Friday, February 14, 2014

So You Have A Femoral Neck Stress Reaction / Fracture...

I've received quite a few questions about my recovery from my femoral neck stress reaction, and thought I would write a post about it. Sorry to our regular readers for the epic length, but I remember when I was injured and trawling blogs and forums, all I wanted to see was a detailed insight into the various stages (and timelines) of recovery I was in for. So here's mine.

Disclaimer: I am not a health or fitness professional. This post is based entirely on my own personal experience. I am a lawyer, and thus the only thing I am really qualified to write is this poorly-phrased disclaimer, which I'm sure lacks any significant legal efficacy. Let that fact be a warning regarding the extent to which you should take my advice on something that I haven't been studying/practicing for the last 7 years.

So by way of background, you can find the post in which I was injured here, the post in which I think I just have a hip flexor strain (and am whining about not running) here, and my post about my diagnosis, here.

I think the biggest question people have when faced with this injury is how long 'til I can run again, and what can I do in the interim.

The answer to that depends on the severity of your injury and particularly, whether you have a stress reaction versus a fracture. A reaction is the inflammation of the bone, which is the precursor to a stress fracture, where a crack in the bone has actually occurred. Fractures will take a LOT longer to heal, so its vital that if you suspect you have this injury (watch this video for a helpful demonstration by my doctor on self-diagnosing hip injuries) you go straight to the doctor and ask for an MRI (stress fractures often don't show up on X-Rays).

Given my disclaimer, I'm not going to be prescriptive. I am going to describe my experience. What I had, how I felt, what I did and the timeline of all of that.

I. Background To Getting Injured.
As my post on my diagnosis states, my injury was caused by low bone density in certain (not all) areas. It was diagnosed by a bone density scan. I'm relatively comfortable that my training - while heavy - was not generally too much, but it was too much with the added disability of weak bones. I was averaging around 55 miles, and had been running that mileage for quite a few weeks, after building up slowly from several weeks running in the 40s. This was not new mileage territory for me; I had run similar mileage in training for my marathon. I was taking at least 1, usually 2 rest days per week.

Leading up to the race in which I was injured, I had had a very light niggling pain in my groin, what I thought was a groin or hip flexor strain. I had had groin strains before, and given the discomfort was a 1 on the pain scale (and was markedly alleviated by stretching my quads, hips and foam rolling my hip flexor), I felt comfortable racing on it. If I had known that it had ANYTHING to do with my bone, I would not have raced. Full stop.

II. Getting Injured
I got injured on September 16, 2013.

I ran my race, feeling nothing but a small amount of discomfort from miles 1-3. Thereafter I felt nothing in the injury area, until after I stopped running at the finish line. Note that I pushed very hard my last three miles, and I suspect that is where most of the damage was done. Again, if I had felt pain during the race, I would have stopped. Especially if I had known it was in my bone.

Immediately post-race, I felt strong sharp pain in the front of my hip almost as soon as I stopped running. I could just jog on it, but knew that it was bad enough that that I shouldn't. I still thought it was muscular. N.B. As the video notes, pain in the front (versus side) of the hip should be treated with caution.

The day after my race, none of my other running muscles were sore, but I could not climb stairs, hop or jog with my injured leg. Walking was low-pain as long as I walked with a stiff leg (no bending at the knee), but very slow (as Kristen will attest). The fact that walking was not bad led me to believe that I didn't have a stress fracture.

III. Recovery

Weeks 1-2 Post-Injury
Pain Level: It took about two weeks before I could properly step up on my injured leg (albeit with some discomfort). Walking with a stiff leg allowed me to walk almost no pain. I could not hop on my injured leg. Pain was about a 9-10 if I did that. Walking was about a 2-3.  Reading back on my training log entries, I note that I had a lot of stiffness in my quads, and pain in my hip flexor, when I drew my knee to my chest. This was significantly relieved by foam-rolling and stretching, which again, led me to believe that I had a muscular problem. Note, however, that foam-rolling and stretching did nothing to affect the "impact" pain, when I performed the hop test.

Cross-Training: Week 1, I did no exercise. Week 2, I believe I ellipticalled a couple of times, before realizing that it was putting pressure on my quads, which led to discomfort in my hip. I swam lightly, because kicking didn't seem to hurt, though it didn't feel like much of a workout. I did some upper body weightlifting as well. I had a sports massage that did precisely diddly-squat (i.e., nothing).

