Coming clean about some medical issues
Ok, so I was going to write the first part of this post
during taper week or my race report but I'm in a position where I really need some
medical advice so I'll just come clean and let everyone in on what's going on.
PART 1
A few perceptive folks have noticed on Strava that
my running mileage fell of a cliff a few weeks ago. Since the week of 6/22 my
weekly mileage has been: 38, 43, 44, 31 (bike week), 26 (camp week), 37, 41, 7,
16. From the 7-mile week to the 16-mile week there were 11 consecutive
days of zero running. In the space of those 11 days I did
an MRI and was diagnosed with a stress fracture of the pelvis, among a few
other very disappointing things.
The reality is that I've been running injured since about
mid-July, and one of the symptoms seems to be a recurrence of the injury I got during
the heart of my Boston Marathon training way back in the late winter (more on
that in a moment). Basically, for about a month, the situation was that post-run
I had significant pain and was limping for about a day. At the outset of a run
I had a bit of discomfort but nothing too bad. But after the run it got really
bad. After a day or two were no symptoms and I was back to normal. But
the recovery time from each run got progressively longer and the pain progressively
worse and so I made an appt with a sports doc. Prior to the
appointment she ordered an MRI of the pelvis (I have excellent insurance). I
had the MRI on Wednesday 8/12 and the appointment the next day. I should note
that my runs were still pretty good quality and I managed an 18-miler at
7:05/mi pace on 8/9 followed by a 60' LT run with 3x 1mi at sub 6:00/mi pace 2
days later (the day before the MRI).
The news from the doctor was mixed. The radiologist's report
and visual inspection of the MRI shows findings consistent with a stress
fracture:
- Bone marrow edema within the right pubic body
- A linear focus of low signal within the right
parasymphyseal region
On the other hand, the doctor's assessment was a bit
different:
- The stress fracture difficult to confirm on the MRI, if
not inconclusive
- Edema is present but she had less concern based on marrow edema
patterns sometimes found in uninjured distance runners
- Most compelling to her, a physical examination including a
lot of prodding failed to produce any pain, i.e. she was pressing on the bone
in the place the MRI identified but it wasn't hurting
- In various clinical tests (e.g. hopping on my right leg,
etc) there were no symptoms, although as I told her in the 24 hours after a run
those same tests would have yielded a lot of pain
There is one more twist
which is that, perhaps due to compensation, my right hip and adductor had
started hurting a bit while running. The doctor's physical exam was positive
for impingement and the MRI showed it a bit as well although it was a study of
the pelvis and not the hip so there isn't a complete set of pictures to
understand the detail.
Amazingly, her
advice was to continue running "as tolerated". I should
mention that cycling and swimming did not seem to irritate the injury at all.
If the edema was bad and the fracture more evident she would have recommended I
cease training for 6+ weeks.
We happen to have a radiologist within EN and he was
incredibly generous with his time and reviewed the images with a colleague of
his who specializes in MSK. He concurred with the uncertainty: "We agree there is marrow
edema. There is what looks like a stress fracture in this area but it is
a bit questionable. I would have called it though, particularly in the
clinical context. The hip impingement stuff is a very soft call, in our
opinion." He went on to explain the generally poor
correlation between marrow edema and symptoms and reiterate that letting symptoms
be my guide for training was the best idea (although I'd say he was quite a bit
more conservative in his practical steps to implementing that, i.e. not running
with ANY discomfort, etc). I had previously sent a PM to another of our EN docs
and he had similar advice although a bit less conservative, probably because he
knew more about my athletic situation.
Overall, however, it just hurt a LOT to run by this point and
I just felt something was wrong and getting worse. So that
fact plus an upcoming bike-focused vacation week convinced me to totally shut
down the run for 11 days. This was on weeks 16 and 17 of the IM build so to say
the timing was bad is a massive understatement. But at that point I had decided
that any performance goals could be thrown out the window and the only way I
wasn't going to put all my training and fitness to the Ironman test was if I
thought there was a good chance I wouldn't be able to finish the race. As I
said, I was able to run a respectable 18-miler, so the priority in my mind was "don't
get any worse".
PART 2
So that takes us up to the current day. Everything above I
decided I wouldn't write about until my taper or maybe even my race report. But
now it gets a bit more complicated with some choices to make and I need some
input.
