Pubic Ramus Stress Fracture Recovery

As many of you know, part of my athletic history is that I unknowingly developed a stress fracture in my pubic ramus while training for my first marathon. Since I was so new to running, I didn't recognize the warning signs and ran through it until it completely fractured. My recovery from this took three months before I ran my first mile, and six more months before my training was back to normal. Since then I have successfully run countless marathons, several ultramarathons, and completed four Ironman triathlons. Over the past four years, I have received countless emails from other people who have sustained this injury. I was so fortunate to have access to an amazing sports medicine doctor who guided me to complete recovery. Unfortunately, many people don't have access to these doctors and treated by physicians who are not knowledgeable with the athlete's body and mind. I decided to compile a synopsis of my blog posts during the time of my injury to tell my story of what it was like to suffer and recover from this injury. This is not intended to be medical advice of any kind. My hopes are that others with the same injury can use my words for inspiration and healing.

The first sign of my injury came three weeks from my marathon. I wrote it off as a groin pull and kept trying to proceed with training. Three days later the pain was worse and was preventing me from running. It presented itself as a stabbing pain when I ran and a difficulty to lift up the leg. I went for one last run to see what was going on.  Here was my description of the run:
 "I decided to walk 2 miles, then try to run slowly: no more than 2 miles but stop as soon as pain takes over the discomfort. Then, a 2 mile walk/cooldown. The walk went great--slow, but no pain at all (just stiffness). When I tried to run it was a different story. The first .5 mile was not pretty, but it was just an ache, nothing sharp. I continued at a 12:00 pace. My brain was screaming:faster, faster! but my body was rebelling. As I loosened up it felt better, but then after mile 1 the sharp pain returned. I stopped after running 1.3 miles, and walked for another 3/4 mile. I had to stop walking because I was starting to walk funny: throwing my right hip into each step, which resulted in a very awkward gait... walking and stretching results in no pain, but it is the pushing action of running that hurts. It also hurt when I tried to kick off my shoes, or simply the motion of lowering my leg into my shorts."

Thinking it was a pulled muscle, I decided to take a complete 2 week taper with no running before my marathon and tried to stay positive. I told myself I could push through the pain. In my last posts before the race I wrote these words:
 "I need all the mental ammo possible to make it through this race. I know lots of you have run through intense pain before: what worked for you? Any and all suggestions about what to do in these days leading up to the race as well as what to do during the race would be appreciated. With these two injuries I've had, I was told to stop running as soon as pain set in to prevent further injury. With the marathon, that won't be an issue (within reason). How can you force yourself to run through pain, and at what point should you throw in the towel?... I am counting on the adrenaline of the day blocking out any pain I will feel from my injury. No matter what happens though, it will all be okay. I should be proud that I have trained so hard for so long. Even though I may not run the race that I planned, I have done all the preparation possible."