Week 3-4: Diagnosis and Beginning Cross Training
 In the third week of my injury, I got a diagnosis. I had a very high grade stress reaction, but no cracks had formed in the bone. My doctor gave me the go ahead to do non-impact cross-training by elliptical or pool running and as much strength training as I felt comfortable (obviously no jumping). I was able to walk on it, and thankfully did not have to use crutches. I am aware that usually stress fractures in this area of the bone come with crutches, so I was grateful I didn't have to use to them.

Pain Level: Hopping was producing about a 7-8 on the pain scale. Walking was a 1-2, and feeling better every day. The stiffness in my quads was beginning to release, and drawing my knee to my chest was not hurting much. I believe now that those muscles were all strained in part on their own, and in part because they were working hard to protect the bone. 

Cross-Training: Lots of foam rolling and stretching. I tried pool running about about 3 times. It was a great workout, but I felt a significant amount of discomfort during and afterwards in my hip flexor muscle. I have since read that pool-running can put a lot of strain on this area (the muscles then pulling on the bone) which can delay healing.

Instead, I found the ellipticals like this one (though not as new and snazzy) where you can set the ramp really high to focus on your gluts. I don't know if it actually strengthens your gluts, but it took all the pressure off my quads and (consequently), my hips. Because I experienced no pain doing this, I began doing regular elliptical workouts (mostly at an easy heart rate, between 145-155) with some intervals thrown in for funsies. Week 3, I did 5 elliptical workouts and Week 4 I did 6. Also focused on adding some good core strength routines in.

Weeks 5-6
Pain Level: (going off of memory) this was a frustrating period, because all my acute pain was gone. I could walk with almost no discomfort, and felt like running was not far off. As Kristen mentioned with her injury, the 90% of healing didn't take long at all. It was the remaining 10% that took the longest. At this point I think I could climb stairs with no pain. Hopping on one leg was probably a 4-5. I could do it, but it was obvious that healing was not complete.

Cross Training: gave pool running a couple more tries, but then focused on elliptical workouts about 5-6 days a week (again, feeling no pain on the high-ramp elliptical), as well as core workouts. Leg strength was still tough. I recall that squats (body or low weight) were ok, but single-leg dead lifts or lunges felt uncomfortable. I tried to do a little, to promote some strength, but kept it very low-key. My rule of thumb (and doctor's advice) during this period was a little bit of discomfort was ok, as long as I was not feeling it by the time I got round to the next workout. It was all about walking that tight-rope of maintaining some fitness and promoting blood flow and movement, but not over-doing it. Lots of stretching and foam rolling, with a focus on hips and quads.

At the end of October, I saw my doctor again, and he gave me another two weeks before I could start running again.

Weeks 7-8
Pain Level: The Pfizinger Plan for returning to running after a stress fracture, states that you should be able to walk briskly for an hour without pain before you return to running. About 6 weeks after my injury, we hiked for 8 miles which, while not particularly brisk, took us several hours. There were moments I was scared my hip would hurt, but I was mostly pain free. I felt a discomfort lower than a 1, which was more of an awareness that my hip area felt weak, rather than any actual pain. Hopping produced about 2-3 pain, but stepping up was fine. I did the occasional 2-3 meter jog down the office hallway to test my hip, and it started to feel like normal again.

Cross Training: Still the elliptical 5-6 times a week. I added some workouts, like "Yassos" (10 x 3 mins hard, 1 min easy), which helped the time pass. I kept trying to do strength (upper body, core and light-leg strength), introducing some single-leg squats and deadlifts.

On November 6, I wrote in my training log: I haven't been able to do single leg strength work until yesterday. My hip feels a little achey, but not "re-hurt" in the way it used to after single-leg stuff. A little acheyness is fine apparently [NB: this was per my doctor's advice].

On November 11, I wrote:  Hip feeling pretty great; I know running isnt far off. Im trying to progress to where I feel zero discomfort doing elliptical upright and all my single leg weights. Once Im there, and Im close, I feel like I could start my 5 min runs. Going to follow the Pfizinger plan to return to running. I would usually be a little more aggressive than this, as I only had a stress reaction. But given that its in the femoral neck (weakest area of the femur + most time off running if I had actually fractured it), its just too risky to be anything less than conservative.

