Aches and Pains of Returning to Exercise

It's been nearly two years since my injury, and the one question I'm asked most frequently about recovery regards how to manage the normal aches/pains of returning to exercise. Let me preface sharing my own experience by writing plainly that you should work closely with the advice of your physician/therapist/etc.  You will experience aches and pains. It is frightening. The challenge is to learn to recognize what is normal vs. what is not. This is not an easy thing to do, and as I indicated before it is scary.

I started lightly running roughly 4 months after my injury. I mean lightly running, as in putting on a brand new pair of Hoka Bondi shoes and toe running gingerly. I never felt achy or sore during my running. Never. Had I felt even the slightest pain or ache during my run, I would have stopped without hesitation.

When I started back to even modest distance (e.g., 6 miles), I would later experience a slight ache in my groin at a point over the old fracture site. But...the ache wasn't quite as deep. This is difficult to explain, other than to write that the fracture ache was deep as in located in the dead center of the distance between my groin and my rear end. At the time of the fracture, it hurt when I ran. It hurt notably when I would try to stand up from a chair (or get out of the car).  The ache of returning to running after non weight bearing was not quite as deep (even though it was located in the same place), and it didn't hurt until later in the day. I'd take a hot bath, and the ache would subside. I'd do aggressive self massage in the groin area, and the ache would subside. I'd try to do an adduction stretch to help with what I knew were tight iliopsoas tendons in the fracture area, and the ache would get worse.  Bottom line:  I agree with what most indicate regarding this injury:  Everything is connected "down there," and the combination of a fracture and prolonged disuse (at least 8 weeks of absolutely no weight bearing) created a recipe for tightness & etc.

I also developed snapping hip (tight tendon again), which exacerbated the ache in the area.

This (ache and snap) would come and go, and as the months progressed (and my mileage increased), I learned to recognize it for what it was. The ache lasted for nearly one year - sometimes it would be gone for a few weeks and then return. Cycling made it worse, which was reasonable. Cycling places the hip (and as such the flexors/tendons) in a contracted state, and I'm certain this irritated the already shortened and stressed tendon.

As of today, I still can't stretch very aggressively on the formerly fractured side. No big deal. I still have the snapping hip, but it has lessened notably within the past six months.

Running now roughly 40 miles a week. Cycling/swimming/weight training as well. I'm always "aware" of my former injury, not in a bad way, as it seems to be healed. Rather, I never, ever want to have this occur again. Therefore...strengthen the glutes and flexors. Cross train more often. Take days off. Repeat. Take days off.  Wear very good shoes. I switched to the HOKA brand 20 months ago. They are terrific. I also use Altra Lone Peak 2.5s for trail running. I no longer care about saving weight on shoes. I'd rather have 12 oz shoes on each foot with major cushion than to go through the injury again. If that's all it takes, so be it.

One Year Out

It's been nearly a year since my injury.  I keep reading the runner's world blog site to bond with the stories of those who've been diagnosed and those who've recovered. Bless them all.

I'm convinced now that my injury was caused by a constellation of things - the perfect storm. 1.  Too many trail miles, day after day. 2. Letting my weight get too low, which may have caused some bone leaching. 3. Not enough rest.

I still fixate on this injury every day, but thankfully I'm far enough away from it that I've learned to mellow about small aches/pains.  It seemed like yesterday when I'd inadvertently step on a dried twig outside and freak out thinking that the noise was me breaking in two.

Back to racing now. Training hard again. Training smarter.

After Seven Months

I've learned to recognize snapping hip syndrome for what it is.

Returning to running increased my snapping hip, and the ache associated with this new bundle of fun was similar to the femoral fracture - so similar that I started to panic.

The ache of snapping hip is deep, and mine was located right over the compression fracture site. I'd run or bike, and within an hour the ache would begin - dull and never sharp.

After two weeks of this, I started to understand the subtle differences.

1. I never had a sharp pain of any kind.
2. I didn't ache getting out of bed or out of a car.
3. There was really a lot of snapping going in this area, and I'm convinced that I was (stupidly) aggravating things.
4. Self massage and ice helped tremendously, whereas with the FNSF ice did absolutely nothing.
5. I could balance and hop just fine.
6. Stretching seemed to make it worse.


By the end of January, the ache began to fade, and now it's mostly gone.

Looking Back

For me, the hardest part of recovery wasn’t the inactivity on crutches. Well, I won’t kid you – that part was mentally difficult. The hardest part was the uncertainty in starting to exercise again. The docs won’t be able to tell you what pain is normal and what is not. The aches I experienced were concerning, but they were different than the pain associated with the original injury and subsequent month. I had naively thought that returning to running would be pain free, but that of course wasn’t the case.  Most likely the fracture itself (and external callus”ing”) had caused irritation of the tendons which slide over that area. That, combined with the tightness brought on by disuse, created a recipe for irritation. This made sense to me in late October, but in the absence of a soft tissue diagnostic test (e.g., MRI) there was no way to know.

I trusted my orthopedic specialist, and I trusted my instinct. I also took to heart the scary advice of others (internet posts) who emphasized the need to be careful.  I know I am lucky. I respect that the bone takes a long time to heal. I’m not kidding myself. Full remodeling of my bone won’t be complete until sometime in the winter(?), I imagine. I know that aches will continue to come and go, but hopefully as I learn to use my hip again and again, things will settle down as before.

On November 23^rd my wife and I ran a trail half marathon in New Hampshire. Nothing fancy, and we made a point of taking it very easy. I was injured on July 12^th, and nearly 4 and a half months later I was able to run this distance again. I may experience tightness and aches for months, if not longer, but I feel I am coming out of the woods.  