My mom always told me that I had a high pain tolerance, and now I am confident that I do. Unknowingly, I toed the line of my first marathon with a stress fracture in my inferior and superior pubic ramus. Here's my description of how the marathon went down:
"Shortly after the Christmas lights (my guess is around mile 4) things started going badly. When I realized I was running back at 10:30, I tried to pick up the pace to 9:00 again. *STAB* Oh no.*STAB* Not now. *STAB* This can't be happening. *STAB* Please, God, no. *STAB* It's too soon.*STAB* No. *STAB* Today is not that day. *STAB* Pain is temporary, quitting lasts forever. *STAB*Beer. *STAB* Bacon. *STAB* Don't stop. *STAB* Keep going. *STAB* Where is SM and JB?*STAB* I can't handle this all by myself. *STAB* I need a friendly face. *STAB* I NEED A FRIENDLY FACE!
All of a sudden, I saw SM on the side, searching for me. I yell out his name, and start crying. He gives me the shaka and says "Looking good girl!" I yell out a shaky "Nooooooo". He yells "are you hurting?" I yell "Yes, and it's starting to buckle. I can't do this." Not knowing how to handle a teary girl, he quickly stammers, "Well, umm, it happens to the best of us." I found out after the race that he ran back up to JM and said "she's not going to make it. She looks bad."
So, there I am, all alone again. The leg starts to buckle. The pain is intense. Each time it starts to buckle, I try to stop from falling all the way to the ground. I figure out a system which involves arching my back to stop mid-buckle. I'm still moving. I'm still moving. As long as I can make it to Diamondhead, then I can walk. Gotta make it to Diamondhead.
I pass by the mile 5 sign. The pain is intense. Each buckle sends searing pain from my groin to my knee. I can no longer stop the buckle by arching my back. Defying my brain, my legs stop moving. I am walking. I am walking. I am walking a marathon that I should be running at least 8:30. Grandmas are passing me. No one else is walking. This is pathetic. You are pathetic. So much for an ambitious first marathon. All of a sudden, I can't walk. My legs seize up. Oh my gosh. This is it. I really am not going to finish this. I can't even walk the rest of the way? All this training for a DNF (Did Not Finish). DNF: Dumb No-good Failure.
I pull off to the side and start to stretch. The river of runners continue past me. I see some people walking, and think "Oh yes, other walkers. Good! I'm not the only one". A man asks me if I'm okay and I tell him I'm hurt. He suggests I walk backwards, and he will make sure I don't hit anyone. I tell him he's nuts. He says "just try it." I try it. He's right! The pain almost goes away! I walk facing him and we small talk. He wasn't running the race; he was support for some VIP according to his security pass. I try walking forward again: agonizing pain.  I am at Diamondhead. I police officer sees me wincing and limping "Ma'am, do you need a medic? He's right over there." I didn't know this until now, but that was the deciding point of the race for me. I was right by the finish line, and could have seen a medic and waited for my friends. I started to say yes, but something (Bacon perhaps? Beer?) took ahold of me and called out "no, I'm okay." I realize that there is no way I can run this whole race backwards. I tell the man I am going to stretch and try running again. He wishes me luck, and is on his way.
I pull off onto the sidewalk to stretch. It hurts. I limp back to the course. We are confined to the lane with police tape, and I'm not sure how to safely get back in the course. I look for an opening and duck under the police tape. *WHAM!* A woman smacks me with her elbow. I stagger and limp, trying to regain my composure. I pull to the far right of the tape since I am going so slowly. A man pushes past me, spinning me to my left. My leg is on fire. I wince in pain. I get hit again. Volunteers are yelling words of encouragement at me: you can do it! don't give up! I realize that if I want to survive the stampede, I better try running. We are at the biggest hill of the race. I try running. Oddly enough, running uphill feels okay. I'm running. I'm running. Well, technically I'm barely jogging, but I'm moving. It hurts so bad, but I'm moving. I want to give up. I see and hear the friendly faces of the teenage volunteers. They sense my pain. "You go girl! You can do it! Keep it up!" They high-five me as I continue. I am not stopping now. I pass the 6 mile mark. I make it to the top of the hill. Holy crap does it hurt. I try to tune everything out. One foot in front of the other. I start calculating when I can start walking. I start thinking "If I can just make it to 11 miles...". The pain worsens as the hill levels out. I successfully navigate an aid station. I