Week 9
Pain Level: Hopping produced about a 1 on the pain scale. I was under the impression I had to be at zero before I could run again, but my doctor was happy with me being able to hop several times on the injured leg, with very minimal discomfort.

Cross-Training/Return to Running: I began this training plan:http://kemibe.com/distancecoach/labreports/stressfracture.shtml. Note that I used the training plan as a guide only. I noticed that I needed more time off between runs than the plan had scheduled; often 2-3 days for the first month. Conversely, I was able to run longer, earlier, than the plan had allowed for. For instance, while many of the runs were still at 20 mins, I was able to go 30 mins. I was very careful to continue the walk breaks and assess how my hip was feeling. I went by this guide: if I felt pain at the beginning of my run, I stopped. If I only felt pain/discomfort towards the end of my run, or the day after, I would simply wait until it went away before I ran again.

Very mild discomfort in my hip continued well into January. I had no pain when hopping (the bone/impact test) but could feel that the muscles around the injury area were still tight, especially when I drove my knee upwards. Foam rolling and stretching my hips (pigeon post, standing quad stretch, seated piriformis stretch especially) really helped.

IV. Epilogue: Some Additional Notes
1) Medication:
I did not take anything for my pain. I have nothing against pain relief generally (and use it frequently for head aches and period pain) but I wanted to be very aware of how my healing was progressing. I also did not want to risk "feeling better" and then over doing it in my return to running.

2) Food:
Throughout my recovery I ate more. More of everything. More than I had been when I was running 50 miles a week (I know, I know). While my hunger dipped for a short time when I was not exercising at all, it returned with a vengence when I was cross training, and I took it as a sign that my body needed more calories to heal. I especially ate a lot of dairy products (chocolate milk after every workout, greek yogurt and almond milk daily + calcium/Vitamin D tablets).

I probably gained about 10 pounds initially and while I haven't weighed myself for a couple of months, I'm fairly certain I've dropped back down close to what I was before. And I've continued eating more. My body NEEDED the calories and macronutrients to first, recover, and second, to support my mileage build up. Im not talking about just fruit and vegetables, of which I ate plenty, but really good quality protein, healthy fats (peanut butter, avocados, etc) and a LOT of carbs by way of potatoes, rice and other whole grains. And while I'm not some snake-oil promoting, naturo-quack who thinks a good diet can cure all, I know in my case I needed it and it really did help. (I might write more about this at some point, but I couldn't have worded Kristen's nutrition post better myself).

3) Mileage and Return to Running:
Many people complain that running feels odd when they restart after an injury. I did not. Running felt perfectly normal (apart from being very conscious of weakness/discomfort in my hip).  

Below is my progression of mileage (per week) build-up to now:
November: 3, 10, 8 miles
December: 15, 14, 22, 28 miles
January: 26, 32, 35, 40 (at the beginning of Jan, I did my first fast run at (coincidentally) my first 5K (approximately 10-11 weeks post injury).
February: 42, 44
I am presently doing a long run of 13 miles each week, and 1.5 workouts (one scheduled, the other low-key fartleks or hill sprints) per week. I plan to hover around the low-40s in mileage for a month or two to avoid injury. The mileage feels very easy, and I haven't had any soreness or niggles to speak of. My calves and quads are occasionally a little tight, but this is normal.

4) Sanity (ETA)
I will be writing a post about the mental side of injuries, but I thought this post needed a specific addendum. This femoral neck injury can be the worst running injury to have. Not only because the healing time can take up to 5-6 months, but because if your stress reaction becomes a stress fracture, and your stress fracture becomes a full fracture, then hello...you're in for a hip replacement about 30-40 years early. Its really scary. And its really vital that you take recovery seriously, and give yourself a real break from thinking about running and maintaining your fitness.

It sucks. I get it. But it will end.  It will heal. It will heal stronger than it was before (the only upside to the injury). And you will be running strong and PR-ing before you know it. But don't waste a single day of recovery time. Give every day your fullest effort in avoiding anything that hurts, and doing everything that helps. That means sleep. Eat. Stretch. Roll. Spend time with your loves. Running will be there when this injury is over, I promise.

So there you have it! Hopefully I've covered everything, but please email us at twolittlerunners at gmail dot com, if you have any other questions.

