This weekend just gone (5th March 2016) was the 6-month-versary of my knees exploding during a tame training session. To say that it’s been an enlightening journey and an emotional rollercoaster is an understatement. In the immediate aftermath of the silly accident with devastating consequences the prevalent emotions were panic and despair. As someone who enjoys being active all the time, suddenly finding myself confined to a sofa without the choice of getting up and moving brought on fear and sadness. I was devastated at the prospect of having to take time off as at my age physical prowess declines at an alarming rate and to this day I don’t really know whether I will be able to regain the full range of movement in my left knee or if I will be able to get my considerable strength back.
It took a good couple of months to reach a definitive verdict about the extent of my injuries: initially, because the x-rays didn’t show any damages, the symptoms suggested I might have suffered damages to the meniscus and/or surrounding ligaments, however the fact that although I was in agony my knee joint was stable and strong called for some thorough investigation.
Thanks to a fortuitous set of circumstances I found myself with access to a superb team of knee specialists at Basildon Hospital (Essex, UK) who rushed me through the system and got me in an MRI machine within days of seeing the first consultant. The scan revealed the truth about my injury: all the soft tissues were intact and in fact “in good shape all considered”, however the pain was being caused by extensive bone bruising mostly along the outside of my left femur but also in the rest of the areas surrounding the knee joints.
What did that mean for me? Apparently, according to the surgeon in charge of my knees, that I was very lucky as I didn’t require any surgery to fix the damages and that I would make a full recovery, eventually, as long as I give time the time to work its magic.
So, what exactly is bone bruising and how can it be treated?
Bone bruising (aka microfractures) is a result of a traumatic injury but also stress to the affected bones arising from repetitive overload of the area when it is not strong enough to take it and not giving it enough time to adapt and repair itself. This, in everyday English, means overdoing it whether it’s working, running, walking, jumping. The symptoms include excruciating pain, swelling, change in the colour of the skin, stiffness of the joint if one is affected.
The remodeling of fractures is an incredibly complex process and there is still much to be learned about it. For the purpose of this blog post I will try my best to explain in the simplest of terms what I discovered reading a number of research papers on the subject.
First of all, when it comes to “ordinary bone maintenance” our bodies essentially carry out two tasks every day: remove old and damaged tissue (osteoclastic process) and replace it with new and healthy tissue (osteoblastic process) in an attempt to reach homeostasis (i.e. keep the status quo).
When bone bruising occurs the osteoblastic process now also needs to fill in all the tiny little cracks making up the microfractures as well as carrying out “ordinary maintenance”. When the trauma initially occurs an acute inflammatory response is triggered. Although painful and uncomfortable for the patient, this reaction is essential to initiate healing and, contrary to what the “Ibuprofen” brigade would have you believe, shouldn’t be suppressed. This phase peaks for approximately a week and then gradually gets less strong but never really goes away throughout the various stages of the healing process.
Following the initial inflammation phase the process of bone regeneration starts: at first the body generates a fibrous granulation tissue at the site of the injury which is then followed by the formation of a collagen matrix made up from a number of molecules that are being recruited and extracted from surrounding tissues (including bone marrow, soft tissue, periosteum, etc.).
The formation of new blood vessels at the site of the injury is the next important process followed by the mineralization of the fibrous granulation tissue. At this stage, although the bones have reacquired some degree of mechanical rigidity they aren’t fully healed yet. It is at this stage of the healing process that osteoclasts and osteoblasts get really to work to reabsorb the hardened callus and replace it with lamellar bone deposition in situ.
This incredibly complex sequence of events can take months and even years to fully regenerate a broken bone. In my specific case I was advised that it might take up to a year from the moment the injury occurred and possibly longer due to my age. (As it turned out it took almost 3 years to heal my bone bruising and I am not sure it’s completely over yet).
What can we do to support the healing process?
Quite a lot, actually. Here is a quick recap, below is the full explanation.
1. Eat more (of the right foods for the job)
The body requires more energy to repair itself which means we need to eat more to meet the new metabolic demands. Depending on the extent of the severity of the injury this can mean upwards of 6000 KCal per day (but most likely less)!
