Ideally left and right sides will be equal, but both should also meet expected minimums eg. 25 good quality single leg heel raises is considered a minimum to be ready to run safely


Springiness- How much elastic recoil can the body part produce and absorb? Two tests that take in the whole lower limb and are functional to running are the single leg hop for height and the single leg hop for distance. Ideally left and right should be equal +/- 10%.


Load Tolerance- walking puts a similar cumulative load on the body to running over a set distance (running is higher load per step, but less steps due to increased stride length) and hence is a great precursor to running. You should be able to comfortably walk at a moderate pace for at least an hour


Impact Load Tolerance- as running produces high load with each step (2.5-3x bodyweight) the skeletal and soft tissue systems need to be able to absorb that over a sustained period. A baseline test is the single leg hop test- you should be able to hop x10 with good form and no pain. Another valuable test is the 6m timed hop test whereby you hop a length of 6m as fast as you can and this should be pain free with time even side to side +/- 10%. This test also assesses endurance and springiness.

The side hop test tests impact load, strength and endurance in the sagittal plane. Two lines are placed 40cm apart, starting in the centre you must hop sideways over one, back to the centre and then over to the other side without touching the lines. The number of hops in 30secs is counted and should be +/- 90% side to side, again quality of movement and incurrence of any injury symptoms is also assessed.


Balance- running requires dynamic balance on one leg at a time. Balance is assessed through many of the above tests when observing quality of movement. It is also worth assessing single leg balance on an uneven surface- you should be able to balance for at least 30seconds. The triple hop test looks at dynamic balance- three consecutive hops for distance are performed and you should land firmly without losing balance each time (here you can also look at total distance covered to assess power, endurance and springiness).


Stability- stability is a function of the joints and the surrounding soft tissue- is movement controlled throughout the whole range of motion? The star excursion test involves standing on one leg (you may bend this leg to increase reach) and reaching out with the other leg along eight lines spaced 45 degrees around the body- here you are assessing distance reached along the line, quality of the movement and balance on the standing leg. Reach should be >95% of limb length and equal left to right +/-90%.

The single leg squat is a great assessment of hip and pelvic stability, quads control and proximal limb strength. This is a qualitative assessment of movement quality, particularly looking at pelvic control in the sagittal plane and hip rotation. This test will also highlight any impingements in the hip and anterior ankle. This test can also be done for endurance whereby athletes should be able to complete a minimum of 10 good quality single leg squats to a moderate depth.


Multidirectional load- do you have strength and power in multiple directions and do you have good balance and stability when changing direction?

The crossover hop test involves three hops for distance facing forward but crossing a line parallel to you feet- total distance covered should be equal left to right +/-10% and balance and postural control should be maintained throughout the test.

The T-test for agility involves 4 cones set out in a T shape, 10m high and 10m wide. You must start at the bottom of the T, sprint to the top then sidestep to the left end and then the right end without crossing over your feet and then run backwards to the starting position. Time is measured and the minimum acceptable time for an adult runner is 10-12seconds (depending on age and gender).



Returning to training after injury

As athletes, it can be quite disheartening being injured and unable to train. Naturally, as soon as we start to feel better we just want to dive back into training. However, we should take a more cautious and measured approach.

  • Strengthen any weak or deconditioned areas:

Pain inhibits muscle activation. Muscles begin to atrophy after three weeks of inactivity, tendon stiffness decreases after three weeks of inactivity and bone density decreases rapidly when unloaded.

These areas need to be incrementally strengthened once safe to do so. This will help to avoid overload and reinjury and also avoid other joints and muscles from compensating.

  • Assess your biomechanics and technique:

Have a coach or health professional assess your technique of your strength training exercises, running gait and sport specific movements eg. swimming stroke or bike fit

Faulty technique can overload certain structures over multiple repetitions, which may lead to further injury.

Correcting technique and balancing strength between agonist and antagonist muscle groups will also optimise movement efficiency and therefore power output and performance.

  • Reintroduce training slowly:

Soft tissue and bone need recovery time to adapt and strengthen in response to loading. Allow at least 24 hours between increased loading events eg. your first and second run/walk session.

Do not increase overall load by more than 10% per week. Load encompasses distance, time, weight, number of repetitions, power output, speed etc. Instead focus on technique and reconditioning the musculoskeletal system to the movements required from your sport.

  • Listen to your body:

Be flexible with your return to training. It is a great idea to have a schedule planned out to ensure an incremental increase in load is balanced with adequate recovery. However, be adaptable to what your body is telling you.