realize I am no longer getting passed. You have no idea how much that emotionally lifted me. I was in "a group". Granted, I was the only Caucasian as far as I could see, but I finally had a group to run with. I kept my eyes on the shorts in front of me and tried to stick with the pack. At mile 9 I decide to take another ranger candy. I knew it was very risky, especially since the first 800 mg of Ibuprofen was still in my system, but I knew I had to do it. As soon as it kicked in, things started going numb in my right leg, which at the time I thought was good. Retrospectively, losing feeling probably was part of the whole fracture thing. I don't know exactly when the fracture occurred, but I bet it was just prior to the numbness. My guess is that the excruciating pain was right before the bone snapped; once it snapped, I lost feeling in that leg.  From mile 9 till the Kalaniana'ole Highway (about mile 11) everything is kind of fuzzy. Once I got on the highway I was back in familiar territory, and kept chugging along. Around the half marathon mark I threw out my back. My back was arching to catch myself with each buckling of the leg, and just couldn't take it anymore. When I tried to walk through a waterstop at the halfway mark, my hips and back immediately locked up, and I had to yell to myself "MOVE! MOVE!" to start running again. I had to apologize to the people in front of me, because they thought I was yelling at them! I quickly realized that there was no way I would walk through another aid station. The rest of the Kalaniana'ole Highway is kind of a blur. Around mile 16 I had this moment of realization that I was running farther than any training run, and that I may finish this race afterall. Once I got past the 20 mile mark I remember thinking that I would absolutely finish the race. I kept hoping to hit the wall, but it never happened with the pathetic pace I was running at.  Once I made it through the lowlands of Kahala, I approached the final hill of the race. People were screaming from the sidelines, bands were playing, runners were starting to celebrate. I started tearing up: I was finishing! I was finishing!  When I passed the last aid station, I knew I was home free. At mile 25 I crested the last hill, and knew I just had to go down the hill and around the bend to the finish. I began to think about what was waiting for me at the finish: beer and bacon! At that point in the race, beer and bacon was my only motivation. I decided that I would gun it for the last mile. I managed to run a sub-9 minute mile downhill. The impact going downhill was agonizing--I could feel my hips starting to lock and the buckling of my right leg was pretty severe. Once I rounded the bend, I could see the finish line ahead. In all my pre-race visuals, I expected this part of the race to be very emotional and to have the Chariots of Fire theme song running through my head. Sadly, nothing like that happened. I vaguely remember people cheering, but like the last 14 miles of the race, everything is kind of foggy. The buckling in the last .2 miles was so bad, I lost my footing and nearly fell completely to the ground a few times. Despite the pain, I managed to cross the finish line looking strong.  As I crossed the line I broke down into tears. I'm not sure if it was from the pain, the joy of finishing, or just sheer bliss from being done with the race. I remember a volunteer asking me if I needed assistance, and I kind of just wandered away. All I wanted to do was get my hard-earned finishers shirt and medal, and make my way across the park to LuLu's to get beer and bacon with my friends. That was our agreed meeting place, and I desperately needed to see a familiar face. It was horrible crossing the finish line without anyone there to greet me.
The park was muddy and slippery, and I had a long way to go to get my finisher's goods. I cried all the way across the park, because each step was worse than the first. I remember encountering a curb and thinking I was lifting my leg, but being motionless. I think I stood there for five minutes looking from the curb to my leg and back, trying to figure out how to step up. Eventually I found a tree that I was able to wrap my arms around to hoist myself up. About 30 minutes later I made it across the block to the restaurant to greet my friends. They were shocked to see me: they thought I quit back at mile 5. After I emotionally lost it, they helped me into a chair, got me some ice, and quickly nourished me with coffee, bacon, french toast, another ranger candy, and beer. Although the pain was still bad, I felt tremendously better being around my friends.   I am going to pick up my finishers certificate tomorrow, then go promptly to the doctor to get a PT referral and some strong muscle relaxants. "