I didn't run for 11 days and did my first run this past Saturday,
a ~50 min effort at moderate RPE. I was encouraged that the pubic bone
discomfort was almost totally absent but the hip / adductor pain
returned strongly. In an experiment that would make a licensed doctor
cringe I started a course of NSAIDs called oxaprozin using an unfinished
year-old prescription (dated March 2014) sitting under my bathroom sink. My
rationale was that before the Boston Marathon in 2015 I got really bad shoulder
impingement that was treated first with oxaprozin then with prednisone and as a
side benefit all of my hip/adductor symptoms disappeared.
The oxaprozin is 600mg tabs and on Saturday after the
morning run I started 2x/day (the Rx was always for 1x/day but back in the spring
it took 2x/day to make the shoulder pain go away, and various internet sources
say normal dosage is 1200mg/day not to exceed 1800mg/day). By Sunday morning 24
hours later I was feeling no issue in the hip (usually I would be feeling it the
next day) and on Sunday afternoon I did a pretty hard tempo run, about 8.5
miles in ~56 min. Amazingly both during and after that run I had virtually zero
hip/adductor discomfort.
I came clean with my experiment in an email to my doctor who
suggested I go to 600mg/day, finish the tabs I had left (which at 1x/day would
take me to Saturday) and keep her posted. She also suggested I don't run on
back-to-back days. So I did just 1 tab on Tuesday and Wednesday (today), and I
ran pretty hard both days with the intention of taking tomorrow off of running
then doing my RR run on Friday, Saturday no running and Sunday my final
"long run" but dialed back to 90 minutes. Now after 2 days of 600mg/day
I had some post-run hip/adductor pain today and will see how it feels tomorrow,
but I feel confident that if I dial back up to 1200mg/day the pain will go
totally away.
Now oxaprozin is an NSAID and my understanding is that the major
side effects to watch out for are delayed muscle recovery in training and, when
racing, renal issues / failure if you get dehydrated. So using it when racing
is hugely risky and basically not to be done. The other side effect I wondered
(and posted) about is elevated HR…since starting the oxaprozin my heart rate
when I wake up is about 7-10bpm higher than normal and I'm running about 10 or
so bpm higher running and biking. Apparently there should be no HR impact. So I
have no idea where that is coming from and perhaps down at 600mg/day it will go
away. Or maybe it's related to something totally different, argh, what???
Finally, about a week before the Boston Marathon my shoulder
was so bad and only 1200mg/day of the ozaprozin was keeping it in check which
my doctor didn't like. She recommended a steroid shot directly into my shoulder
but I didn't want to do that right before the marathon lest it impact my arm
swing etc. So she prescribed 5 days of 20mg/day prednisone. I did that and
finished it about 2 days before the race. Not only did my shoulder pain go
away, but the hip/adductor issue that had gone from really severe to just
nagging over the prior month or so disappeared completely. And I guess since
the prednisone is a corticosteroid the risk of renal failure is not an issue.
SO NOW WE GET TO THE PART WHERE I NEED ADVICE……………………………I am
18 days from race day. What should I do?????? My current plan:
1. Run hard the rest of this week, the logic being that I'm
probably not doing any harm I can't recover from (i.e. what I did in early
August followed by downtime and meds and now I'm running strongly). I'm
resigned to my longest run from now to the race being 90' this Sunday, and after
that nothing over 60'.
2. Run reasonably hard the first part of next week (week
19), then do a deep taper
3. Take up to 1200mg/day of the oxaprozin if that's what I
need to run pain free through the first half of week 19 (need to get some more…I'll
have to figure out how to swing that…internet pharmacy????)
4. Do what I did before Boston and take a 5-day course of prednisone
on the front end of week 20 (I was able to have a doctor friend call that in
for me so have the meds in hand)
Step #4 is the one I can't test but if racing using NSAIDs
is really risky then I shouldn't be messing around with that, and my experience
in Boston was that it seemed to work really well. Btw are these meds considered
a PED and banned? I'm not sure it changes my course of action but would be good
to know.
As usual this post turned out to be a lot longer than I
expected but thanks for reading and any thoughts, suggestions, advice, etc are
all hugely appreciated.
Comments
Prednisone is my nemesis, so I always cringe when people mention it. Lots of personal experience thanks to Crohns disease, but in more the 50-60 mg range, so I really don't know what to expect with lower doses. One of my big issues when I go on pred is weight gain, irritability, and insomnia. Did you have side effects when you took it before?