If you have pain greater than 2/10 intensity stop. If pain lingers or is worse for more than one hour after exercise, reduce your training load. If there is an increase in morning pain or stiffness, reduce your training load. If you feel overly fatigued take a rest day- even if not scheduled.

If you feel great, continue, but still don't increase load more than 10%- your musculoskeletal system still needs time to adapt.

  • Cross train if appropriate:

If appropriate to your injury, cross training can be a great way to maintain fitness and get the mental health and social benefits of exercise. However, the principles of loading still apply and technique should also be checked especially if you are new to the form of cross training that you are undertaking...the last thing you want to do is get an additional injury from cross training!

  • Switch your focus:

Although it is great to have performance goals, now is not the time to be putting physical and mental pressure on yourself to have reached a certain performance by a certain date. Instead of focussing on your athletic performance, focus on your rehab exercises and honing your technique and biomechanics.

This is also a great time to focus on your life outside of sport- activities or projects you usually don't have time for, learning a new skill, getting ahead in your studies or furthering your career, or even just making the most of having more time and/or energy to spend with family and friends.


Joint hypermobility


Hypermobility is when joints move past the normal range of motion. This can be due to ligament laxity (genetic or from trauma), lots of stretching/training of a joint into increased range of motion eg. gymnasts, abnormalities of the bony structures of a joint eg. hip dysplasia.

Hypermobility can occur in one joint, several joints or throughout the body. Generally when it is throughout the body it is due to a genetic weakness of the ligaments.

Hypermobility is a spectrum in terms of degree of mobility and in the effect it has on the individual. Some individuals with hypermobility may be asymptomatic, whilst others can have chronic pain and disability from it. Most people will fall somewhere in between those two extremes.

The standard tool for assessing if a person has generalised joint hypermobility, eg. it affects multiple joints in the body, is the Beighton score. The Beighton score assesses finger hyperextension, thumb opposition, elbow and knee hyperextension and lumbar spine mobility. The total possible score is 9 and a score of 4 or above is defined as hypermobile. Generalized joint hypermobility is distinct from flexibility, which is due to increased stretch/or length of muscles and tendons.

When a joint or joints are hypermobile pain can result. This can be due to damage to surrounding structures including irritation of local nerves due to the joint moving further than it should, degeneration of the joint cartilage due to abnormal wear on the joint, muscular spasm due to working harder to control movement of the joint.

Due to hypermobile joints having excess wear on the joints, there is often premature degeneration and/or arthritis. Affected joints and limbs may also be weaker through inefficient transfer of power and often coordination is affected.

When a person has pain in or around a hypermobile joint the exact cause of the pain should be determined. Which structure is damaged or irritated? Why is the joint hypermobile? This will then guide the treatment.

The main goal of treatment for hypermobility is to stabilise the joint(s) to reduce pain and further damage. This will often involve rehab exercises aimed at strengthening the surrounding musculature, learning control of the joint movement, retraining biomechanics if appropriate, training joint proprioception. If there is a bony abnormality this may need to be surgically corrected.

There is emerging evidence that ligamentous laxity can be treated with prolotherapy injections with good results. Prolotherapy is an injection of dextrose solution into a lax ligament, this causes an inflammatory response and subsequent deposition of more collagen- strengthening and tightening the ligament.

Generally hypermobile joints should not be stretched and pushed to their end of range. Yoga is often not advised in hypermobility unless guided by an experienced instructor with knowledge of the client's condition, with a strong focus on technique and control of movement.


https://www.amjmed.com/article/S0002-9343(17)30220-6/fulltext

Ginger-Molasses loaf

From the Run Fast, Eat Slow cookbook

I was gifted the Run Fast, Eat Slow cookbook for christmas this year and it is full of nutritious recipes. This is the first one I've tried and it's delicious! I was attracted to it because I love ginger and it is sweetened with blackstrap molasses, which means this loaf is high in vitamins and minerals, including iron, and low in sugar.

Ingredients:

1.5 cups rye flour

1 inch piece of fresh ginger grated

1/2 tsp ground cinnamon

1/2 tsp salt

2 tsp baking powder

1 tsp bicarb 

1 egg

1 cup plain yoghurt

1/2 cup blackstrap molasses

4 Tbsp butter melted

1 tsp grated orange zest

1/4 cup raisins or sultanas

Method: 

Mix together the dry ingredients in a mixing bowl. In a separate bowl mix together the wet ingredients. Combine the wet and dry and stir to combine.

Pour batter into a lined loaf tin and bake at 180C for 45minutes.


