On March 5th, I semi-knowingly set off on what would be my last run for months. I was about to find out I had my 4th bone stress injury and my first in 9 years. But let’s rewind a bit. How did we get here?
the history
In the fall of 2021 I signed up my first ultramarathon, a 50 mile race in Raleigh, NC. I hired a coach, employed my husband as my “live in” dietitian, and committed to doing whatever I needed to to train safely and healthfully. Training for that first 50 miler was one of the best 6 month periods of my life. After a couple years of unsuccessfully trying to get back into distance running, and procuring my second autoimmune disease (Hi, Hashimoto’s) I was THRILLED to be running the highest mileage I ever had injury free…and feeling great! The race was as perfect as your first 50 miler could be and it was one of the best days of my life. After the race all of my many aches and pains resolved except some pain in my lower left hamstring, kind of behind my knee. It didn’t feel like anything crazy and at the time I told myself the only thing it was doing was making it so I couldn’t squat down without a lot of pain. I slowly got back into running, after an epic Hashimoto’s flare, and set my sights on my second 50 miler, PM2HR, in October 2022.
Training for that second 50 wasn’t quite as glamorous as the first. As the months went on I became really dependent on my every other week physical therapy sessions, my subtle, no big dead, hamstring pain moved up my hamstring and became high hamstring tendinopathy. I told myself “when you run this far you’re going to have some aches and pains” and did whatever it took (PT, strength training etc.) to keep the discomfort at bay and it didn’t impact my runs…until it did. A few weeks before the race I started to not be able to run without limping because my left high hami and glute complex were in pain. I kept my coach and PT in the loop and I made a choice to make it through the race and take time off after to resolve the issue. It barely bothered me at “ultra” pace, mostly just on the faster stuff, so I was able to run my second 50 miler in October 2022 with no hamstring pain in sight. Woo!!
After the second 50 I took about 6 weeks down with very little to no running and lots of PT, biking, and swimming to help get that hami to a better place. Looking back, and knowing what I know now about hamstring tendinopathy, I’d do some thing differently but by the end of my “off season” my hami was barely even noticeable (but not gone) and I felt ready to train for my first 100 miler!
learning #1:
Unresolved soft tissue injuries can contribute to Bone Stress Injuries (that’s stress fractures and reactions) over time. If you have a soft tissue injury, learn from my mistakes, take care of that sucker ONE HUNDRED PERCENT before diving into higher mileage.
training for 100 miles
Now it’s winter 2022/2023 and I was training for my first 100 mile ultramarathon, the Umstead 100. The race was to be held on April 1st, 2023. Again, I was flying high and feeling good, until I wasn’t. I can’t remember exactly when, but slowly over a couple of months my hamstring issues came back and my whole left hip area would “take a few minutes to warm up” every run. What I didn’t tell anyone is at the end there I was literally limping for about 1/4 mile before things would get warm and the pain would mostly go away. I became completely dependent on my every other week PT and couldn’t make it even 2 weeks between appointments without pain. My strength training volume went down as my mileage went up (another thing I’d do differently next time, just for my body personally) and my hami pain got worse and worse. I kept telling myself, “you don’t train for 100 milers without some aches and pains,” and I did THE WORST thing you can ever do (yes, despite being a CSCS and dietitian, I’m still human and I just wanted this 100 so bad I let myself not be logical). I rationalized that “everyone else I knew training for the 100 I was had injuries and little aches and pains so it must be a part of the process.” WRONG. That is wrong. Other subtle changes that happened from December to March were:
- my hamstring pain came back and impacted my run form
- my menstrual cycles got further and further apart until I didn’t have one at all in March 2023
- my weight slowly decreased about 4-5 pounds over the 4-5 month training cycle
We’ll come back to these findings in a bit.
learning #2:
Just because “everyone else” is doing something or experiencing something doesn’t make it right. Just because everyone else on your team under eats and seems to perform well, doesn’t mean you should. Just because everyone else you know that runs doesn’t do strength training and “runs fine” doesn’t mean you should skip it. What I always tell my clients, and obviously needed to be reminded of myself, is this stuff always catches up with athletes. I can’t tell you when, I can’t tell you how, but if you don’t fuel and strengthen your body, something’s going to (figuratively or literally) snap sometime whether it’s a soft tissue injury, RED-S, or an increased risk for osteoporosis when you’re an older adult, it does make a difference.
the stress reaction
One more bit of relevant history before we talk about the injury at hand. In 2014 I got my first stress fracture in the shaft of my femur 21 days before I was supposed to toe the start line at the Boston Marathon. I would not have caught my current femur stress reaction nearly as soon if I hadn’t had the experience of my first one.