Still thinking it was a severe muscle pull, I wrote these words the morning after the marathon: 

"Last night was horrendous: I now know what a pain level of 10 feels like. I kept waking every 30 mins because it hurt just to lie; when I woke up at 2 am I felt nauseous and tried to get out of bed to go to the bathroom to puke. The pain when I tried to move my right leg was indescribable. By the time I got to the bathroom my body went cold and numb from head to toe and my vision was full of millions of black dots. I remember thinking "I am going to pass out on the floor" and caught myself on the toilet. Thankfully I quickly recovered. I made a smart move to the couch (easier to get up and down from than my high bed) and propped my legs at a 90-degree angle with pillows. That allowed me to get a little more sleep before the sun came up. Thankfully my landlady had extra crutches lying around, which made my life a little easier. I caught a ride to the doctor, and was able to see a sports medicine specialist. He was more interested in what caused the injury to begin with, and brought up the stress fracture factor. One thing that I haven't really talked about is that ever since I started training, I have been amenorrheic. I asked a general doc about this is August and her response was that it wasn't a big deal and I shouldn't worry about it until after the marathon. When I mentioned this to the doc today, he was shocked. He said that it absolutely was a big deal, and as soon as I figure out what's going on with my leg we need to get that taken care of. It's kind of a mystery to me, because I am in the normal BMI range and eat plenty of food, but it is certainly something that I need to get taken care of. Anyways, I am getting (another) MRI on Wednesday, barring my insurance company approves. I am pretty confident it is only a muscle problem because that muscle is swollen to about twice its normal size. Regardless, I want to play it safe, so I'll go get the friggin MRI. The doctor wrapped my thigh with an ace bandage, which felt like a warm cocoon of healing. The only thing that feels better? The tylenol with codeine he gave me! Whee!
I can now maneuver my way from the couch to the bathroom a lot easier than this morning. I have been lying on the couch all day, and am bored out of my mind. I am already planning my next marathon...Big Sur, anyone?"

Which were promptly corrected with these words after my MRI:

"My pelvis is broken. You can see one of the breaks in the photo above (I asked for a copy of my films). See that clear line in my bone, surrounded by a big white area? Yup, fracture. Also my whole hip/leg is completely swollen thanks to the edema (bleeding) in the area. I had no idea...I don't have any external bruising...maybe it's because I have had a compression bandage the past few days? According to the radiologist I broke my inferior and superior pelvic ramus. That means that two bones--complete fracture. The radiologist thinks it was a stress fracture before the marathon, and the clean fracture happened during the race. He couldn't believe that I ran the marathon. He said that he has only seen this type of fracture in car crash victims. I don't know anything else right now--I will see my doc tomorrow. What's scary is that the doc said this isn't supposed to happen to people my age, and I should get a bone density scan. All I know is I am F*CKED. Sorry to use that language, but I think it is warranted here. Since my roomates suck and haven't asked me once if there is anything they can do to help, even as they see me crying just trying to get a glass of water, I am moving in with some friends for a few days. I don't think it has emotionally hit me yet, as I keep cracking jokes about it. I just feel really out of it and nauseous. I'll update you when I hear more."

 Here were my words from a follow-up appointment with my doctor later that week:

"Yesterday (Thursday) I went back to the doctor's for my MRI followup appointment. Basically there is nothing to do except to let it heal on its own. For now I am to rest as much as possible until the pain subsides. The muscle pain is pretty much gone, and I am so thankful for that. The worst for me is just lying around and not doing anything. This has also screwed me up professionally: I was about to start a big experiment and can't even think of making it out to the lab for many more weeks. I have a long road ahead: more MRIs, potential PT, bone density scans, hormone/blood tests, etc. The good news is the doctor knows how much I want to run again, and fully intends on getting me back to running as soon as possible. A lot of non-runners have said "well, at least you ran one marathon, so you got that out of your system". This experience makes me want to run another one that much sooner! Granted, I am not going to be stupid and try to do anything too fast, too soon. When I heal--and I will-- I will be very cautious about training."

The first few weeks of my recovery were a rollercoaster. My doctor warned me that recovery would not be linear: there would be days where I felt like I was almost healed, followed by days where I felt like I was back to square one. Here are some samplings from posts I made during this period:

"Crutches suck. Not being able to drive sucks. Not being able to do anything by myself that requires walking and hands sucks. My arms hurt. My body is in a contorted state when I stand or sit to take pressure off my pelvis. I haven't been able to shave my legs since before the marathon. I still have dirt on my toes from the marathon since I can't bend over to wash my feet. I am tired of sleeping on my back with pillows under my knees. I can no longer be susie sunshine about this f'ing injury. I am so over trying to find the good in this. I am running out of clean clothes; how am I supposed to do laundry? I am tired of being confined to my apartment. I am perpetually dehydrated since going to the bathroom takes about 15 minutes round-trip. I really wish I had gone home to the family for the holidays. I have a friend visiting in a few days: how am I supposed to play tour guide when I'm hobbling around on crutches? I had a dream last night that I was running on the beach: when my Garmin beeped that I had ran 5 miles, I had this realization that I wasn't supposed to be running since my pelvis was broken. I think I have just found my personal hell."