Understanding Iron


Iron is a mineral in food that binds to the haemoglobin in our red blood cells. It is also involved in synthesis of haemoglobin. Iron is essential as without it the haemoglobin can not properly transport oxygen from the lungs to our cells.


When we get a blood test for iron there are several different values measured:

  • Serum iron is the amount of iron in your blood

  • Serum ferritin is your store of iron. Ferritin is stored in the liver, spleen and bone marrow.

  • Transferrin is a protein that transports iron

  • Transferrin saturation is the percentage of transferrin that has iron bound to it

  • Haemoglobin is the amount of haemoglobin in your red blood cells

Normal values:

  • Iron 7-27umol/L

  • Ferritin 30-300ug/L

  • Transferrin 2-3.6g/L

  • Transferrin saturation 13-47%

  • Haemoglobin 115-165g/L


If ferritin, iron and haemoglobin are low then you are classed as having iron deficiency anaemia and will be instructed to increase iron intake through food and supplements or potentially through an iron infusion.

Sometimes iron and haemoglobin can be within normal limits, but ferritin low. This is a sign that you are becoming low in iron and you may have symptoms of fatigue and decreased performance.

Ferritin levels will rise with acute inflammation or illness, so sometimes you can get a 'false positive'. Doctors will also look at levels of Transferrin to get an accurate picture.

If your iron or ferritin levels are too low you will likely feel fatigued and weak, your physical performance will decrease, you may be dizzy or have headaches, you may have shortness of breath or increased heart rate, you may look pale.


It is recommended that adults consume 10-15mg of iron per day to maintain healthy levels- with women advised to consume closer to 15mg/day. Of this 10-15mg of iron, only 1-2mg gets absorbed and 1-2mg is lost per day through bleeding, menstruation, mucosal sloughing (shedding dead cells), skin peeling and sweating. Athletes may have higher losses than this due to increased sweating and "footstrike haemolysis" where heavy repetitive foot strikes on hard surfaces can destroy red blood cells.

Some people may not absorb iron very well, particularly if they have a gastrointestinal disorder or are taking anti-inflammatory medications. The hormone hepicidin also reduces the amount of iron in circulation and decreases the absorption of dietary iron. Hepicidin is upregulated in states of iron excess and inflammation (eg, after intense exercise). Other factors that influence iron absorption are vitamin C and animal protein, which increase absorption, whilst polyphenols and phytates (found in legumes and whole grains, tea and coffee) and calcium reduce absorption.


Dietary iron is classified as Haem iron or non haem iron. Haem iron comes from animal sources (liver, red meat, poultry, fish and eggs) and it's absorption is less affected by polyphenols, phytates and calcium. Non- haem iron comes from vegetable sources (dark leafy greens, fermented soy products, iron fortified foods) and it's absorption is generally quite low. Non- haem iron absorption can be increased by eating with vitamin C and/or haem iron sources and avoiding polyphenols, phytates and calcium around meal time.

To maximise iron absorption it is also a good idea to try to consume iron when hepicidin levels are low eg. not directly after a hard workout.


In cases of low iron it may be recommended to take oral supplementation of iron. Low doses of iron (40-80mg) on alternate days are most effective as high doses increase hepicidin and block absorption. Iron supplements are best consumed with a source of vitamin C to maximise absorption.

In some cases an IV iron infusion may be recommended, here the iron is absorbed directly into the blood.


Iron supplementation should always be taken under guidance of a medical practitioner as excess levels of iron can have serious health consequences.

It is a good idea to have your blood checked annually to monitor your iron levels. If you tend to be chronically low in iron, despite consuming adequate amounts through diet and/or supplementation, then further investigation should be undertaken to determine if there is malabsorption or other factors at play.

References:

https://journals.physiology.org/doi/full/10.1152/japplphysiol.00631.2001

https://www.qml.com.au/Portals/0/PDF/Newsletters/052_Q_May19.pdf

https://pubmed.ncbi.nlm.nih.gov/11029010/#:~:text=Absorption%20enhancing%20factors%20are%20ascorbic,on%20iron%20absorption%20is%20described.

https://ashpublications.org/blood/article/126/17/1981/34441/Oral-iron-supplements-increase-hepcidin-and


Tendinopathy

A summary of the 2009 model of tendon pathology by Cook and Purdham

What is tendinopathy?

Tendon injury can occur from "overuse" whereby the chronic load placed on the tendon is greater than the tendon's capacity to regenerate. An overuse tendon injury is called tendinopathy and results in pain, decreased exercise tolerance and reduced function.

Tendinopathy can occur in the mid-tendon or at the end of the tendon where it inserts into the bone.

