Back on the Injury Train: Pubic Ramus Stress Fracture

Buckle in guys, this is a long one because the injury train is leaving the station and we’re on it.

I really do have the worst luck, because not only do I end up injured often, but I end up with some unusual injuries. This time around it is a stress fracture of the pubic ramus. To be exact, it is a “a healing nondisplaced transverse stress fracture of the anterior aspect of the right inferior pubic ramus, with moderate marrow edema and periosteal reaction.”

My diagnosis came the day after I was slated to begin my 18-week Grandma’s Marathon training plan and a week after I registered for the Brooklyn Half Marathon, so sadly those races are on hold, as are all others for the foreseeable future.

This injury is a scary one. When you search the injury, you mostly get LetsRun threads with people sharing stories of requiring 6, 9, 12 months to get back to running again after this injury. Optimistic tales are few and far between. As someone who just took 6 months off running, I’m not eager to do it again.

But there is also a selection bias. Those with long recoveries, I believe, are more likely to share their story or seek out advice on running forums. After a deep dive on Google, I did find some individuals who had “normal” 6-12 week (not month!) healing windows for this injury.

I also noticed a common thread for those who saw their injuries persist for months vs. weeks: they cross trained. Hard. Many of those who complained about their injury being stubbornly persistent used elliptical or biked from the moment of diagnosis. Those who recovered quickly rested entirely.

Given that research and my own experience with a stress fracture back in 2015 and my knowledge of my lifestyle (getting to/from work requires a minimum of about 3 miles of walking a day), I’m self-imposing a very restrictive recovery timeline on myself. I’m determined to be the best pelvic stress fracture patient around.

Here’s a timeline of my symptoms, some potentially aggravating circumstances and what I plan to do moving forward.

4 weeks Pre-Diagnosis, Week of January 14

I traveled to Turks and Caicos with my family. I packed an older pair of running shoes planning to just ditch them rather than pack them for the return flight. On my very first run, I thought, “Oww.” I was super tight and felt all out of sorts, but I ran anyway. And continued to run the rest of the week.

3 weeks Pre-Diagnosis, Week of January 21

I experienced my first symptom this week. I felt better running at home in different shoes the first few days, but then I ran a workout on Tuesday. It wasn’t anything too crazy, and the workout when really well, but the day after the workout I had a slight twinge at the top of my hamstring, right at the gluteal fold (you know – where you have that crease where your leg meets your butt). It was pretty minor, but I noticed it.

That same day, I had seen my Active Release Technique (ART) guy, and he broke up what he called a “huge manicotti” in my hamstring. A “meatball” he said, is a knot that is big and round.  A “manicotti” is a knot that is big and long, like a manicotti noodle.

For the most part, it only seemed to bother me for the first few strides of a run, right as I was getting going. But then I didn’t notice it, so I continued to run the next few days.  My progression long run that weekend felt fine, but I felt some minor pain after the run, so I decided to take a few days off to let it rest.

2 weeks Pre-Diagnosis, Week of January 28

After the few days off, I continued my training as usual, but cut out a workout I had planned. Easy running felt largely okay. Any pain I felt was really limited to the first few strides and the first few strides after any stop, like at a street light.

I had a 5K race on the calendar that was supposed to serve as the baseline heading into my Grandma’s training plan, so I ran that as usual, too, since the pain was restricted to the beginning of the run, so I was thinking maybe it was tendonitis. In fact, I won the race!

But then I did my long run the day after the race, and that wasn’t great. The pain was more persistent and it moved! Sometimes I felt it at that spot at the top of the hamstring, sometimes I felt it more on the inside of the leg down the adductor. Sometimes I felt it down at the knee. Later that afternoon, I had pain when walking as well. I immediately scheduled an appointment with my orthopedic doctor and decided not to run until then.

1 week Pre-Diagnosis, Week of February 5

My appointment was on Thursday, February 8. Like I said, I stopped running before then, but I did spin a couple days that week leading up to the appointment. I also had acupuncture that week on Tuesday in the hope that that would magically cure me (it didn’t).