Got any cool injury stories or tips? Whats the worst running injury you've ever had? Did you nearly throw your fridge out the window in frustration? Did you have the presence of mind to eat everything in the fridge before you threw it out the window?

20 comments:

  1. You did a great job with your recovery. I admire your patience and conservative approach. I think the hardest part of being injured is stopping yourself from working out harder than you should. I know you're not quite back to where you were before in terms of miles and paces - but well done - and you are definitely on your way! ~K

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  2. Thanks for sharing! I'm now on week 10 or so of recovery with the same injury. I have been more cautious mostly because I thought it was a full stress fracture instead of just a reaction so I put myself on full crutches for two weeks till I got the MRI results. I had a shaft fracture during my track season when I was in college and it felt the same so that had me worried! It's so hard not to feel panicked all the time with any residual pain that is present, especially because its such a high risk area! Seems like the more you think about it the more it hurts, it's an endless degenerating cycle! I haven't started running yet but think I am getting close. Thanks for sharing, I was waiting for you to post about your recovery after I found out about your injury through the google machine :-) Good job being patient and disciplined! It's so hard not to be paranoid! Thanks again and happy trails!

    -Hannah

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  4. I wish I had found this in February/March when I was first diagnosed with a bad tibial stress fracture. It's been a long road, and I started running again in July, short distances, only to decide I would be better off laying off a little longer. X-rays now look like we're healing (still show what looks like a stress reaction), but I can't wait to get back into full out marathon running. Lunges/running still bother it to a point, but it's coming along slowly but surely. You sound really patient and sane with all of it, which is really impressive. Thanks for the tips!

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  5. My femoral neck stress reaction took 1.5 years to stop hurting but it eventually did. I am currently dealing with a stress fracture of proximal femur on other side. Hoping it won't take nearly as long.

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  6. Thank you so much for sharing; I'm just off 30 days on crutches for a fnsr and you are so lucky you avoided that little situation, let me tell you! I'm about to start PT, and reading this post has been so helpful. The mental side has been the hardest; I haven't known what to do without my trusted therapist of 7 years: the long run. It's uplifting to read your recovery story and know that if I'm patient and kind to my body, I'll get it back. THANK YOU!

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    1. Thank you so much for your comment, Elizabeth. I'm so sorry to hear you ended up with a stress fracture - they are terrible. And I suffered an actual SFx in my foot last year, so I know how it feels.

      Patience and kindness to your body are 100% crucial. You are so right!!! I guess I learned that your body wants to get better, and knows how to do it. You can help it, by doing PT, by getting your mental game on, treating EVERY bit of rehab/rest you do as training, and by resting as much as possible. OR you can get in your body's way by being impatient and getting frustrated. If that means you need to take time out to think about things other than what your physical body is capable of, then its probably a good time to focus on that other very important stuff!

      Im so so glad that you were able to see a therapist though during that time too.

      P.S. You WILL GET IT BACK. And it will happen quicker than you thing.

      ~ Penny

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  7. +1 on the "Thank you so much for sharing" comments. I've been dealing with a similar kind of hip pain for a week and am concerned about a femoral neck stress reaction. The insult added to my injury has been this: I've been training for my first Boston and am only 4 weeks out. As I await my appointment with the orthopedist, I really appreciate your detailed and eloquent narrative. You mention the "mental side of injuries," and I haven't checked for that post yet, but I'd guess that we might all agree that community helps in that sense. I'd never wish misery on others so that I could have company, but you know . . .. Stay healthy and strong.

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    1. Hi there - I havent gotten around to doing a whole post on the mental side of things, but what Ive written in the post (and in response to Elizabeth's comment above, probably covers it.

      There is no denying it is hard, but I found it easiest to view as PART of my training. Not just doing the rehab/PT stuff - though that is training too. But starting to develop the mental toughness that requires you to make hard choices - to rest when you need it, to not push too hard when your body is telling you "no!"

      Community definitely helps - I completely agree. As does thinking about what is truly important to you in life; although it sounds awfully cliched, it does help you gain some perspective on what is really important in life!

      I hope you get well soon - please let us know how the ortho goes and whether you are able to run Boston!!