In 2009 Cook and Purdham proposed a continuum of tendon pathology (see image).

Reactive tendinopathy is an acute response to overload eg. increased volume/speed/weight/force or unaccustomed activity or a direct blow to the tendon eg. a knock or fall. The large tendon protein cells proliferate rapidly (hours to days) to thicken the tendon to reduce stress. Normally tendons adapt to load via the small protein cells proliferating causing stiffening of the tendon, which takes about 20 days.

The reactive tendon can revert back to a normal tendon if enough reduction of load and/or recovery is allowed.

Tendon dysrepair is an attempt at tendon healing with large amounts of cell breakdown. Due to the greater amount of cell activity there is increased vascularity (blood vessels to the area). This occurs in response to chronic overload. It is possible to return to a normal tendon from this state with load management and appropriate exercise to stimulate the cells to repair and reorganise.

Degenerative tendinopathy is a result of chronic overload and repeated bouts of reactive tendinopathy. The degenerative tendon has areas of cell death and loss of collagen and infiltration of vessels, there is little capacity to reverse these changes. Degenerative tendons are often weaker and can rupture if placed under high load.

Unfortunately pain is not a reliable predictor of tendon health as pain can occur at any point along the spectrum from normal to degenerative tendon and often severely degenerated tendons are pain free. Increasing load on a tendon will usually induce pain. A skilled practitioner will assess pain in conjunction with other signs of tendon health to accurately prescribe rehab exercises and loading tolerance.

Treatment:

A reactive tendon (or in early dysrepair) should be relatively unloaded to allow adaptation and return to normal health. This involves having two-three days between high load activities and avoiding eccentric or elastic loading eg. jumping and power activities. At this stage biomechanics should also be assessed to check if high loads are being put through the tendon with relatively low load activities.

Anti-inflammatories can also be used at this point (if there are no other contra-indications) as they reduce cell response. Corticosteroid injection has been shown to be of benefit in reducing tendon thickening, but it is unknown if it may cause long term changes to the tendon.

For a tendon in late stage dysrepair, or a degenerative tendon, treatment should focus on stimulating cell activity to increase protein production and reorganise the tendon structure.

Eccentric exercise is highly effective in increasing collagen structure in abnormal tendons, decreasing vascularity, improving tendon structure and decreasing pain. This process takes four-six weeks and it is acceptable to feel pain during this stage without adversely affecting the outcome.

Friction massage, extracorporeal shockwave therapy, ultrasound and surgery have all been shown to have some degree of beneficial effect. Prolotherapy- injection of blood or glucose- has been shown to stimulate cell activity in degenerated tendons. Sclerosing therapy and glyceryl trinitrate have also both been shown to be beneficial.

References:

https://bjsm.bmj.com/content/43/6/409

Peanut Butter Protein Balls

These tasty little treats provide a good source or protein, healthy fats, carbohydrate and fibre so they are a perfect small snack on the go or post workout. 

Recipe:

Combine all ingredients together with a spoon then shape into balls with your hands and refrigerate- easy!

1/2 cup natural peanut butter

1/4 cup honey/rice malt syrup/maple syrup

1/3 cup vanilla protein powder (I use a vegan protein powder, but whey would work too)

1/3 cup coconut flour

1/2 cup rolled oats

1 Tbsp chia seeds

1/2 tsp cinnamon

Bone Health

Our skeleton is a vital part of our anatomy and often something we overlook and take for granted. But, taking care of our bones is vital for a long and active life.

Bones are a structural support for our body, protect our organs, house bone marrow- which produces our blood cells- and store minerals, such as calcium.


When we are young our bones are soft because osteoblasts (bone making cells) are laying down bone quickly. As we age this softer bone gets remodelled into strong lamellar bone. Peak bone density occurs in the mid twenties and after that bone density can only be maintained. Males begin to gradually lose bone density from around 30years of age and women quite rapidly lose bone density after menopause.


It is therefore important to try to achieve a high peak bone density when we are young and maintain that, or at least slow the loss, as we age.

Factors that influence bone density are genetics, gender, ethnicity, diet, activity, hormones, drugs/medications, illnesses, alcohol and smoking, body mass, vitamin D deficiency.


Being female, asian or caucasian, having wide long bones or family history of osteoporosis all increase our risk of having low bone density and unfortunately we cannot modify those factors. However, we can affect the other factors to maximise our bone density and slow the rate of bone loss.


Diet: Diet is a hugely important factor in our overall health and in that of our bones. The fuel that we put into our bodies is what gets used by the body to carry out every function.

