Orthopaedic and Neurosurgery Specialists ONS, Greenwich, CT

Unknown Unknowns

Known Knowns. Known Unknowns. And, yes, Unknown Unknowns! The latter, according to Donald Rumsfeld, former US Secretary of Defense, are “things we don’t know we don’t know.” How is this relevant to me?! As I’ve written about in my training recap #10, I may have suffered another stress reaction. Or it may be a neuroma (benign growth of nerve tissue between the toes that causes pain). Or it may be something else. An example of known unknowns. But there is probably something I don’t know that I don’t know. Unknown unknowns.

Let’s take a look at each in turn, before we explore whether or not there may be something unexpected that I didn’t know I didn’t know. Thank you, Secretary Rumsfeld!

Known Knowns

First, some useful background and context on stress injuries for runners.

Stress reactions and fractures are relatively common overuse injuries in runners, and there are a myriad of factors why these occur. Stress injuries are inherently difficult to diagnose with certainty. In my case, a suspected stress reaction – where the bone has not fractured completely – typically cannot be diagnosed with an X-ray (often, including for me, X-rays are negative). Proper professional diagnosis may require an MRI. X-rays, however, can rule in/out other injuries in the affected area. An MRI can show potential fluid in the bone marrow and swelling of the surrounding tissue. This should rule in/out a stress reaction or fracture, and determine the grading of the fracture.

What I know is that I suffered an injury during a Sunday long run on March 31. After 4 miles of a planned 6-mile run, I experienced pain in the area of the 2nd and 3rd metatarsals on my right foot, and stopped. This injury felt similar to one I experienced on November 7, 2018 .

In February 2012, I sustained a metatarsal stress fracture in my right foot. For the first 4 weeks, I took a few days off here and there, and in between tried to run again. An MRI confirmed the stress fracture, and the importance of immobilizing the injured area with an Aircast boot. Once in the boot, the injury healed in 6 weeks. I missed 10 weeks of running.

From the above experience, there are several Known Knowns: stress reactions and fractures (1) require proper, professional diagnosis (X-ray and often MRI) and (2) take time to heal, and conservative treatment will accelerate recovery, and (3) running through such an injury is a bad idea.

Known Unknowns

There are three things that I know I don’t know. These are known unknowns. One of these will be eliminated, whether or not it’s a stress reaction, with the results of an MRI within 2-3 days (MRI was yesterday at Orthopedic and Neurosurgery Specialists in Greenwich, CT).

The other two will remain unknown. Because I did not have the November 2018 injury professionally diagnosed, I don’t know that it was a stress reaction (it’s a hypothesis). In addition, and although I took off 5 weeks from running (but did not wear a boot), I don’t know whether the November 2018 injury properly healed. Therefore, I don’t know if the March 2019 injury represents a re-injury, or it’s a new and different injury.

Unknown Unknowns

Now that we’ve established what I know I know, and what I know I don’t know… what about anything that I don’t know I don’t know? Hmm.

What I had not considered was my response to the November 2018 injury. That was not my first injury in the area of the metatarsals on the right foot. The experience and physical sensation was similar to my February 2012 injury, which was confirmed through professional diagnosis (X-ray and MRI) to be a stress reaction. After an initial misguided attempt to self-diagnose and run through the 2012 injury, I was in a boot for 6 weeks and had to take off 10 weeks from running. An eternity for a passionate runner.

Without explicit awareness and acknowledgment, I repeated this approach in November, not pro-actively seeking out a professional diagnosis and treatment, instead self-diagnosing and taking 5 weeks off. I started to ramp-up again in mid-December following the 10%-rule, and reached 20 miles per week (on 6 days) after 3 months. Only to experience renewed pain in the same area in March 2019. Before shutting it down and having the injury diagnosed with an X-ray (negative) and MRI (awaiting results).

Same issue. Same response. No learning from the 2012 injury and adapting the response to the 2018 injury, and possibly avoiding the 2019 probable re-injury. Unknown Unknowns. In December 2018, I did not think about 2012. While I remembered that I had a stress reaction a few years earlier, I did not recollect the details including diagnosis and treatment, nor did I invest time and effort to research and apply lessons learned (all the data was in my online running log!). Therefore I didn’t know I didn’t know.

Time to think about the most important question…WHY?! More to come…

Important Note: Nothing in this blog post is intended or should be considered as medical advice. I am not a physician or medical expert. I am sharing my own experience as a runner with stress injuries. Please consult a physician with any medical issues.

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