The week of February 6th I was starting a little mini taper for my biggest weekend of training on February 18th and 19th. It was a Wednesday, and I woke up feeling like my left quad and hip flexors were completely locked up. The front of my left hip was really tight and painful. Of course, I panicked and proceeded to have emergency convos with my PT and coach over the next 10 days trying to figure out how, out of nowhere, I was suddenly a runner with front hip pain when I’ve never had that in my whole life at any time…except 9 years ago when I had my first femoral stress fracture.
I saw my PT February 16th and we threw the needles at my whole left tight area and nothing was particularly tight. The next day we packed the car and headed to Western NC for a 50k race I was doing as a training run. I won (!!) the 50k and had no significant pain. The following day I ran 20 miles back at home and I had completed my biggest weekend of training ever – about 51 miles.
Over the month of February I had weird, nondescript thigh pain that slowly turned into pain on impact just in one spot on the front of my thigh about 6 inches above my knee. I felt it on some runs, and not on others so I was telling myself it had to be muscular. On Tuesday, February 28th I stopped in the middle of my run and said to Michael, for the first time, I think I might have a stress fracture in my femur. It just hit me like a ton of bricks that I was reliving February 2014 when I had my first stress fracture in my femur.
Now, I want this to live out here on the internet forever for any runners having nondescript thigh pain wondering if they have a stress fracture. Both of my femur BSIs presented SO weird. Here’s all the things I felt in my left leg before diagnosis:
- Shooting pain from the site of the stress reaction up into my hip
- Sporadic pain on impact, worse on concrete and downhills, but not with every step or even on every run
- Pain shooting up into my hip when I did a plank or pushup or really drove into my heels on a movement like a deadlift
- Tight feeling in my left quad, hip, and inner thighs but without any actual muscle tightness when it was foam rolled, dry needled, or assessed
- Dull, throbbing, aching feeling in the area when I wasn’t doing anything
- And then the weirdest but most telling one, if I pushed my thigh into a hard bench or chair while seated I had 10/10 horrible pain in my thigh. I later learned this is similar to the “fulcrum test” done to evaluate for a bone stress injury
I share this just to say, in my experience the first month or so of having a femoral shaft bone stress injury (BSI) it doesn’t feel like you’d think a stress fracture to feel. Neither of mine initially presented as pain on impact. My first femoral shaft BSI didn’t present like a typical stress fracture until I’d run on it for about 2 months. I’m not saying if you have these symptoms you do or don’t have any particular type of injury, that is outside of my scope and every body is different. See your PT, see an ortho – get opinions from the experts but don’t be scared to advocate for yourself if you think a BSI needs to be ruled out.
On March 2nd I saw my PT and told her I thought I had a femoral shaft stress fracture. She did the fulcrum test, which was positive, and recommended I see an ortho for a MRI. I was so nervous and I could feel my 100 miler dreams slipping after 10 years of dreaming I was SO close, my taper was literally supposed to start the next week. I found an ortho who could see me the next day, and within 5 days I had my MRI.
On March 8th, 2023 I got a call from my ortho that I did, indeed have a stress reaction in the front of shaft of my femur, about 4-6 inches above my knee and I should stop running. When I went back to see him for a follow up I wasn’t pleased with the options I was given and the lack of empathy. I was nervous, WHY had I had two uncommon BSIs in my left femur? Did I have a bone density issue? Was my celiac disease causing absorption issues? He told me if I wanted to prevent we could do surgery to put a rod in my femur (what??) and that OF COURSE I had one, I was training for an ultramarathon! He felt no further investigating was needed and that it was normal to get an injury like this training for an ultra. UGH! Needless to say, my fabulous network of friends and coworkers helped me find a doctor who is a much better fit who, along with an amazing PT and dietitian, helped me figure out I am perfectly healthy with perfectly healthy bones and great bloodwork, but I likely had a case of mild RED-S (see the list of findings from earlier: weight loss, oligomenorrhea, and a stress reaction) and really messed up by letting my hamstring fester for so long. I will 100% get to run ultras again and medically there is no reason I shouldn’t.
learning #3:
Great providers are out there, you just have to relentlessly advocate for yourself and never settle until you find them. Don’t settle. I know it’s hard, time consuming, and expensive but there are great doctors, PTs, and dietitians out there. Be willing to share what you’re going through with others, you never know who might know who or what experiences your friends have gone through.
recovery
The first ortho said since it was a stress reaction and not a fracture I didn’t need to be on crutches, just to avoid high impact activity (running/plyometrics) and it would heal. For those unfamiliar, a stress reaction is what happens when you catch a stress fracture early enough and no actual fracture line has occurred yet. They tend to heal faster, obviously, because you’ve caught the injury before it can progress. So I went two weeks swimming lots, biking, and working and wouldn’t you believe it my pain got WORSE, especially when I swam. Come to find out when I saw my new, fabulous doc at Duke Sports Science Institute, based on where my stress reaction was flutter kick was likely causing too much torque on my femur and irritating the stress reaction.
In order to help speed up the healing process she recommended I use crutches for 2 weeks. I was as compliant as possible – shoutout to my amazing clients and coworkers for helping me and keeping me honest – and got to come off them after two weeks. After that I was supposed to do 6-8 weeks of low impact activity before I could return to running. My recovery ended up taking about 12 weeks in total – 2 weeks before I met my new doc, 2 weeks on crutches, and then 8 weeks after that. As I write this it’s mid July and I’m still not back to running fully. Turns out hamstring tendinopathy is a stubborn little beast and I’m committed to fully resolving it before my next training cycle.
This next bit is really hard for me to share, but I think it’s super important because it shows just how sensitive your bones can be to some of the seemingly small issues over time.
To hear I might have a touch of RED-S (Relative Energy Deficiency in Sport, formerly known as the female athlete triad) was really hard for me. I’m a dietitian and a trainer, I literally tell people to eat more, lift heavy, and support their endurance training for a living. How could I have let this happen?! I was a little embarrassed and hesitant to share my experience with this injury because I felt like I should know better. But the reality is, sometimes you just fly a little too close to the sun and have bad luck. When you run long distances injury doesn’t have to be inevitable, but there is a high risk when you push your body to new limits, especially when you have autoimmune diseases. I’d never trained for a 100 miler before, I didn’t know exactly what my body would need and how much room for error I personally might have (…seems like not a lot). I’ve learned a lot and am excited about trying again. It wasn’t my time for 100 miles quite yet and that is ok.
I’m proud that I caught this injury very early, made the smart decision not to even try to run the 100 miler, and withdrew from the rest of my potential 2023 races to make sure I let my body come back to running at whatever speed it needs to.
In distance running we’ve normalized always having aches and pains and losing some weight during training as “costs of doing business.” It’s sometimes even bragging rights to have pushed so hard that your body is hurting or to be down to your “race weight” by the end of the season. But the reality is that aches and pains can lead to season ending injuries and weight loss during the season can exacerbate that process and increase your risk of injuries even further…not to mention the detrimental impacts it has on performance. Let’s stop normalizing these things in the sport and waiting until things are catastrophic to address them.
the learnings
learning #1:
Unresolved soft tissue injuries can contribute to Bone Stress Injuries (that’s stress fractures and reactions) over time. If you have a soft tissue injury, learn from my mistakes, take care of that sucker ONE HUNDRED PERCENT before diving into higher mileage.
learning #2:
Just because “everyone else” is doing something or experiencing something doesn’t make it right. Just because everyone else on your team under eats and seems to perform well, doesn’t mean you should. Just because everyone else you know that runs doesn’t do strength training and “runs fine” doesn’t mean you should skip it. What I always tell my clients, and obviously needed to be reminded of myself, is this stuff always catches up with athletes. I can’t tell you when, I can’t tell you how, but if you don’t fuel and strengthen your body, something’s going to (figuratively or literally) snap sometime whether it’s a soft tissue injury, RED-S, or an increased risk for osteoporosis when you’re an older adult, it does make a difference.
learning #3:
Great providers are out there, you just have to relentlessly advocate for yourself and never settle until you find them. Don’t settle. I know it’s hard, time consuming, and expensive but there are great doctors, PTs, and dietitians out there. Be willing to share what you’re going through with others, you never know who might know who or what experiences your friends have gone through.
learning #4
No amount of weight loss is OK during high volume training. Meeting your bodies energy needs is possible and CRUCIAL no matter how high your training volume is. Your race weight is the weight at which you can train hard, perform well, and eat as needed to fuel your sport. When you get into ultra distances the amount of energy you’ll need can be astounding and effortful, but it’s worth it to fuel your training!
learning #5
This is more of something I told myself all during training and it was so helpful when I got injured – the good stuff and the tough stuff in life sit right beside each other. 2022 was an insane amazing year of training for me and then BAM! 2023 I’m injured. And when I got injured I said this same thing in my head over and over – the good stuff and the tough stuff sit right beside each other. I know that on the other side of this injury and recovery is another big ole chunk of good stuff, I just have to keep going and trust I’m going to get there. Injuries also really remind you how wonderful your people are.
Now, if you made it this far thank you SO much for hanging with me. If you’re currently injured, I’m sending you thoughts for a speedy recovery. I hope sharing my experience helps you feel less alone in navigating an injury and maybe helps you advocate for yourself. And if you’re not injured, here’s your reminder to FUEL that training!
Again, nothing in this post is meant to serve as medical recommendations, advice, or treatment. This is just me, a human, sharing MY experience with recent injury and what I’ve learned. PLEASE seek the input of a qualified medical professional if you think you might be injured.