Bones are made primarily of collagen (a protein) and calcium.

Insufficient dietary calcium triggers the body to produce more Parathyroid hormone to stimulate the release of calcium from bones for essential nerve and muscle functions.

Protein intake requirements vary based on our age, activity level and other lifestyle factors (such as illness or fracture healing). However, evidence has shown that protein intake of 1.1g/kg/day has a beneficial effect on bone density vs protein intake of 0.8g/kg/day for everybody. Older people, athletes and people healing fractures or other tissues potentially need even more protein than this.


Vitamin D: Vitamin D regulates calcium levels and bone resorption. It is mainly absorbed through our skin from sunlight, but is also absorbed from nutrients in our diet. For most people, getting 10-15 minutes of sunlight onto bare skin (no sunscreen) daily between 10am-3pm is sufficient to get optimal levels of vitamin D. However, some people may need to also consume more dietary sources of Vitamin D such as fatty fish, eggs and fortified foods. If you choose to supplement vitamin D, be aware that it only works to reduce bone resorption when taken in conjunction with calcium.


Body Mass: Being underweight or severely overweight has been linked to decreased bone density, particularly in adolescence and old age. Having increased lean mass is the most beneficial for reaching a high peak bone density and then maintaining a high bone density in adulthood. Lean mass is the mass of your body tissues excluding fat and water- so your muscles and organs etc.


Activity: Being active, particularly weight bearing activity and strength training has a highly positive effect on bone density. Applying stress to bones in the form of high impact activity eg. running and jumping or putting large forces through bones eg. lifting heavy weights causes the bones to increase calcium deposits and osteoblast activity so that the skeletal system is strong enough to match the demands put on it.

Studies show that bone density is highest in athletes of high impact sports such as running and jumping sports, second highest in low impact weight bearing sports such as dancing, moderate in non weight bearing sports such as cycling and swimming and lowest in sedentary individuals. For example, women who sit for more than 9 hours a day are 50% more likely to have a hip fracture than those who sit for less than 6 hours a day.


Hormones: Oestrogen is present in both women and men. It has been found to be the major bone regulator in both sexes by its effect on reducing bone resorption, inhibiting bone remodelling and maintaining bone formation.

When there is decreased oestrogen due to amenorrhea, menopause, hysterectomy, some medical treatments or medications then bone resorption increases above the level of bone formation and consequently, bone density decreases.

Amenorrhea is the absence of the menstrual period and can be primary- where initial menstruation is not observed in females by the age of 15- or secondary- where there is cessation of menstruation for 3+ months in previously menstruating females. Amenorrhea can be due to gynaecological or medical issues or it can be due to a chronic state of relative energy deficiency- whereby caloric intake (food intake) is chronically lower than caloric output (activity). Due to peak bone density being determined in adolescence, it is of particular importance that there are adequate circulating levels of oestrogen in young adults to allow high levels of bone formation.


Drugs/Medications: Some drugs and medications can have a negative effect on bone density- steroids, non steroidal anti inflammatories, some cancer treatments and drugs, thyroid hormone replacement, blood thinners, immunosuppressants, aluminium containing drugs, diuretics.


Alcohol and Smoking: Alcohol intake above two units/day increases risk of fracture by 23% and high intake of alcohol can cause secondary osteoporosis by decreasing bone formation, negatively affecting calcium metabolism and poor nutritional status.

Smoking increases fracture risk by 25% by causing an imbalance in bone turnover. Tobacco smoke also indirectly affects bone density by increasing oxidative stress, decreasing sex hormones, decreasing calcium absorption and decreasing lean body mass.


Other factors that have shown positive effect on bone density:

Collagen ingestion- can come from collagen supplement, gelatine or bone broth.

Curcumin supplements- curcumin is the bioactive compound found in turmeric.


Leading a healthy and active lifestyle is your best defence against decreased bone density and also illness, which can indirectly affect bone density. Try to maintain a healthy weight with high lean mass: fat ratio, eat a nutritious diet rich in protein and calcium, partake in regular weight bearing exercise and strength training, avoid drugs, alcohol and smoking where possible.