Although in my books this is a great excuse for eating more high calorie foods like pizza, cakes, ice cream, chips and crisps I am also acutely aware of the immense balancing act that needs to be made here. Yes we need more calories but we are also forced to move less and so unless we are crafty as to how we go about this process we are at risk of getting massively fat which will create a whole other set of issues when we are finally mobile again.
My strategy in this respect was to increase caloric intake by staying away from “man-made” foods like pasta, pizza, etc. and increase the consumption of natural starches like sweet potatoes, potatoes and other root vegetables. This was also the time that my post-workout protein powder came into its own: because they are carefully formulated to provide all the nutrients needed to support the process of repairing the body from the micro-damages of intense exercise I was able to integrate my diet with a product that was relatively high in calories and nutrients but low in volume to consume.
2. Increase intake of proteins and amino acids
The extra amino acids are needed to aid in the synthesis of new proteins to help create new bone tissue. Bones are 50% made of proteins embedded with mineral crystals and if we don’t receive enough through our food the end result is a rubbery callus instead of rigid bone, longer healing time and the possibility of complications arising.
A number of amino acids are especially important for fracture healing: lysine, arginine, proline, and cystine.
Lysine, for example, is known to increase the amount of calcium absorbed into the bone matrix, and aid in the regeneration of tissue. It’s also your best friend in the fight against viruses, especially in the control of Herpes Simplex – natural sources are: grains, nuts and seeds.
Arginine is known to assist with wound healing through collagen synthesis and the formation of new bone and it’s effective when used in conjunction with Lysine when it comes to muscle growth. It’s found naturally and abundantly in a variety of foods, however supplementing with it is contra-indicated if the patient suffers from cold sores.
Proline is a critical component of cartilage and therefore essential for joint health, we usually get more than enough of this amino acids from our food and doesn’t really need supplementing with.
Cystine is a powerful antioxidant and the precursor of Chondroitin Sulfate which is the main component of cartilage.
Most of these amino acids are found in natural protein sources but also in good quality whey protein supplements. These can be incredibly useful for increasing the amount of proteins consumed on a daily basis knowing that all the nutrients required to support bone healing are there. Again, they are low in volume which means they are easier to consume than the larger quantities of meat or pulses required to extract the same amount of grams of protein as you would get from a scoop of whey powder.
Do pay attention to what your body tells you: I found that as I am going through different stages of healing I am naturally drawn to eat more or less protein. I remember during a particular week eating up to half a Kilo of meat in one meal and then still reach for the protein powder shortly after.
3. Manage free radicals
These are released in large quantities and this can place our anti-oxidative reserves under stress. Plus we need to deal with the inflammation that is a natural component of the healing process. Unfortunately common painkillers found off the shelf act to suppress the effects of the molecules causing the inflammation which are also essential for a speedy recovery.
I cannot tell you enough how much this sucks as after the first 36 hours following my little accident when the pain was excruciating and was preventing me from sleeping, I decided to not take any more painkillers. Thankfully we can supplement our diet with natural antioxidants like Vitamin C, E, Omega-3 and Alpha-Lipoic-Acid to help with the inflammation. Curcumin has recently gained prominence as a powerful anti-inflammatory and anti-oxidant and the effects are felt quickly.
Personally I prefer using Kombucha for this purpose but have also, admittedly, increased the number of curries I make from scratch every month. 😉
4. Vitamins and Minerals
Fourth: we need to make sure that we are taking in the correct amount of both. Vitamin D3 is very important for bone health because it’s the primary regulator for the absorption of Calcium and so is Vitamin K which assists with binding Calcium to bone. Zinc, Calcium, Phosphorous, Copper and Silicon are important minerals all having a fundamental role in bone repair.
The best strategy for ensuring adequate supplies of all the important players in fracture healing is to supplement the diet with a good quality multi vitamins and minerals product. When I say “good quality” I mean the sort of supplement that is available from reputable specialist fitness sites as opposed to your local supermarket’s £1.99 special.
This may seem so obvious that it doesn’t warrant mentioning, however it’s important to listen to what our body is telling us even in this respect. Healing from a major traumatic event takes a heavy toll on the human body so it’s OK to give in to exhaustion and sleep like a hibernating bear.
