My Stress Fracture Story
When I finished the NYC marathon in 2018, I hadn’t thought about qualifying for the Boston Marathon. I knew this was a bucket list item for many runners, but I didn’t give it much thought. It wasn’t until I was in the shoe store getting a new pair of sneakers, when the guy helping me asked if I was going to sign up for Boston. As the timing lined up well, I decided I would give it a go.
Cheering Squad: TaMarathon
I began training for the Boston Marathon in January 2020. This was going to be my third marathon. My first was the Tel Aviv marathon followed by the NYC marathon, both of which I had trained for in the summer. I do not like running in the cold, but I also wasn’t about to run 20 miles on the treadmill! Shorts out, ear warmers in.
When the pandemic hit in March 2020, I was about 2 months into training. When the race was ultimately cancelled in early April, I was nearly through my training cycle.
The Fracture That Must Not Be Named
Instead of just stopping my training plan, I decided to see it through. Maybe I’d run a virtual marathon in the end. Plus I’d done all those runs in the dead of winter, at 6 am in the dark, with frozen toes - it had to be worth something! In May, I started noticing a few twinges when I was running. Up until then, I had never had a serious running injury. I always had some niggles before races, and have had some IT band soreness and a bout of plantar fasciitis. Unfortunately my habit of “keep running and it will go away” had worked until then, so I mostly ignored it.
On the first day it was possible to run in a T-shirt, I remember running along the West side highway. I turned around to run back and felt a sharp pain in my groin. What was that? Carry on it will pass. I finished the run (face palm). I continued running for about a week, despite the runs beginning to feel torturous. Something was really wrong. There was a deep ache in my groin, that got worse while running. This wasn’t something I could shake off, massage out, or foam roll away.
I saw an orthopedist who ordered an x-ray. Nada. She asked if I wanted to get an MRI. Assuming this was some bad muscle strain, I agreed. I remember the zoom call where she pulled up the pictures of my bones, and showed me (with a pitying face seared into my mind) where there was. a. stress. fracture. On my left inferior pubic ramus bone, plus a stress reaction in the superior pubic ramus (essentially the precursor to an actual fracture). While this is not a common location for stress fractures, my doctor reassured me that she’d had the same thing (and she does iron-man competitions so I felt slightly better?). Plus, of those who get this injury, female distance runners are the most common.
A stress fracture is every runner’s worst nightmare, because it is one of the injuries that requires serious time off running. My doctor suggested I use crutches for a few weeks. No walking, and certainly no running. I got off the phone and cried for a while.
People in NYC are surprisingly nice to people on crutches
Why Did I Get a Fracture?
The usual reasoning behind stress fractures is doing too much too soon. Too much mileage, too much speed, too quickly. Yet this was my third marathon, and the other two had gone off without a hitch. I hadn’t altered my training majorly. What went wrong this time?
My doctor asked if I get my period regularly, which I did. Periods are an important health indicator, as when our bodies are under intense stress (cue marathon training), it can shut off systems that are not immediately important, such as the reproductive system. Yet when women do not get their periods, their estrogen production dips. Estrogen is required for bone strength. Hence, missed menstrual cycles can contribute to bone injuries.
In addition to menstrual health, my doctor checked my labs. My vitamin D and iron were in the low normal range. Vitamin D is necessary for the absorption of calcium, and so is critical for bone health. My vitamin D was 25.8 ng/mL in a range of 20-50.
Iron, which is needed to transport blood and oxygen around the body, is super important for runners. Long distance female vegetarian runners (did I win the lotto?) are at higher risk of becoming deficient in iron (monthly losses, iron lost in sweat and the GI tract while running, low intake). My ferritin levels, which measures stored iron, were 20.6 ng/mL in a range of 13-150. Ideally, runners thrive at higher ends. She suggested I take supplements plus a multivitamin. I had my labs rechecked 3 months later, and my iron went up tp 35 and my vitamin D went up to 45. Woohoo! While this was good news, my return to running was still far off.
I don’t know for certain what caused my stress fracture, but it was likely a combination of high mileage running over too long of a period, combined with winter running, plus cumulative stress of school and training. I also wonder whether I was unintentionally underfueling, adding further stress. If the marathon hadn’t been cancelled, I would have taken some time off in April. Since it was, I didn’t take off the necessary time. As hard as it can be, rest is critical for runners who want longevity in the sport.
My Return To Running: Boston Marathon Round 2
My return to running was painfully slow. My fracture was diagnosed in May, and around August my doctor said I could try the return to running program. This included 1 minute running, 5 minutes walking x 5 every other day in addition to physical therapy. The first round didn’t go well - I still had an achy feeling in my groin. So I put it off until October. That’s five months without running.
The second time around, it went a bit better. I increased my running time by one minute each week. These runs, mind you, were more like shuffles. But I was happy to even be shuffling! I felt so grateful to be able to run again, I didn’t care how slow it was.
I continued building up very slowly, until I was back to fairly normal running by around January. Registration for the Boston Marathon was open again, and I was feeling up for it. I decided to get another MRI done to make sure my fracture was healed. These words were on the MRI print out: “there has been interval healing of stress fracture of the left inferior and superior pubic rami.” HALLELUJAH!
It’s now September, and I’m deep into marathon training with a 30k run this Sunday (wee!).
What I’m doing differently this time:
Being conscious of eating enough. RED-S (Relative Energy Deficiency in Sport) is common among distance runners, and can lead to injuries
Making sure I eat enough carbs throughout the day, plus before, during, and after my runs
Carbs plus protein at every meal
Eating foods with calcium, and continuing with my multivitamin which contains vitamin D (vitamin D is found in few foods aside from fatty fish)
Adding in more strength exercises that are runner specific. Strengthening my adductors, quads, glutes, hamstrings
Working with a coach to talk through any achiness I sometimes still feel
Strength training with a partner increases motivation
Just know that if you ever get a stress fracture, it will eventually heal. Trust the process and you will get back to running. I know it is painful, more so mentally than physically, if running is your thing. I actually asked my physical therapist if she thought they’d write about me in an academic journal, about the girl whose stress fracture never healed. And here we are, running a marathon in a little under a month.
Here’s to fueling ourselves well, allowing for rest, and not giving up!