My doctor was kind of confused by my list of symptoms at that point:

• Dull pain at the top of the hamstring / glute insertion
• Inconsistent dull pain on the lateral hip
• More of a shooting pain down the adductor when putting on pants / socks
• Pain on adduction against resistance
• Pain when pushing the door open with my leg / foot
• Rolling over at night causes pain in the glute area
• Sneezing or lifting something heavy causes pain in the glute /pelvis area
• Jumping on the right leg (where all the pain is) feels fine, but jumping on the left leg causes pain on the right side
• No pain when standing up
• No pain when going up or down stairs

My doctor thought that perhaps I had an adductor strain, but sent me for an MRI to be sure. He said I could run in the meantime. I ran once for 1.5 miles and it felt awful, so I decided not to do it again. The MRI was scheduled for Feb. 10.

The Diagnosis, February 13

My doctor called with the bad news on Tuesday, February 13. He didn’t have any experience with this kind of injury, though, so he referred me to a specialist. Turns out that specialist is a trauma doctor, since most injuries to the pelvis are caused by trauma. The soonest I could get an appointment with that doctor was Wednesday, February 28.

So I was left to develop my own standard of care for the first few weeks. Based on everything I read, I decided I needed to be aggressive.

1-2 weeks Post-Diagnosis, February 14-27

No walking, no cross-training, no standing up, no bearing weight / carrying or lifting heavy things. Sit down to put on pants. Goal: Stay entirely under the pain threshold. No NSAIDs, since they can slow bone healing. All the calcium (aiming for 1,500 mg a day).

The problem with a pelvic stress fracture is that a lot of very important muscles attach to your pelvis. You’ve got your hamstrings, groin and adductor/abductor muscles connecting from the bottom and your back and abdominal muscles connecting from above. For the inferior pubic ramus bone in particular, you have the adductor minimus, adductor brevis, adductor magnus and gracilis muscles all connecting. This is why lift my leg to put on pants or socks without pain.

To let the bone heal, I needed to limit the use of these muscles, which put stress on the bone.

Since my commute requires a lot of walking, I worked with my boss to be able to work from home for 2.5 weeks (the rest of the week of Feb. 12 through the week of Feb. 26. My goal was to keep my steps below 2,000 steps a day. I didn’t always accomplish that, but I did my best. Those 2,000 steps were just me walking around the house – going to the bathroom, going to the kitchen, etc.

During this time, walking stopped causing pain and I stopped feeling pain while rolling over in bed around the end of the first two weeks.

Hip Specialist, February 28

My visit with the hip specialist wasn’t very helpful. First, I got there at 8:30, my appointment was at 8:45, but I didn’t see the doctor until 10:30. Not impressed. (X-rays were speedy though – I was in and out of those in 10 minutes, done by 8:55 a.m.)

When the doctor finally graced me with his presence, he said my stress fracture wasn’t yet visible on x-ray, and he really had no additional insight into what caused it. He just said, “continue to take it easy and see me again in six weeks.” No extra guidance beyond that.

Like I said, far from helpful.

3-4 weeks Post-Diagnosis, February 28-March 13

I started working back in the office just a couple days a week, mainly for my sanity. Commuting is still a bear though (and expensive) since I’m still limiting my walking and taking cabs for part of it.

I’m targeting closer to 4,000 steps a day as I slowly bear some more weight. I’m mostly pain-free, but given that it wasn’t showing on the x-ray yet, I know I’m far from in the clear (especially since I have an unusually high pain tolerance).

(PLAN) 5-7 weeks Post-Diagnosis, March 14-April 3

I’m mixing things up hear and getting LASIK on March 15. I was planning to this later in the year, after the Grandma’s Marathon, since they recommend you don’t exercise for a couple weeks after the procedure. Since I already can’t exercise, I figured, why not now? This should also help my healing, since it will involve laying around the house listening to audiobooks and podcasts for two days.

I’m aiming start working in the office again full time the week after the procedure, the week of March 19. I’ll still avoid any extraneous walking, but resume the day-to-day commute.

(PLAN) 8-9 weeks Post-Diagnosis, April 4-17

My follow up with the hip specialist is scheduled for April 4. I’m really hoping that the bone shows strong evidence of healing and that I’m cleared to begin cross training. All I want for my birthday later that week is to be able to exercise again.

If I’m cleared, I’ll start rebuilding my poor, atrophied muscles on the spin bike.

(PLAN) 10 weeks Post-Diagnosis, April 18

If my body doesn’t hate me and the healing gods smile upon me, hopefully I can resume a return to running run/walk program.

FINGERS CROSSED!