References:

https://journals.lww.com/nutritiontodayonline/fulltext/2019/05000/optimizing_dietary_protein_for_lifelong_bone.5.aspx#:~:text=Bone%20mineral%20density%20has%20been,with%20a%20normal%20protein%20diet.

https://www.osteoporosis.foundation/health-professionals/about-osteoporosis/bone-biology

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093446/

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-019-2656-3

https://bjsm.bmj.com/content/39/8/547

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424385/#:~:text=The%20main%20effect%20of%20estrogen,likely%20also%20play%20a%20role.

https://osteoporosis.ca/about-the-disease/what-is-osteoporosis/secondary-osteoporosis/medications-that-can-cause-bone-loss-falls-andor-fractures/

https://www.hindawi.com/journals/jos/2018/1206235/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793325/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774085/

Homemade Fruit Jellies


Fruit Jellies
Fruit Jellies
Cover frozen berries with water
Cover frozen berries with water
Mash berries once soft
Mash berries once soft
Mix gelatine to a paste
Mix gelatine to a paste

It has recently been discovered that gelatine has a protective effect to bone and connective tissue by increasing collagen synthesis in the body. In fact, studies have shown that if you consume 15g of gelatine 1 hour before a short burst of exercise that you more than double the rate of collagen synthesis and encourage tendon, ligament and bone repair.

Gelatine comes from collagen and is almost 100% protein. It has benefits on joint health, skin moisture, hair growth and nail strength, brain function and mental health, strengthens the gut wall and protects the liver.

I wanted to access the many benefits of gelatine, but I wasn't keen on the idea of buying packet jelly or gummies which are both loaded with sugar. So I decided to have a play and see if I could make my own with just fruit, water and gelatine.

These are now a staple in my fridge and I have had success with all different types of berries and with mango.

Recipe and Method:

Pour about 750g of frozen berries or mango (or experiment with other fruit) into a medium saucepan.

Cover fruit with water and bring to the boil.

Boil until fruit is soft then remove from heat.

Mash fruit into water with a fork or stick blender- it doesn't have to be fully pureed

In a separate jug/bowl/mug place 3 heaped Tbsp of good quality gelatine and mix into it 4-5 Tbsp of your fruity water mixture. Mix into a paste.

Pour the gelatine paste into your saucepan of fruity water and stir until smooth.

Pour the jelly mixture into a large pyrex dish and leave to cool on bench and then in the fridge

Once set (approx 2-3hours) cut into squares and enjoy.

This should keep for about one week in the fridge.

Pour fruit gelatine mix into a dish to set
Pour fruit gelatine mix into a dish to set

Coming to terms with changes in my body composition

Me at my peak fitness early 2019
Me at my peak fitness early 2019
Me 10 weeks post left derotational femoral osteotomy
Me 10 weeks post left derotational femoral osteotomy

18th November 2020

In the couple of years before I was diagnosed with hip dysplasia I was in my peak physical condition. I was the fastest I have ever been and also had the most lean muscle that I have ever had, whilst having low (yet healthy) body fat.

I worked very hard for that with my training and diet plan to optimise my performance and body composition. 

(In my teens and early twenties I had an eating disorder and at times was very underweight, but that was an unhealthy leanness with low body fat and low muscle.)

In the last 18 months since I was diagnosed with hip dysplasia, and particularly in the last year since my first surgery, I have slowly but surely gained body fat and lost muscle mass. I no longer have an eating disorder, but I still have struggles with my body image, especially when it feels like I don't have control over my body. Naturally, it has been quite depressing to see my physical fitness and what I consider my peak body composition slip away.

Throughout most of my hip injury journey I have been very restricted with what exercise I can do and to what intensity and duration. This has not only affected my mental health, but also my calorie expenditure. Theoretically to maintain my weight, then most of the time I should have been consuming less calories than when I was in peak training. I have not been counting calories, but I am 99% sure that my energy intake has not decreased much. For me the motivation to eat a pretty strict diet has been pretty low when there has been nothing to be "in shape" for. Plus, what with not having my usual training outlets and being in lockdown for most of 2020, I have been at home a lot more than usual. I am notoriously bad for being a "picker" particularly when bored. So, although my meals have been smaller and less calorie dense than when I'm in full training, my snacks and treats have been a lot more abundant!

The positive I have taken from this is proving to myself that I am recovered from my eating disorder, as previously I did not need motivation to avoid treats or restrict my intake as I had a huge fear of calorie dense foods and a compulsion to stick to all the food rules I had made myself.

So, with that in mind, I have gone down the route of learning to accept and appreciate my changing body and it's "softer" appearance. I am choosing to acknowledge that I am going through a tough time currently- physically, mentally and emotionally- and give myself grace for relaxing some areas of my lifestyle to reduce strain. Sometimes a piece of chocolate gives me that little burst of endorphins that I miss so much and can't currently get from exercise!