It’s also a good exercise in letting go of everything that we cannot control under the circumstances which is almost everything. It’s a good time to catch up on books, website revamps, blogging, social media, your favourite tv shows and, why not, allowing your other half to be a Knight in Shiny Armour and unleash his/her inner Jamie O at meal times. 😉
I think that during the first couple of weeks after the accident I slept like a puppy as I found it almost impossible to stay awake. I had to sleep on the sofa so that I could have my left leg supported and virtually immobilised against the backrest.
Still to this day, judging when it’s time to stop and rest is probably the hardest thing I have to do each day. It’s so tempting to fall into a self inflicted guilt trip about not doing all the things I think need to be done but won’t cause humanity to become extinct if I don’t tend to them, not exercising, etc. whereas being tired is really feedback from the body saying it needs to slow down and rest to carry on its healing work to get rid of the bone bruising.
As soon as it’s safe to do so it’s a good idea to start walking gently and for short periods of time to subject the bruised bone to a small degree of loading. If done sensibly and gently this process will speed up healing as it stimulates the activity of osteoclasts and osteoblasts plus it will help keep blood circulation in top shape. Muscle wastage is an unfortunate consequence of spending prolonged amounts of time laid up in bed unable to move. It happens at an alarming rate and it’s therefore imperative to start rebuilding the lost muscle as soon as it’s physically possible and safe to do so.
Once again we must honour our new boundaries and only work within our reduced capabilities. This is a time when it’s totally OK to walk away from a workout half way through it if carrying on could jeopardize our progress. In fact there is no shame in skipping a workout altogether for the same reason (see resting above). It’s also a good opportunity to revisit our basic training and perfect the simplest movement patterns by ensuring 100% correct form at all times. This little exercise will pay large dividends in the long run because it will help re-establish neuro-muscular connections and by the end of this healing journey we will end up stronger and better built than we were before the accident.
Where am I at in all of this bone bruising business?
Well, 6 months on and I have relearned to walk correctly which I seem to manage most of the time. When I cannot and I start dragging my left leg it’s usually a sign that I am exhausted and I need to stop and rest or, if for some reason I cannot stop, at least try to be mindful of how I move to ensure I am using the joint to the full range of motion available to me at the moment and don’t put the opposite hip under too much stress.
My ROM is far from 100% but getting increasingly closer as the bone bruising slowly gets better. The tendons and ligaments in the joint are still contracted to protect it and the only thing I can do is to gently persuade them to let go a little bit more every time I exercise or receive physiotherapy treatment.
Going to the gym has boosted my mobility in leaps and bounds. Because I cannot do anything that involves any amount of impact or loading of the joints beyond my own body weight I have gone back to basics and favour body weight exercises over weight lifting which I limit to upper body exercises carried out whilst sitting on a bench or swiss ball.
Mirrors are my friends: I can check my form and force myself to only do perfect reps. And as much as I hate the idea of doing cardio I have made friends with the recumbent bike that allows me to catch up on my favourite books while I mobilize my knee.
The results of my three dimensional approach to heal from bone bruising taking into account lifestyle, nutrition and exercise, speak for themselves. The affected leg is getting stronger all the time and muscles are building back up nicely even if slowly. Although still a bit painful at times I can now go up and down staircases normally and can sit down on chairs without triceps dipping every time. I still have a long way to go but am confident that I will go back to the normal before the accident eventually.
Over the next few months I will carry on with the same regime in terms of nutrition and supplementation and will start to introduce weights for the lower body exercises very soon too.
I sincerely hope that nobody reading this ever find themselves in the same situation as I got into as severe bone bruising truly sucks donkey’s balls, however if you are already in it I hope that you might have found some of this information useful and that it will help you speed up your healing. If you need help with your recovery I can design a bespoke nutrition and exercise program for you – just book a discovery call via the form below.
Marsell, R. and Einhorn, T. A. “The biology of fracture healing” – PMC3105171 [NCBI]
Marsh, DR and Li, G, 1999, The biology of fracture healing: Optimising outcome, British Medical Bulletin, 55(4):856-869
J. Jamdar, et al., Journal of Alternative and Complementary Medicine 2004,
10 (6): 915-916.
Eneroth, M, Olsson, UB, and Thorngren, KG. 2006. Nutritional supplementation decreases hip fracture-related complications, Clin Ortho and Related Res, 451:212-217