Thanks for that long post. Many blanks filled in. First off, I know the corticosteroid drug family (even topicals, just ask Lance...) is considered performance enhancing. You can probably see why from your own experience. In the short term they can enable you to put up with lots more sh*t of various kinds than without them. Here's a page with the list of banned substances and practices but I'm not sure if it is current. Most non-opiod pain relievers are allowed from what I can see. Maybe they're thinking if you're not hurting so bad as to need morphine-type drugs have at it if you're dumb enough determined to race. ;-)
http://sportsanddrugs.procon.org/view.resource.php?resourceID=002037You're dealing with some serious skeletal difficulty here, particularly in such a fundamental part of your core, Matt. Your data show you're far stronger than most and that bodes well for you - unless you're not going to just coast at this race. If you're pushing yourself to your limits it doesn't really matter how strong you are since you'll be at your particular limits.
Practical advice? See if you can do some weight-reduced training. You have demonstrated that you can withstand some pretty hard efforts for long periods while on oxaprozin (OXP, because I hate typing it). That's great if you really are going to do it up on race day but try to lessen the ongoing damage in this final stretch. You can still get good training in for your running legs with water running. [Yes, I'll wait. You back? Good.] I used that and kept good fitness when I dealt with a metatarsal stress fracture and when recovering from an unscheduled, poorly planned collarbone renovation. I did it 3 different ways, rotating the different workouts like the different run workouts we normally do. Doing intervals in all three types of workout conditions is just fine. All 3 can be boring though.
- Just plain 'running' with barefeet in the deep end of the pool with a float belt. I do believe it keeps you in better posture than if you were treading water, which I would also do for the arm work sometimes. Having your feet/legs fly as best they can in the water is great for speed and proprioception.- Wearing fins, the longer the better, to really make your legs work against that resistance. Again, use vertical posture in the deep end and have at it. Yeah, see how long you put up with that before your legs are screaming at you.
- Running in a shallow swim lane. If the pool isn't busy and the life guard is okay with it run laps in the 3-4 ft water. You'll still be having foot strike but it won't be as punishing because of the bouyancy reducing your impact force. That black line is slippery. I used these since I knew I was in for a long rehab with that stress fracture. http://www.aqxsports.com/images/stories/ATS_diagram.jpg Great traction and they allowed them in the pool. I've also tried the yoga-toes socks I have to wear in yoga classes to keep from sliding out of some poses and really killing myself.Do give it a try. You are going to a lake or pool for swimming aren't you over the next weeks? If anything you'll get yourself better able to handle standing up and scampering out of the water - and not having to woozily shuffle over to T1.
I'm not a doc, but I work real close with several respected sports med/orthopods in this area so I'll pose this scenario to them soon. I'll let you know what they say. Obviously, you'll have to take that with a grain of salt b/c they can't eval you or look at your case/films. But, I'll let you know, none the less.
IMO...I'm pretty sure not racing just isn't an option since you are (and have been) able to run. You've done so much work to get here, I would be really surprised if the extra rest would sabotage your race efforts. If running (and running fast) doesn't seem to shut you down with pain, I'd lean towards no running for 10 days just to take the stress off of the stress fracture. I know it takes much longer for this kind of thing to heal. I'm not talking about healing. I'm talking about buying time until race day. Reducing the number of impacts. Save them for the race. You have plenty of time to stay off and heal after. I'd suggest spending those 10 days really working on your stretching and making sure those hips and hamstrings don't tighten up over the time off. Then, use that week leading into Wisc to fire the run back up. Short/light stuff just to get the feeling back. Then, race as fast as you can tolerate. I'm betting you will push thru any discomfort and have a strong run, even with some time down leading into it.
I don't like chronic NSAID use. In this case, it could be justified for race day. You've done your homework on the potential badness. It's a statistics game at that point. I'm a believer in letting the body's workers do their thing. If swelling/inflammatory response exists, it's cuz there's work in progress. Reducing that doesn't make the healing come faster, just makes it easier to tolerate, some say it even slows the time down.
But, for race day? Yes, the dehydration/endurance event/kidney probs is well documented. Don't get dehydrated. You're way smarter than this. Stay on top of it. Odds are WAY in your favor that you'd get through this without kidney problems. Some would even suggest Extra Strength Tylenol on race day. I've tried this once and with good results. But, it certainly could mask early signs of pain/damage happening in your case here. Seems that you know the difference between nagging ache and acute/intense ''there's a big problem here'' pain....you seem to know where your line is.