      ~ Penny

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  8. Last November I injured myself on a sprint workout getting ready for a 10k. I didn't think much about it and thought it was a hip flexor issue (as did the trainer). So I just ran through the race in pain (did horrible too) and took the winter off in hopes of hurdles for track. In the spring I started running a little and the pain (more like discomfort) returned. My hip would get sore and I had no flexibility in that area so I went to a sports injury doctor and the x-rays and MRI showed a Femoral Neck Stress Fracture. I wasn't allowed to put weight on my hip during my 5 weeks of crutches. After the crutches I had another month of no weight besides walking and swimming. Summer started by then and I began to run again. It felt weird and I could only make it 6:00 minutes at a 10minute/mile pace. I still get discomfort in my hip and it may never feel normal but it doesn't hurt like last November when I could barely walk.

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    1. The mental part of coming back from an injury like that is harder than the actual pain. I think every hip pop and every sore day that my injury will come back. I take it easier on sprints now and I can't sprint like I use to be able too. I take it easy which is not always a good thing. I still run slower than before (a year since) and I am having a hard time getting back to full training. Sprints, hills, and hip stretches are uncomfortable and sometimes scary. I don't want to go back on crutches or get pins put in. I also am getting more pain from my knees since. Hopefully with running this winter I can come back faster than ever. °•Good Luck•°

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  9. Two Little Runners,
    Thank you so much for this post. Very helpful to see a detailed log of your own experiences with recovery, and I deeply appreciate your remarks on the mental side of being injured. I attend a service academy and having to deal with a femoral neck stress reaction as a cadet is very difficult from a mental standpoint...
    -Another Runner

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  10. Super helpful, I loved your story, thanks for sharing!

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  11. Two Little Runners,
    Your post was most helpful, and encouraging. Thank you. Yesterday I was told I had a femoral neck grade response following an MRI last week.

    I used to swim at a high level through university, but having stopped swimming and starting work about two years ago I started combining running into my circuit training to try and maintain my fitness (and save time!).

    I had quite bad hip pain in April, walking was challenging and hopping was painful. I hadstarted running once/twice a week (max.10k), combined with once a week of Barry's Bootcamp from Feb/March time. Following the pain, I started seeing a physio for 4 weeks who thought it was my glute not firing. None of the exercises helped the pain I was referred to a specialist a month later (i was still off running & I had re-started circuit training at this point as the pain had subsided).

    I saw the specialist as a 'just in case' who thought an mri would be good to rule it out, despite no longer feeling pain.

    My results showed a grade 2 stress response and she has put me on crutches without any weight bearing for a month. Quite surprised with what the mri showed as i have not felt anything for a month or two? Has anyone else had anything similar?

    On day one of crutches, finding it a challenge already but glad that I caught it early.

    Any hints or tips would be highly appreciated!

    Thanks,
    - Swimmer trying to be an average runner

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  12. I know I am commenting on a very old post but I found this among many other (very scary) posts about stress fractures to the femoral neck. I was just diagnosed with a FNSF two days ago and I'm a mess. I was planning on running Boston in 11 days so obviously that's not happening. But I am starting to worry I really will never be able to run again. Running is my favorite thing in the world.... I don't even know what to do when I wake up now. All I think about is this injury. I can't focus on work and I can't distract myself at home with TV. I wish I could wake up from this scary nightmare. Your post is very helpful and I am hoping my recovery is as miraculous as yours! How did you deal with the mental side of things?

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  13. What a great post! 5 weeks into a FNSR which I initially thought was a hip flexor strain. I waited 4 weeks to see an ortho as I thought it would get better - some days were better than others, but I always has the consistent tug/pulling/pain when getting up from seated position to walking so I knew something was off. He ordered an MRI. I went on vacation for a week (painful hip during vacation). When I returned I got the MRI and it showed a MAJOR FNSR - as in bright white lighting up my entire right hip on the film. Edema galore. He put me on crutches and will evaluate after 4 weeks. I realize this is a conservative approach, but after two stints on crutches for other fractures and various other strains, tears etc., I realize the conservative approach IS the BEST approach no matter how active your are. I am a bundle of energy so I understand the misery of being told to stop doing all the things you love doing. I do think the first time on crutches for anyone can be humbling. I pretty much embraced the entire thing this time - signed up for Spanish classes, have a list of movies a mile long I want to see, got a gym membership (yikes!!-I'm not a gym person) just to sweat in sauna and get an upper body work out in with weights. I do core work off the side of my bed at night -crunches and side crunches. Push ups on knees. I am making it work - I know I will come back stronger and will be running in no time. I have been doing Bikram yoga for 18 years and I can't even do that - I think accepting where you are, embracing the shit out of it, and realizing that the injury is not that bad - it's not a life threatening disease or disorder. We recover. It could be worse. I also feel that it is a good reminder to slow down in life in general. Injuries can do that...slow you down. Thanks for sharing this injury though - this is new to me and my doctor made this sound like a once in a million chance of this occurring. Like someone above said...a freak occurrence. Does anyone feel like they have to console those that ask about the injury? OMG..the looks I get and the "I'm soooooo sorrys"....."You must be going crazy"....... "Awwww, poor thing...." or whatever else spouts out. That drives me bonkers! It's a blip in life...just a few months give or take. It is what you make of it.