I am choosing to appreciate my body for all the amazing healing and adaptation it is doing and for allowing me to lead a very physically demanding lifestyle for 30 years with a sub-optimal anatomy. I know that in order for my body to build bone and muscle I need a protein and nutrient rich diet, so I ensure I am eating plenty in the recovery period after surgeries (at least 3 months). I realise that if I were to reduce my intake at this time, I would actually be selling myself short as my body could have delayed healing and therefore delay my return to activity.

I am choosing to embrace this time as a step away from my usual strict routine and enjoy some of the indulgences that I wouldn't usually. I am accepting that I am currently in a phase of rest, recovery and adaptation and now is not the appropriate time for me to have my leanest and most muscular body composition. I have faith that that time will come again though, and I will have so much energy and motivation to do the work to get back to my peak because I have not exhausted myself now trying to chase something that is currently unattainable.

I am choosing to love myself for who I am as a person and not for what my body looks like. There is so much more to me and I have so much more to give than just a physically fit body!

This shift in my mindset has not come overnight and I have to remind myself of these things each day. Every time I look in the mirror or put on my clothes I am reminded that my body is different to how it was 18 months ago. My mind often will automatically jump to its default condescending and berating self talk and I have to consciously pull it away from that and remind myself of all the points above.

We can't always change our circumstances, but we can change our mindset.


How to keep a positive mental attitude whilst recovering from injury or illness.


I have experienced more than my fair share of injuries and some of them have been incredibly debilitating. I also had chronic fatigue in my early twenties. As someone who is incredibly active and goal focussed, it can be very hard when the things you love to do are taken away from you and outside of your control. Maintaining a positive mindset is crucial to getting through these times with your mental health intact.

Things that I have learnt along the way and have helped me to get through some of my toughest times:

1) Allow yourself to feel the negative emotions and self pity. 

It is ok to wallow in your misery from time to time, in fact it is an important part of accepting your situation. Blocking out negative emotions doesn't get rid of them, it just buries them deeper where they dwell and eat away at you. A quote I love is "telling someone they can't be sad because others have it worse is like telling someone they can't be happy because others have it better"

You are allowed to be sad about your situation! Feel the emotions, have a cry and a whinge to someone close to you and let go of some of that tension. 

2) Have a support network around you

Friends, family, partner, healthcare professionals, counsellor/psychologist can all play a role in helping you get through a tough time.

It is not a sign of weakness to talk about and feel your emotions or to ask for help. It is actually a sign of strength to recognise that you need that and be humble enough to ask for it or accept it.

Friends and family can not only provide physical and emotional support, but also a different perspective and a welcome distraction.

A counsellor or psychologist can be invaluable in allowing you to download your emotions without feeling like you're dumping on your loved ones. They can also help by giving you lots of tactics to help manage your emotions or point you to other forms of help if necessary.

Doctors, Physio's, Dietician's etc can also all play an important role in helping you recover. You don't have to do this on your own!

My friends, family, boyfriend, physio, surgeon, GP and counsellor have all played a vital role in helping me get through my hip surgeries.

3) Let go of expectations

I have had to let go of expectations of what I will be able to do on each day of my rehab journey and setting dates for when I will be able to do a particular thing. The reality is that progression is very rarely linear, particularly when it comes to injury or illness recovery. Having an expectation that you will be able to do a particular thing on a particular day can often build you up for disappointment, or cause you to push your body to do something it's not ready to do (which will ultimately set you back). It is a good thing to set goals, but I prefer not to tie these to a particular date- rather take each day as it comes. Somedays you may struggle or have pain doing something that you were able to do the day before, other days you may find that you take a giant leap in progress. Listen to your body telling you what it needs, rather than your head telling you what you think it "should" be doing!

4) Live in the moment

Continuing on from the point above, live in the moment of each day. Focus on what you can do that day and where you are at that point. Try not to project hypothetical future outcomes. It can be very overwhelming to think of how far you have to go, how long until you can do the things you love etc. It is much more manageable to think about what you can do/what rehab you need to do on the present day. You never know exactly what tomorrow will bring so try not to waste your energy on planning and stressing about the future.

5) Comparison is the thief of joy

It is so easy to compare ourselves to others, but also to compare ourselves to younger versions of ourselves. This generally does nothing but make you feel worse about yourself. We are all on our own unique journeys. Some people seemingly get dealt a better hand, unfortunately that is just life and all you can do is make the best of the hand that you are dealt. Tough times really do build you stronger though, often physically and almost always mentally. The resilience and adaptability that you build through facing and overcoming adversity can have such a positive effect on your life.