You've worked so f'in hard to get to this point. Every race you take on, you do so in that 'all in' mentality. I hate to hear about this. Your post implies that you are not interested in even considering not racing. The safe answer from most of the docs out there will be ''Don't Race.'' But, the next best thing will be something along the lines of 'do what you have to do, but make sure you rest up/heal up appropriately after' or you could be in for a hobby change sooner rather than later. That's not my opinion, but I bet that's what I'll hear. Just from my brief time here with you in EN, I know that you're as tough as they come and I expect you'll be full steam ahead through this race, heal up after, and be ready to go next year.
healing mojo your way.
for me, I don't like the idea of having meds in your system during the race. I feel like we put our bodies through so much during the course of an IM that asking it to also process meds can potentially be damaging...this of course is based on no medical research. Just my thoughts. I also am not a huge fan of masking pain during an IM. You need to know if your body is hurting so you can adjust.
Anyways, so what I'm saying is to base everything on your symptoms. However, this means you need to actually feel your symptoms. If you are taking large doses of NSAIDs, well, harder to do things based on symptoms. The mentality should be to use NSAIDs for their anti-inflammatory effects, not to decrease the pain and make running tolerable. Don't give yourself a hard plan right now, just keep testing things out and taking days off as needed. Water running and elliptical could also be used as lower impact to supplement lower run volume. A few Chicago area PT clinics also have Alter-G's, not sure how difficult it is to get time on them, but that is also an option. While I'm sure you are worried about fitness losses with reduced running, just a reminder that a good IM run pace is still much slower than your speediness. I'm guessing that while you might lose your top end speed, your IM speed might not be as impacted.
@ Matt...really sorry to hear this man. But I think you will be okay if you rest. I think you've heard me say this but "Rest is a magical thing" leading into an IM. You have a HUGE reservoir of fitness built up. I've seen it. A little extra rest isn't going to drain that reservoir. In 2013, I crashed on my bike 5 weeks before IMWI, brusing my hip, quads and shoulder. I didn't swim for almost 2 weeks and did very little running for 2 weeks as well. I actually think that the rest helped me more that the injury hurt me, and it lowered my expectations going into the race. What happened? 30 minute IM PR.
One of the hardest things to do is to get to the start line of an IM without some part of you less than 100%. Everybody racing will be fighting some nagging injury so don't think everybody else is superman and coming to the line in perfect health. Don't let your injury psych you out; I know it is hard but stay tough mentally.
So I think your plan sounds good overall. I couple of comments. You don't need to do anything longer than 18 miles in last 2 1/2 weeks before an IM. No need to try anything longer. I'd also cut out any pure speed intervals until the race; from my own hip injury experience, those seem to aggrivate it more than a longer, steady run. I like Keith's idea of pool running but if you don't want to do that, just substitute extra swimming yards for running miles. The extra swimming will just help you to be less fatigued getting to the bike and hence the run.
I would avoid the NSAIDs during the race as you've documented. Carry a couple of tylenol in a samll baggie, or put them in your run special needs bag so you can pick them at mile 13.
I can't comment on Item #4 that close to a race. I did take the same stuff for my bad hip last May, but it was 8 weeks before the ITU LC Worlds race, and it really helped me get better.
I wish I could contribute more to the obvious judgement call you need to make about what to do now...but I am curious why they didn't do that sort of obvious-sounding test when the MRI was ambiguous.
I guess the other question is if there is some sort of fast-acting med I could take during the run if things start to go south as an alternative to committing to NSAIDs before the race.
Do you have a facility nearby with the Alterg treadmills? I've also done pool running in the past when injured, deep end of the pool with a flotation belt. Boring, but I would go there when the kids teams practice, seeing 10-12 year olds swim for90 minutes straight is pretty impressive and inspiring and keeps you going. I have PRed or run close to PR in at least a couple of marathons where I had to shut it down for the last 3-4 weeks, and given that IM run is at an easier pace than standalone marathons I wouldn't worry about the impact on your time as long as you get to the start relatively healthy.
Don't hesitate to walk or do whatever is best for your long term goals. This is only one race.
As far as pain management during the race I have heard Acetaminophen recommended over Ibuprofen during races. Something about Ibuprofen and sodium. Maybe risk of hyponatremia. I am not doctor however.
@ Matt...Sorry to hear things aren't getting better. I know it is frustrating after all the hard work you've put into this training. Keep your chin up, and rest the running legs. Swim more. The hay is in the barn anyway fitness wise.
A few thoughts: I think that your power zones are still good for the bike. If you take the meds, yes your HR may be higher, but I'd stay with your power targets since that comes from your legs.