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    1. I could have written this previous comment! Thought I had a hip flexor strain, waited 3 weeks to have my MRI (had to go on a vacation first same as you :) had super mild pain but not bad). Had been walking fine without pain, just couldn't walk fast or run whatsoever.
      MRI showed moderate bone marrow edema and FNSR/developing stress fracture. Ortho shocked me with the news of 4 weeks of crutches!! It seems everyone else is told to walk, but I agree with you conservative is obviously safest.
      Looks like it's been 4 weeks since you posted this. How are you?? (I'm on day one of crutches)
      I'm struggling with feeling as if I'll do damage even with the position I sit or sleep. Don't know if it's okay to cross my legs or not, and I've been driving even though it's my right hip. Curious to hear how your 4 week appointment went.

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    2. Oh, sorry I missed this - welcome to the club! First, acquaint yourself with this group:

      http://community.runnersworld.com/topic/femoral-neck-stress-fractures?page=20

      and

      https://runningfnsf.blogspot.com/

      Along with this blog post, these two sites were/are the most helpful to me. They are both positive, but realistic blogs/groups that contain great information on all the stages of moving through this injury. I posted under Stephanie Lamberson and you can read my story there.

      I was on crutches for 8 weeks (via 2 opinions by orthos) and have been off crutches appx 2 full weeks. I started PT last week. What an injury! My only suggestion is to read the different posts as mentally, the discomfort and pains and aches were the most concerning for me. Most of my injuries have healed normally......pain, discomfort, then slowly it all dissipates. This is not the case with this injury. It seems to linger for quite a while. I am VERY compliant patient...not patient, but compliant (ha).

      Don't compare your recovery to others....it seems this one is different on everyone.

      My recovery is going to be slow. I think what surprised me the most and this was validated through others in the Runners World blog (thankful for that) is that the discomfort, acheness and soreness will continue for sometime. I don't have the pre-diagnoses pain that we had, but it's muscle atrophy (sore feet tendons, muscled, knees etc) combined with the injury healing. It's annoying as hell if nothing else. A real MENTAL exercise. Listen to your doctor. I feel that although my doctor might be a rockstar of achilles tendons, he is was not familiar with this injury and not a good source of information. I conducted my own research carefully on-line - sorting the good from the bad. The two blogs/groups above were very helpful to me. Don't let anyone's story be YOUR story....it's all individual. My mind at one point of my time on crutches was convinced I'd never walk again.....the places the mind goes. I had to do a little biofeedback and change the direction of the mind train. Find something you can do in the gym (I hate gyms and swimming) or pool and do it religiously - give yourself a purpose each day. For those of us that run or are super active, this can be a real downer. I joined a club that has a sauna and hot tub - I would (and still) go into the sauna for 30 minutes just to sweat. I practice my yoga deep breathing in there! The hot tub was great for sore muscles. Swimming with a pull buoy between legs (no kicking) and using only arms is a decent stretch. I add hand flippers for variation. I think of all the folks on the sites, I am in the super conservative recovery mode. Are you off crutches? You can email me at stephanielamberson@yahoo.com or find me on Facebook-if I can provide any background or tips on dealing with this mentally, physically, I will. Something my PT brought up and I learned through my years of yoga, is being kind to yourself and sending your hip/leg a ton of loving energy rather than being pissed off that you can't run or be active or aren't healing as fast as someone else. The mind can control physical outcome in some ways. It's hard as hell with injury....but you HAVE to! Please find me if you wish! Would love to chat.

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