Looking back, several things:

1.     The internet is both helpful and frightening. There are terrific sites on diagnosis of the femoral neck stress fracture. There are also plenty of patient chat sites (e.g., runner’s world has a thread dedicated to FNSF). The thread sites are scary, and my heart goes out to so many who had it worse than I.

2.     Find an Orthopedic specialist you can trust, and obey her/his advice.

3.     Do not cheat. Repeat. Do not cheat. Do not go off crutches until you are released. Do not try to exercise until you are given permission. This is a very serious injury.

4.     Eat well. Take vitamins. Put Elmer’s Glue in your milk (ok, just kidding – but my friend Billy suggested this).

5.     Come back slowly but surely.

6.     Expect aches & pains  - but be cautious.
7.  What seemed to help during the NWB healing:  Heat. I'd take a hot bath nearly every night, and I purchased a small electric heating pad.
8.  What didn't seem to help:  Cold (Icing did nothing).  Stretching - this made everything worse.
9.  Biggest difficulty: Learning to recognize the ache of the iliopsoas snap.  Certain exercises seem to make this worse, particularly biking. The ache is right over the same area as the fracture site. With a certain movement, I can get the tendon to snap over, and the ache releases.

Good luck to anyone who goes through this.  

My heartfelt thanks to the staff at Harrington Hospital in Webster (particularly the orthopedic folks and the radiology folks). I felt confident each time I visited, and this helped my healing.

If I can help you (advice, sharing, listening), don’t hesitate to contact me. Remember, I am not a physician. I am only a patient.

Return to Running

On November 16^th I went for an 8 mile run at a very slow pace (maybe 12 minute mile?), and the next day I went for a 9 mile run (again, at a very slow pace). The ache had continued to diminish since the beginning of PT sessions, and the frequency of snapping hip had also declined. The runs felt good – still slow – but good. I could run normally for the first time in months, and I could look forward to slowly increasing my pace and mileage as the winter unfolded. 

Last X-ray

By November 7^th the ache was still present, and it had gotten slightly worse (a 3 out of 10), though I had also started light running and static cycling. The snapping hip was also still present. Out of fear that I might also be causing bone damage, I requested another Xray, and the results indicated that the bone was nearly fully healed, with only partial evidence of callus on the compression side, nice lines, and the slightest of dark circle in the compression area (evidence of a bone cyst).

The results were a huge relief, and the bone was continuing to heal, giving me confidence that the ache was largely soft tissue trying desperately to readjust to being used.

FNSF Aches and Pains

By late October I was given permission to incorporate some light cycling into my return to exercise. Mind you, this involved nothing more than using my bike on the indoor trainer, with fairly little resistance. This experience felt a little scary, which was expected, but what I didn't anticipate was the soreness that followed. I'd get off the bike and carefully test things (e.g., a gentle hop test, and I mean GENTLE). I'd have no pain at all when doing the simple tests, yet 20 minutes or so after cycling I'd have soreness in the area of the fracture. This would last the rest of the day, and naturally I got scared. This soreness would be gone by the following morning, but would return if I tried to use the bike. My hypothesis at the time (which turned out to be correct with the benefit of hindsight as I am writing this) was that the bent over position of biking (particularly with aero bars) plus the relative flexed positions of the iliopsoas tendons and hip flexors were causing my tight tendons to be irritated. 

 By October 26^th the aches began to lessen, and I experimented with trying to run. I went to a state park that had a series of flat and “safe” trails (no large stones or roots), the majority being covered in fallen leaves an inch or so thick. Walking was fine, but trying to run was scary. There’s no other way to better characterize the tentative fear of trying to run, and even though the surface was very forgiving, running felt foreign. I ran for only a tenth of a mile at a pace that was slower than what I could walk, but it was a running gait in the sense that I was putting light impact on one leg at a time.  All said, I ran perhaps a total of a half a mile, spaced at 5 sessions of a tenth of a mile with walking for a few minutes in between.

How did it feel?  In a word, strange.  On my injured side, the quads were tired, and my adductor and iliopsoas were very tight. The tightness after running was something new for me (not that I have notable flexibility or have ever been a dedicated runner that stretches much).  It was clear that the injury and subsequent non-weight bearing had notably affected something deep inside my hip/groin, and later that night the ache returned.

I didn’t try running again until November 1^st, though in the interim between the first run and the next, the ache was concerning. It wasn’t a sharp pain ever but rather a dull deep ache that would begin at some point in the morning when I started to walk around and continue throughout the day. I’d experiment with standing on my “bad” leg/hip to see if I could support myself (i.e., to see if there was any pain).  There wasn’t any pain at all (which was good), but the ache would persist.

I also experienced a notable snapping hip (something else that was new for me), where the iliopsoas tendon would audibly snap over something deep within. I’d have a moment of panic, thinking that my femur would certainly snap in two, followed by a relief from the achy pain within.

On November 1^st I finally started Physical Therapy, beginning initially with an assessment of my relative (left leg/hip vs. right leg/hip) flexibility and strength. After a series of tests, the PT indicated that my flexibility was high in both legs/hips, and my strength was slightly less in the injured leg (no surprise). He also found that extreme passive adduction (moving the injured leg far away from the body) would cause a sharp pain right in the injured area. (I had actually known this for a couple of weeks, as certain stretches, like an aggressive groin stretch, were painful). His thought was that the tendon was so inflamed from the injury and so tight from disuse that the ache was evidence of the tendonitis and snap.  As a result, I started doing a series of targeted strengthening exercises.