"I had a very good follow-up doctor appointment today. The shearing muscle pain has given way to a deep-seated, throbbing ache which he says is from the bone. I should expect this pain for the next few weeks as things heal. I will probably be on crutches for another 4 weeks, and won't be able to drive for a few more weeks.Once I get off crutches I can begin some pool exercises, and in about 3 months I can start running again. I forgot to ask about pool running, but will bring it up at my next appointment. I reluctantly asked if I will ever be able to run another Marathon, and he says that if I train less intensely as I did for this past one, I should be able to run Honolulu next year. My doctor is awesome: he is a sports medicine specialist and told me he will do everything he can to get me running as soon as possible. In return, I had to promise him not to do any activities until he okays them. He told me that he is worried that I may be stubborn and try to do too much too soon--now what on earth gave him that idea?"

"Yesterday I was able to touch my toes. That was a major accomplishment. After realizing I still had mud from the marathon on my baby toe (gross, I know) I was determined to do something about it. Very carefully I opened my stance, grabbed onto a bar for support, and went for it. Success! Hand-toe contact! I am da (wo)Man! I also spent the majority of yesterday out of the house. I texted a friend with a message along the lines of "If I don't leave my house I am going to do something crazy" and thankfully he came to the rescue. After running errands, he mentioned that he was going to a party at a local running store and invited me along. At first I said no, because I thought it would make me sad, but I decided to go for it. I am so glad I did: almost everyone had a major injury in their past, and they were all so motivating. I came home from the evening with my spirits high. Granted I was in considerable pain after being mobile all day, but it was well worth it."

"Despite my complaints, being a handicapped tourist definitely has its perks. These benefits aren't limited to just being in a wheelchair. While on crutches, we got whisked to the front of all the lines at the Pearl Harbor memorial. I also got many sympathetic looks while I made it to the beach today. No matter what the doctor says, I can make sand and crutches work. Want proof?"

"(to the tune of Viva Las Vegas) Freedom, I've got it! Freedom, I've got it! Freedom, Freedom, I've goooooot iiiiiiiiit! I did something yesterday I haven't done in over three weeks: drive! Although my doctor said to wait until he gave me the official okay, I decided that I had regained enough muscle control to safely drive a few blocks. The concern about driving was never due to my bone injury; it was due to the fact that because of the internal bleeding I had lost all muscle control in my leg. Two weeks ago I couldn't lift my leg unless I physically lifted it with my hands. Now I can lift it all on its own with the slightest twinge of pain. Since I am still not at 100% I am apprehensive about driving, so I plan on staying mainly house-bound for the time being. But just knowing that I have the ability to drive myself to the doctor or store is such an uplifting feeling. I must admit that when I first got in my car I glanced to make sure no neighbors were around, then I wrapped my arms around the steering wheel and gave it the love it deserved. Oh how I missed you, my love.

This morning I also realized how much progress I have made. Two weeks ago it took 10 agonizing minutes to make a pot of coffee. This morning I maneuvered the linoleum landscape without a crutch in sight! The steps I take without crutches are beginning to resemble normal steps; granted, I still cock my hip and limp into each step, but the limp is less exaggerated with each day. I can't wait to show my progress to the doctor tomorrow."