Focus on making the best of your current situation in any way that you can and realise that most things are temporary and ever changing. Maybe you were fitter, healthier, stronger or leaner at another time in your life, but I doubt you were facing the challenges that you are now. The best may be yet to come, or it may not be, but then maybe you will reframe what "your best" is.

Try to stay in the present moment and refrain from looking back at old photos etc that leave you pining for more. It can often be good to take a step back from social media at this time too.

6) Appreciate the little wins each day

Try to truly appreciate everything you can do and every little progression you make. After all, as cliche as it sounds, life really is about the journey and appreciating the small things.

There are always things you can do, no matter how small. In the initial periods after my hip surgeries I was weak and in a lot of pain and had to just rest. Rest is usually my enemy, I do not enjoy it! But I begun to really appreciate the phone calls and visits from friends, having a cuddle with my boyfriend or dog, reading a good book etc. Then when I was able to move a little more I really appreciated being able to make myself a meal and walk out to the garden. 

The good thing about being at rock bottom is that the only way is up! Each little progression you make is another positive aspect to your life and another step closer to where you want to be.

I've always loved and been grateful to be able to run, but I used to find walking really slow and boring. Since spending a lot of time on crutches however, I have a whole new appreciation for the underrated act of going for a walk. The views on the way, the slower pace meaning you can take in so much more and/or chat to a friend as you go, the simple act of just moving your body.

7) Look out for opportunities

Often there are opportunities around every corner if you open your eyes to them. With the time out of your normal fitness routine you could put time into something else. Maybe strengthening another area of your body that you usually neglect, or honing in on a physical skill. Maybe working on your mental game through meditation, visualisation or brain training. Maybe learning a new skill that is unrelated to your sport. 

Having purpose is really important for your mental health, and can also be a good outlet for pent up and energy and tension, especially when you can't partake in your normal activities.

The recovery from my most recent hip surgery is taking longer than expected and I have been unable to return to my usual work. With the prospect of more surgery next year I thought I should make a plan for some sort of physio work that I can do whilst still on crutches. After a bit of soul searching I came up with the idea to start Evolve Rehab and Coaching and it has given me a renewed sense of purpose as well as taken some of the pressure off my shoulders to heal quicker (which is outside of my control).

8) Be kind to yourself

Injury and illness are very humbling processes. They can take you from feeling strong and capable to weak and doubting your own ability. A lot of our identity can be tied up in our physical capacity and when that changes against your wishes you can be left feeling lost.

 Often we can get mad at our bodies and rebel against them and try to bend them to our will. Unfortunately, this generally only serves to dig us deeper into a hole.

I have learnt that I have to surrender to what is outside of my control and give myself grace for what I am going through. Our bodies and minds are amazing and they have an incredible capacity to heal and adapt, but we have to allow them to do that.

I have put on weight, lost muscle mass and lost fitness throughout my hip surgery journey. I don't like it. I want to be at my peak athletic ability, but I'm not and if I fight that and try to hold onto that the longer it would take for my body to heal. My body has needed rest and adequate nutrition to grow new bone and build muscle. I am amazed at my bodies ability to heal my bones fast and adapt to a new hip structure and new biomechanics. I choose to honour my body and be thankful for it healing and recognise that now is not the season for me to be at my physical peak.

After my first hip surgery I recovered fast and bounced back into fitness remarkably fast, because I had listened to my body, given it what it needed and been kind to myself. Working with your body will always trump working against it! 

November 12th 2020

Beetroot Protein Brownies


Beetroot Protein Brownies
Beetroot Protein Brownies

Food has always been something I've been very interested in and as I've grown older and learnt more about optimal nutrition I have discovered how important protein is for repairing and building tissues. Whether I'm in training or recovering from an injury or illness protein plays a vital role.

I love to bake and experiment in the kitchen and I came up with this nutritious recipe to satisfy my sweet tooth and get in a good dose of protein.

In a food processor combine until smooth:

1 medium beetroot

1/2 a zucchini

1 banana

3 scoops vanilla or chocolate vegan protein powder (whey powder will not work)

1/2 cup cacao powder

1/3-1/2 cup of brown rice or buckwheat flour (to get a thick consistency)

1 egg (or 1Tbsp chia seeds plus 2Tbsp water if vegan)

pinch of salt

optional: teaspoon of chilli flakes for a kick, sprinkle of raisins for extra little bursts of sweetness and/or cacoa nibs for some crunch

Spread into a lined slice tray and cook at 180C for 20-30minutes until a skewer comes out clean.

Cool on a wire rack and then cut.

Evolve Rehab and Coaching
Copyright  2020  Lauren Starr
evolverehabandcoaching@gmail.com
 
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