On the run, start easy and see how you feel. Whither you take the meds or not, this will be a run all about your RPE and how much pain you can tolerate. The IM run will create its own type of pain even if you are healthy, but you will have an added factor. Try to delay to the extra suck as long as you can, and remember that the suck will hit everybody late in the run.
Make sure your nutrition and hydration are spot on for the run. You can control that and don't need another issue to deal with on top of the injury.
Hope this helps. I'll be rooting for you. I hope to see you coming out of the water on the helix, on the bike at Old Sauk and on the run course.
Just a follow up after I talked to a reputable/experienced orthopod (who works on a ton of big time athletes in the area). I showed him your post and gave him a little background on your story (top shelf AGer, small & light build, etc)
He said it sounded like inflammation rather than a fracture. The marrow edema is common for many things in addition to stress fractures. Like others have mentioned, there could be further diagnostics if you had the time. But, with your race looming, he was confident that you wouldn't do any long term harm. Potentially, you could be working your way into making this a chronic injury that would come back. But, if you were to race, and race hard, recover/rehab appropriately after, you would get past this thing. He said that if he knew your habits firsthand, like diet/nutrients and core strength, he would be confident that it was not a stress fracture unless there had been some trauma somewhere in the story. He was also quick to say that NSAIDs and Tylenol on a big day like Wisc would be a risk/rewards thing but that the rewards outweigh the risks since you are on top of details like hydration.
I know you have a ton of unknowns going into this. This little post doesn't clear any of that up b/c you don't know me or this doc from 'adam'. But, in a taper fog where panic has a way of working it's way into anyone's head, I hope that this helps you in some way.
Good luck, pulling for you!
edit: osteitis. since the marrow edema showed up around the pubic body, this link gives some info on it http://www.physioadvisor.com.au/10474150/osteitis-pubis-pubic-symphysitis-physioadvisor.htm
Just to be clear, your docs have all the data points to make the call. Obviously, any diagnosis to the contrary that comes from an online post should be taken with a grain of salt. And, at most, just gives you something else to follow up on with your guys.
As to the input you got, I am in the same place. Whether or not there is or was a stress fracture the problem now is certainly inflammation. The efficacy of anti-inflammatories is proof enough for me, and the discomfort deep in the pelvis has subsided completely with the hip/adductor pain remaining. I probably ran through the stress fracture and a combination of compensation and overuse led to the inflammation. Given this has been around for a long time I'm a bit worried about the labrum in the future, but at this point in time I'm focused on getting to September 13 and happy to spend as much time as I need on the shelf after that. Obviously I'm not going to run through something that carries massive risk of long-term consequence but consistent with the view you heard, it's a risk/reward thing where I think I'm on okay ground.
The medication strategy isn't in my race plan because I haven't decided on it yet. Option A is to take 1200mg NSAID on Saturday and 600mg before racing on Sunday. While the hydration issue is of concern, I think the more likely risk is that my stomach gets irritated and that my HR is elevated thus throwing a wrench into my pacing. Option B is take nothing and if I have onset of pain at the beginning of the run pop 3-4 Advil gelcaps and hope for the best. I'm not sure acetaminophen is helpful because while it is a painkiller I don't know if it addresses the inflammation. Hey, if it's that bad on the run I'll take both if it keeps me running…………….
I'm leaning to option A but after today's (Monday) run I am seriously standing down on running from now until the race and plan only a test run on Friday – a 30 minute run with some pickups – to see how I feel before making the call.
this is opinion of this family physician. again, this is opinion based on my experience, the medical science as I know it, personal experience, etc.
would not use nsaids close to the race. at this point I seriously doubt that anti-inflammatories are doing anything beneficial (like helping healing) other than helping with pain. staying away from things like kidney failure on race day is not something you can will away with staying on top of hydration. kidney failure, and the other bad consequences of nsaid use, are not fully controllable.
personally I would stop the nsaids a couple days before the race and move to Tylenol. we are just looking at pain damping. 3000-4000 mg of Tylenol per day is the maximum for regular daily use before worrying about hurting liver. but taking up to 3000 mg a day for a few days, including race day, should be fine.
steroidal anti-inflammatories, like prednisone, are performance enhancing. so watch the rules on that one. and like nsaids, I doubt prednisone would help with actual healing. nsaids and prednisone may actually decrease healing.
so assuming there is nothing that is going to be harmed with running through the pain (I know, we can't fully assume that), a bit of Tylenol should be useful. and Tylenol should not mask serious damaging type of pain.
sorry to add confusion a week out. but thought you needed this perspective.
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