This weekend I should be racing in the Manchester marathon. 2 hours and 42 minutes was becoming an achievable target. I had completed a few challenging long runs and was becoming relatively comfortable at 3.50min/km pace. One of these included a block of 18k marathon effort and I was bang on pace.
Instead, I'm joining the masses who don't make a marathon start line due to injury. It is six weeks since I was forced to stop running and I didn't run again for just under four weeks. Thankfully, I'm getting back into training now without any recurrence so I can write about the last six weeks with a clearer mind.
When an injury rears its head there are three big questions flood your mind. "What the f**k is this"?, "Why did this happen", and "How long will this keep me out for?".
If I'm being honest I can only answer one of those with certainty. I've thought a lot about the answers to the other two and that's what I want to elaborate on here. I think many runners will have been in the same scenario and I hope the thought I've put into this experience may be helpful. What I'd like to highlight here is that having a background in physiotherapy and strength and conditioning doesn't inoculate you from the typical thought processes and emotions an injury throws up. Possibly, it even increases frustration!
Right, I better let you know what actually happened. On February 24th I ran with a friend and clocked up 31.5k. 12k of this was at marathon effort. This would have been similar to my previous two long runs. I felt quite good during the run and the last block of marathon pace was for 20 minutes and I averaged 3.49min/km pace. I double checked with my friend and I didn't mention anything about a niggle or soreness during the run. The following day was a recovery day and we spent a few hours visiting friends, I didn't mention anything there about a sore thigh either. On the Monday morning I had a 75 minute run planned with 6 x 20 second strides towards the end. This would have been a staple in my programme. Moving around the house that morning I could feel some soreness at the front of my thigh but didn't think much of it. That changed as soon as I started running. The sensation of easing yourself into a run and feeling some muscle stiffness or soreness that disappears as you warm up will be familiar to most. I was expecting this to be the case but I knew pretty quickly this was different. I was clearly protecting my left thigh and moving awkwardly within the first couple of hundred metres. To continue running wasn't my finest move but my gait did improve and I could run with what felt like my normal mechanics. That deep gnawing pain in my thigh never left though and the planned strides were not an option.
I knew it didn't feel right but I was very slow to consider this as a genuine problem. My thought process at the time was, "A couple of easy days on the bike should sort this out". My planned run for the Tuesday morning was swapped for an indoor bike session which felt okay. Some awareness of the feeling in my thigh but far less than running. I went to the gym that afternoon for diagnostic purposes more than anything. I'll come back to that.
I got outside on the bike on the Wednesday morning and snuck in another 45 minutes later that evening. Clearly I was only fooling myself as the Thursday morning was a serious wake up call. There was soreness on walking that had me considering whether I should be using a crutch. I could move at slow paces around the house but my outdoor walking pace was down by about 50%. Not great when the goal is to run 42k at your absolute limit.
Potential diagnoses had been running through my head for the previous few days. This development solidified my suspicion of a bone stress injury in my femur. The process of arriving at a diagnosis involves weighing up the evidence from the training history, medical history, subjective experience of the symptoms and the objective limitations the injury are causing.
My first type of injury to rule out was a muscle strain. There was no sudden onset of pain that you'd typically associate with a muscle injury but in endurance sport muscle injuries can have a more gradual onset. Muscle injuries can usually be identified by stretching the muscle in question through it's full range of motion or contracting the muscle forcefully. Poking the muscle usually feels tender too. That gym session I mentioned involved both of these actions. I was able to complete a seated knee extension without thigh pain and I could pull my heel towards by backside without any pain. I did feel like I had less power on my left side. I tried a single leg squat in the Smith machine but this was immediately painful and I was apprehensive about trying it. This weight bearing type of loading would stress a bone more than the seated knee extension. Any sort of double leg jump reproduced pain in the left thigh on landing. Poking my thigh didn't reveal any obvious focal point of symptoms either. There's no way I'd be able to poke my femur, it's different if it's a more superficial bone like a tibia or metatarsal.
At this point I had decided to manage the injury as a bone stress reaction. Accepting this was difficult as I felt my training was well structured and didn't include aggressive spikes of volume or drastic changes in intensity. I was pushing my limit of what I could handle volume wise and I had moved from five to six running days but it felt like a gradual increase. The other factors that predispose people to bone stress injury didn't apply to me I felt. My bodyweight had been stable and I actively increased carbohydrate intake around my longer or more intense training sessions. I wouldn't have classed myself as being in a negative energy balance but to accurately calculate this is quite complex and I appreciate it's common for runners to misinterpret where they stand. I did not have a recent blood test to check calcium and vitamin D levels but taking a vit D supplement is something I do every winter. Muscle bulk and muscle strength levels correlate with bone stress injury but I would be confident I'm at the higher end of the scale here compared to the majority of runners. My general health is good and there is no family history or personal history of low bone density. My summary here was that it was possible that I was under recovering for the amount of training I was doing.