(One month after the initial injury: "I have been riding the recovery high for the past few days. Tuesday I got my follow-up MRI, and spent the rest of the day obsessively analyzing my films and researching bone healing. I still have some minimal bleeding in the muscle surrounding the bone, which explains some of the lingering pain and tingling I feel. Thursday I went to see my amazing doctor, and he said the magical words: "I think you can get in the pool now". It was like the heavens opened and a bright light shone upon the room. I swear Handel's Messiah was playing in the distance...
He was imperative that I only do activities to the point of pain. He said "listen to your body, let pain be your guide...and not let pain be your guide like how you did during the marathon. Seriously listen, and stop the moment you have any pain." I said that may be difficult since my Mom says I have a high pain tolerance. He kind of looked at me, looked at my hip, and said "uhh, yeah, you could say that."
I asked if I could skip the pool swimming and go straight to the ocean swimming, since my skin and hair appreciates the saltwater more than the chlorine cocktail. My doctor gave me a funny look and said "maybe you should start out where you are no more than 25 feet from land at any given time."
Point made.

 
In addition to the swimming, he gave me the okay to do strengthening work at home. I created a plan that involves a lot of isometric core work, and did some work this morning. Boy, my muscles have weakened! My legs were trembling by the time I finished my side planks. After the muscle work I grabbed my suit and headed to the pool. Before I tried freestyling, I practiced rotating my right leg in circles and lifting it to the front, side, and back. Everything felt really good--no pain--so I decided to try some laps. I barely kicked my legs and mainly used my arms. After two laps I stopped and tried to practice full-on kicking while holding onto the wall. That hurt. I resumed my minimal kicking laps and stopped after 5 laps because it was starting to hurt. At this point I should be very conservative with my rehab. I figure I can be more aggressive with swimming once I strengthen my muscles with my terrestrial plan. I found out that the pool has aqua joggers to use for free, so I won't have to shell out big bucks for one of my own. Score!
Although it still hurts a little bit to walk long distances without the crutches, I think I am ready to let them go. The more I walk without them, the faster I am healing. I keep sending happy thoughts to my myofibrils, and so far they are behaving. It's a good thing, too, because I have completely worn out my crutches."

(two months after the injury) "Yesterday my friend stopped by to borrow my Garmin. She was contemplating buying one, but wanted to test drive mine. Naturally, I agreed since it has been collecting dust for quite sometime. Although I should have remembered that the last time I used it was for the marathon, it was still a shock to turn it on only to see my stats from that fateful day. It really bothered me; and I kept thinking about it for the rest of the day. After a few weeks of feeling okay about not running, suddenly I can't stop thinking about it. I feel a knawing ache when I drive by runners, and longingly look at my running clothes drawer. And--I'm not ashamed to admit this--I pulled out my Mizunos and gave them a light caress last night. I saw my doc on Thursday and he says I still have another month left before I can run again---can I make it?" 

Then finally, three months after the initial injury, the moment had arrived! I was given the green light to run one mile! I even wrote up a race report in its honor. After that one mile my doctor said to run one mile, three times a week for two weeks. Then 2 miles. Then 3. The progress to return to running was agonizingly slow. It really helped having a doctor who understood how my mind worked. He kept warning me that too much too soon would put me right back at square one. He emphasized that if I wanted a successful return to this sport I had to follow his advice exactly.  Slow and steady. Cautious and controlled. Sure enough, with his advice I was able to return to running and qualified for Boston a year from the initial injury. Since then, I've had zero problems with my hip. My bone density was tested and I was on the borderline normal range. I'm taking hormone supplements (aka oral birth control) to ensure I don't go amenorrheic again (which puts you at a high risk for stress fractures). Now I have the knowledge and experience to understand the warning signs of injury and back off training when I get the initial twinge. 

So that, in a not-so nutshell, is the story of my broken pelvis. For those of you who haven't experienced an injury like this, please consider this a warning to pay attention to signs your body is sending. For those of you who have experienced this or are currently in the process of dealing with this, I hope that my story helps you feel like you're not alone in your journey to recovery.

May we all run smart and strong and remember: