Tiago Costa

Internet entrepreneur and triathlete (Ironman Finisher). Founder of WayNext – digital agency and other companies. Blogging for myself, this is not the agency voice. Welcome!

Inferior pubic ramus stress fracture running / triathlon

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I am currently dealing with an inferior pubic ramus bone stress fracture originating from running and overall triathlon training.

TL;DR: it took me 8 weeks completely off any kind of exercise and 3,5 months to start training again. I believe that having stopped any training immediately after diagnose could have reduced the time off. Almost 5 months after the injured I still don’t feel completely healed.

It seems like there is not a lot written on stress fractures on amateur athletes, at least not the kind of fracture I am currently dealing with.

This is why I decided to write this post so that maybe other athletes can relate and find some support here. For background purposes I shall mention that I am an amateur athlete, I have been running for more than 15 years and into long distance triathlon for the past 6 years (with several half and full IM distance races under my belt). I am also mindful about training load and intensity and strength conditioning but I must admit sometimes I may push it a bit more than I should without sufficient recovery.

It all started by mid November on an early Saturday morning run doing six 1.500m repeats. I was feeling a bit worn from the previous day heavy deadlifts at the gym but I still headed out the door for this running session. Everything was fine until the last 1.500m repeat when I decided to push a little harder and made it at 3:43/km pace. I finished the last repeat feeling good but as I finished the recovery and was starting to run again at cruise speed (say 5:00/km) I felt a strong pain in my left glute.

I immediately understood something was off and being an athlete for quite some years now I got the feeling that was not just another niggle. I went back home in a lot of pain, dragging myself for about 10 minutes at 6:30/km pace. A couple of hours after the session I could barely walk. Any leg movement was very painful and I was limping while taking the dog for a short and very slow walk. Took some iboprofen but the pain did not go away until I went to bed.

The next day I woke up feeling less pain but it kept me from training. I did some stretching and foam rolling for the next few days and arranged an appointment with my physical therapist. He thought it should be a micro rupture on the glute muscle and we did some sessions trying to handle it. The pain was reducing but it never went away. Basically pain would be on and off erratically throughout the day. I kept swimming and cycling but running was too painful. Also sitting for too long would be painful, I remember that I would be in a lot of pain when driving for more than 90 minutes.

About 3 weeks in, still with intermittent pain I went to the orthopaedic doctor which thought it could be a tendinopathy and prescribed an MRI

The MRI results came with different news reporting a stress facture at the inferior pubic ramushttps://publicdocuments.sth.nhs.uk/pil3357.pdf.

Image from the PDF document linked above.

I then went to my sports doctor by early December who prescribed another anti-inflammatory and a calcium and vitamin-D supplement to promote the bone healing process. He also requested another MRI to be done 1 month later.

During this period I kept doing some upper body strength work at the gym, swimming with a pull-buoy and doing some long walks to keep the body in motion to prevent a complete fitness loss and maintain some mind sanity.

One month after the initial MRI the time came for the follow-up exam, meaning that I had about 5/6 weeks with no running or cycling. The second MRI results were disappointing. Unfortunately the fracture was still not healed and there was even some bone edema on the fractured extremities. On the current matter of affairs my doctor decided to put me back on anti-inflammatory because of the edema, keep the calcium and vitamin-D supplement and add magnesium supplementation. At this time I was currently looking at an additional 7 long and exasperating weeks and this time completely off any kind of exercise, so no running, no cycling, no swimming, no gym, no long walks, basically just plain, dull and boring everyday life – talk about embracing the suck. Life can be hard for an endorphin junkie.

After 3 months without any running and 7 weeks completely off any type of exercise and while taking the anti-inflammatory I was feeling completely healed. No niggles or funny feelings on the affected area but after another 10 days without any meds I started getting those back – soft niggles and weird feelings. I had no pain but sometimes I felt that there was something weird in the area of the fractured bone. I had lost all my exercise routines and I had even started to wonder how did I had time for so many training hours a couple of months ago – I was mostly working and sleeping more hours to fill the void. It really messes with my mind being completely off exercise for so long and on top of that not knowing for sure when I would be able to resume and how long would it take for me to get any kind of fitness; because any fitness and specific muscle mass was now gone.

The time came for the third MRI and the results show that the fracture is still not healed. This time, I was already 3,5 months in from the injury date and about 8 weeks completely off exercise so in reality I was expecting better news. Even if I felt some really soft niggles every now and then, I was hoping that the fracture would be healed and I was already fantasising about being able to start exercising again so this is a major bummer.

I was yet to go to the doctor to get his opinion on the MRI results but since I now know that this whole bone fracture things are measured in months or weeks, not days, I believed I would remain sidelined at least until mid-April, probably later. This is also to say that this year’s triathlon season was not happening for me because I would not have the time to prepare for anything interesting like a 70.3, let alone a full IM (little did I knew that the triathlon season would soon be over for everybody because of Covid-19).

Anyway for the time being I would be happy to just be able to go outside to ride for a couple of hours and clear my mind.

I went to the doctor a couple of days after receiving the third MRI report and, while I was not expecting it, he said I could get back into training. This means I had green light to start cycling, swimming and doing strength work. Regarding running he recommended I would wait two more weeks and then start it with really easy and short runs to allow my body to slowly adapt to the load on the injured bone. 

So this was basically the greatest news I could have and I immediately went back into training. I rode twice during the weekend and started swimming as well.

I still scheduled an appointment with a sports PT to see wether he could help me with a couple of sessions devoted to improving overall strength and condition making it safer to get back into training at full swing.

A couple of days after getting permission to restart training the Covid-19 pandemic was declared meaning that training routines were severely impacted. I only managed to attend to one sports PT session because of it.

I am now 3 weeks into training and that has been mostly riding the trainer and doing some strength and conditioning work on my own since I have decided not to go to PT because of the virus. I have also been using the Strech Cordz to simulate some swimming since all pools are closed at this time.

I have also resumed running starting with short walk-run efforts and I was able to run very slowly (around 6m30/km pace) for 10 minutes. I have since upped the running to 3x 20 minutes with 3 minutes walk in between.

I am finally posting this on April 5th 2020 and I been been riding the trainer 4-5 times per week, running slowy 2-3 times per week, doing some core and strength and conditioning work and swimming simulation with the resistance bands.

I have some weird feelings on the stress fracture zone after riding hard and also after running but it doesn’t hurt nor it feels anything like the pain I had when it all started. I also have muscle soreness, especially after running, but I believe this is all to be expected after the injury and such a long period of time off any exercise.

Meanwhile I have ran 20m at around 5:40/km but I lack the confidence to go faster even if by now the heart rate is starting to drop to a normal level for this pace.

End of May Update: I have been cycling and running for the past weeks. I still don’t feel confident to run more than 80 minutes or to go much faster than 5:00/km pace. I have some discomfort on the injured area so I always refrain from going longer or faster. On the bike the fitness is rising and I have managed to ride 90/100km at ~3.3w/kg which is a somewhat strongish intensity. I have also noticed that my discomfort increases during the weekdays when most time is spent sitting on my butt, so I have been trying to move to different chairs through the day to avoid the fatigue. With all the pandemic going on I have only managed to swim 15m at the sea because all pools are still closed (and I suspect they will remain closed for a really long time). I have also been working on some core and flexibility twice a week on my own.

End of September Update: for the past month I have finally been running with less restrictions, not adding too many training sessions (about 3 per week) or long distances (most training sessions are around 10 to 15k) but adding a bit more intensity. I feel like I am almost completely recovered, I can feel a very light niggle every now and then but it has been decreasing its intensity. I have also been working on the bike with no limitations; the swim is still being left behind because of the pandemic.

1 Year Update (Nov 16th): I have recovered what I consider a decent running fitness, while still not pushing it too hard. I am still not as fit as when I got injured but I guess I could be if I would aim for it, which is pointless at this time without any races planned. Running is pain free with minor (really minor) niggles every now and then and biking fitness is also on the rise (still have not done an FTP test but I would be surprised if it had not improved since last year).

I will update this post in the future because I spent endless hours searching for this online and I valued every detailed report I could find so I hope someone else finds this useful if they are injured.

Author: Tiago Costa

Internet entrepreneur, Ironman Finisher and kitesurfer. Founder of WayNext – web agency and other companies. Blogging for myself, this is not the agency voice.

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