Return to Running after Pelvic Stress Reaction
I’ve been out of running for the last 8 weeks due to the diagnosis in December of a stress reaction to the pubic ramus (bilateral) and significant inflammation in both adductor muscles. Constant deep groin pain for the 1.5 years was always present when I ran. It finally got to the point in December where I had so much weakness in the groin/hip area that I felt as if my feet were always dragging behind as I ran. I couldn’t let out a sneeze and it was waking me up at night when I moved in bed. So I saw an orthopaedic surgeon who ordered an Xray (nothing seen) and an MRI (stress reaction, adductor inflammation and inflammatory fluid seen). Doc said no impact activities for 8 weeks, but I could do any non-impact activity that didn’t cause pain (cycling didn’t hurt at all).
My 8 week road to recovery looked liked this:
- Weeks 1-2: No swimming, biking or running. 5-6x/week light core strengthening (Pilates, Core Performance, other random core exercises), stretching (Yoga and general leg/core stretching) and 4 ART sessions.
- Week 3: Started adding in some easy cycling on the trainer (no pain); continued 5-6x/week core work and stretching.
- Week 4: Started Jan OS (bike workouts only); continued 5-6x/week core work and stretching.
- Week 5: Added a couple swim sessions but they bothered the groin a bit, so I haven’t swam since. Also added a 2 mile brisk walk. Continued OS cycling workouts, 5-6x/week core work and stretching.
- Week 6: Added 2x/week deep water running (simulated OS run intervals). Continued OS cycling, 2 mile brisk walk, 5-6x/week core work and stretching.
- Weeks 7-8: Added 2x/week elliptical machine (simulated OS run intervals) and 2 ART sessions; 1x/week deep water running; continued OS cycling, 3 mile brisk walk, 5-6x/week core work and stretching.
- Should I be concerned about this hip flexor tightness/pain enough to give it a couple more weeks of rest?
- Are there some hip flexor stretches and strengthening exercises you recommend? I’ve been doing these stretches pretty much everyday:
http://www.exrx.net/Stretches/HipFl...lexor.html
http://www.exrx.net/Stretches/HipFl...lexor.html
- Is there some self-massage/TP stuff I can do to the hip flexors?
- If I do continue to ease back into the running, should I eliminate/replace the OS run workouts with these easy “ramp-up” runs? Or is it okay to continue simulating the OS run workout intervals on the elliptical or in the deep water, then add in the easy “real” running on other days?
- Could some yesterday's hip flexor tightness/pain have been exacerbated by running on the roads/hills? Should I be doing these “ramp up” runs on the treadmill instead?
Comments
Hi Jim,
Thanks for all the background information. Very helpful.
It makes sense that running would cause you to feel "something" in the area where you had pain as you build back into it. I would stay on flat roads or treadmill at a comfortable pace. Pain trumps everything and i would stop. In the "off" impact time were you strengthening your adductors? Or hip flexors? With core work it is hard to exclude those areas so I would expect they got strengthened.
I would build back slowly. Sounds like your plan looks good. Add 1-3 short little easy runs a week: 10-15 minutes and build from there. Still do pool, eliptical to make up for lack of running volume.
Leigh may have a lot more to add. She is awesome.
Carrie
I wouldn't say I was doing strengthening exercises that 'target' the adductors and hip flexors - just general core routines (Pilates DVDs, Core Performance, the OS core workouts, etc.) that seemed to be hitting those areas while working everything else (abs, hips, back).
Hey Jim. sorry for the hold up.
The key for returning post stress fracture is not to force it. While the fracture site itself may be healed, your muscle coordination and balance between the various muscle groups are still all out of whack. Those first few runs and even the first few weeks back are going to feel awkward and like you aren't running "right" if that makes sense. combine that with being hyper aware of anything that feels "off" and you're bound to have that mixture of pain/tightness as the muscles and injured area are put under strain.
I like your set up as far as the run walk goes. That's the way you want to do it out of the gates especially as you build up your time. Some tweaks that I would make would be this:
1) early on, running surface will be huge. think dirt/grass (unless you're like me and won't see that again for oh...3 months
 
-->treadmill --> road. every run doesn't have to be off road or inside, but good to at least make some of them that way.
2) keep your long run in the pool. nemo has some great resources listed to help you out but the simplest way is to throw on your HR monitor and to do intervals to tolerance. 3-8 minutes all out + recover + repeat. You should be able to get your HR up into your bike zones at the very least if not higher (usually 10 bpm lower than your outdoor run zones). The pool long run will be a huge training stimulus for you. Get up and over that hour mark and focus on form (good knee lift/hip flexion, full hip and knee extension, toe off/push off). If the muscles are sore/tight from land running, this will be where you will really feel it.
3) Instead of even parts walking/running, try a setup more like this- 10 minutes walking to warm up + MS as 5 on 1 off. shoot for 3-4 reps to start. 10 minutes walking to cool down. Shoot for 2x/week + water long run. Next week try 2x10. Week after that. 2x15. week after that 1x20 and from there, safe to bump up slowly as tolerated with no walking breaks. If as you try to bump it up, things feel uncomfortable...always choose the shorter interval. Minimum two successful runs at a given interval time before bumping up. Keep that long run in the pool until you can comfortably run 30 min with no break or symptoms. Once you get up to 20-30 min, you can add in a 3rd weekly run. Once 3 weekly runs are good at 30 minutes, safe to leave the pool once and for all.
4) While the acute symptoms may be tightness in the front of the hip, really focus on working your hamstrings and adductors. Both of those criss-cross in the inner back of your thigh and assist with a full push off. When they get tight/tired they yank on that pubic arch, shorten up your stride and load your quad/hip flexors. If you have a stick or foam roller, work them nightly (will work on a video and put it up this week for you if you'd like). Trigger point ball/tennis ball between the inner thigh and hammies is also key. You'll find all kinds of fun sore spots in there that you didn't even know you have.
5) with #4 in mind, make this come back your time to really focus on your run mechanics. full hip extension and pushing off your toes all the way is key. triathletes/cyclists are notorious for adopting that high cadence/shortened stride and ultimately it gets a lot of us in trouble with cumulative fatigue.
I'm probably forgetting stuff, but fire away with any questions.
Leigh - First of all, thank you so much for taking the time to put all this great information together for me! Very much appreciated!!
What you are saying makes a lot of sense. I'll keep the deep water running going, especially for the long runs (to simulate the Sunday OS workouts). How do you feel about the elliptical machine 1x/week to simulate the Wednesday OS intervals?
I've tried using the HR monitor while deep water running but I just can't get it to read a HR when the strap is underwater, no matter how tight I make it (plus it's a Garmin 305 so not waterproof - I was putting it on the pool deck with plans to check it every so often, but when I wasn't getting a reading a bailed on that). So I just go on RPE.
Anyway, I'll incorprate the run/walk progression you recommend and monitor things closely. Totally makes sense.
As far as the massage stuff...I do have a Stick, foam roller and some balls. I use the Stick a whole lot more than the foam roller, but I really don't feel that tight or sore in the hamstrings when I use it. Maybe the foam roller and ball will get a little deeper? I definitely feel it with the Stick on my quads and calves, though. I'll also get back to using the foam roller on the adductors. This is what I was doing for the adductors...www.youtube.com/watch And for the hammies...www.youtube.com/watch
Any other manipulation recommendations for the hammies and adductors to ease up this hip flexor discomfort is greatly appreciated!
Thanks again - you da best!
Note to self: Find this thread when you are ready to run again and re-read Leigh's advice on run/walk progression to get back into it again. Good stuff!
I actually have no idea what polar I had for the pool. I do know that HR was literally all it did and was a cheapie thing from way back in the day that somebody gave me. either way, RPE is fine for the intervals. I just meant it more as a work really hard in there and you will see some familiar numbers. I always hear people say that they can't get up over 130. Just means too much flotation and not enough motion. Depending on the belt you're wearing and your size the former is very likely. I know when I was serving my pool term, as I got better and needed more of a challenge I sawed off chunks of the foam (I was using an aqua jogger belt so lots of foam to work with) so that I would sink down more in the water. Then I swapped to one of the kiddie floatie belts that the Y had and worked with that. trying to keep your head above water is good motivation.
@ Jim- the elliptical is a good cross training choice. my only advice there is to try and keep your feet in the middle of the foot plate. it's always natural to let the foot slide up so your toes are pressed up against the front. this will load up the knee and quad.
Will work on a video to show you what I mean. When things are really tight, you'll feel it from what those videos are doing, but most days I find I get nothing out of them either. Give me a few days.
I also employed your walk/run approach for 2 run workouts last week. I felt great during the "on" portions - no pain at all. And the hip flexor concern after my first run back seemed to work itself out in the next 2 sessions! I really concentrated on form and proper biomechanics. Looking at some video I took of myself running, I still have some work to do on getting full hip extension at push off - those hip flexors just seem too tight to allow full extension (or its it that the hamstrings are too tight?). It looks like I may be leaning forward from the hips too much so I'll try concentrating on pulling in the abs and keeping a tall spine. Of course, the video was taken of me running a pretty slow pace so maybe that will open up more with speed??
Thanks again for your help!
Hey Jim, sorry for the hold up on the video. just been swamped lately but will get on it this week/weekend.
great news to hear that the run went well!! that's a great sign.
The big muscle group to work on is still the hip flexors and adductors (they criss cross in the front), but the hammies and glutes are the next big group to work on.
re: full extension. it doesn't have to be super exaggerated like when you watch video's of the pro's. it will vary by body type. when I try to focus on it I think to myself "stay on this foot, extend hip until my knee is straight and my heel starts to come up off the ground." Once I get into a groove with waiting for that instead of rushing the stride, I add some power to it and start actively pushing off the big toe as I straighten my knee and hit heel off. Add in tight abs and tall spine and you are golden.
Leigh, any luck on that hip flexor/adductor/hammie video? Your lower-leg video was so helpful, I was hoping to learn some nuggets on the hip!
Mike
thanks for the reminder. sorry for the hold up. video done and will post in morning.
Okay, here we go.
Hip Stuff from Leigh Boyle on Vimeo.
">vimeo.com/moogaloop.swf
Thanks Leigh! Great stuff
It's now been 4 weeks of slowly ramping up my running from 5' easy run intervals to hitting a couple 30' continuous runs this week, all with no pain! I've followed your advice exactly in the mileage ramp up and am feeling excellent! I'm going to incorporate the stuff from your video and probably start adding in some strides next week and hopefully some intensity in the coming weeks. I really think this 8 week break and the slow ramp up focusing on mechanics will ultimately put me at a higher level with my running this year than in the past. Staying disciplined and running slow and steady on my return has been key.