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?