The gold standard investigation to confirm suspicion of a bone stress injury is an MRI scan. I was in two minds about whether I should actually go for one. A well accepted rule of thumb is that imaging is most useful if you need to exclude serious pathology or if the expected result would change how you manage the injury. In this case there were no red flags to suggest anything serious and the middle of the thigh is not a high risk site for a bone stress injury to progress to a stress fracture or pose a complex recovery. I knew the management would include offloading my leg and gradually reintroducing impact based exercise. I accepted early on that this was a 6-8 week issue and my marathon was in trouble.
My reason to go for the scan was that if this was a high grade bone stress injury (3 or 4) I would need to be more aggressive with my offloading. Bone stress injuries are graded from 0-4 and where they sit on this grading can give an indication of recovery times.
A work contact was happy to refer me and I ended up having a scan six days after the onset of symptoms, I got lucky with a cancellation on a Sunday morning. The radiology report came through eleven days later and this is where the fun started. An elaborate description was given of what was going on with my hip joints but unfortunately there was no comment on anything further down in my thigh. Breakdown in communications can happen when imaging is ordered but I was frustrated we didn't have a clear answer. I didn't have access to the images either, only the report.
I got in touch with the relevant department and a whopping twelve days later I received a call from a radiologist. The gentleman I spoke to was a specialist in musculoskeletal radiology and was happy to report there was absolutely no evidence of a bone stress injury in my left femur. The surrounding soft tissues looked good to him too. As you can imagine, not what I was expecting.
Thankfully, by this stage symptoms had settled down well and a few days before I received the call I had already started to trial some easy running. A week before the call I had started hopping and jumping exercises. The call did reassure me I was in a good position to continue what I was doing and boosted my confidence that I wouldn't see a recurrence.
Clearly, It did throw up the question of what actually caused the pain in the first place. It was enough pain to impact my walking and ruled me out of a marathon I was well set up for. The other considerations were whether it was a referred pain from somewhere else, it's possible to have pain in your thigh due to a back problem or a hip joint problem but that seemed very unlikely. I have read some anecdotal reports of a lag on MRI scans detecting bone stress injuries but I haven't seen any published literature supporting this. I even asked some well respected sports medicine professionals on Twitter and they were highly sceptical!
I spend a lot of my time talking about pain in work and an appreciation for the multifactorial nature of pain presenting itself has to be considered. Minor niggles being amplified to race ending pain is a real phenomenon when worry, stress and fear are thrown in the mix. I have met plenty of runners who feel their race is over but after a chat, thorough assessment and a positive prognosis, they feel better immediately. In this case, I can't identify any reason my brain would have decided this was a good time to shut down my running. I was excited about the race and I even had a deload weekend lined up as I was going to friend's wedding. I do believe the "issue was in the tissue"....and I'm sticking with a bone stress response.
On that note, I do have one theory that I think is relevant. I had some glute tendon soreness on my right side from the way I was standing during some of my work tasks. I could feel this while running but it never bothered me to the point of cutting out runs. It's quite possible I was loading my left side more while this was going on and that's what tipped me past the point of what the tissues were happy to tolerate. This would have been a three to four week period before I developed the thigh pain. By that point the glute soreness had completely resolved too.
At the time of writing (seven weeks post injury) I'm on my way to having my second week of running over 50km's without any bother. I plan to gradually build this up to the 80-90km range and pick races up to half marathon distance over the summer. I haven't decided on a marathon for later in the year yet, I'm still finalising non running related travel plans. I may be satisfied with trying to improve over 21k but I know there are a couple of good options if I do decide on a late 2024 marathon.
Writing this article is a good way to move on from what was a frustrating period. I decided against sharing details of this injury in real time as I felt it was occupying enough headspace as it was. Pouring more energy into writing about it and responding to comments would have negatively affected my recovery I think. Receiving direct messages from people who had noticed my Strava and training related posts fall off a cliff was appreciated, thank you!
I'd like to share a few key points before wrapping up;
If an ache or pain is influencing your running mechanics you should be thinking about getting it checked out.
You probably don't need a scan for your injury. The vast majority of running injuries respond well to a period of offloading and a gradual reintroduction of stresses.
If possible, make a call on your race early. Deciding to abandon Manchester when I knew I was going to have an extended period without running helped greatly. I knew I wouldn't be able to run the race as I wanted to and that was enough for me to pull out. It allowed me focus on recovering in keeping with how my body was responding rather than stressing out about the rate of recovery and whether I'd be able to compete on the day. Largely, that's out of your control.
Not being able to run is infuriating. It's unlikely you'll be able to replace it with anything that gives you the same buzz. That doesn't mean you shouldn't try though. Trial different cross training modalities and see if any of them suit. This will vary depending on your injury but if you find something that gets your heart rate up and you can stick at it for 30 minutes+ you're doing well. I watched a lot of "Drive to Survive" while on a spinning bike!
Typically, you will have one injured bit. Train all the other bits. Trunk work, upper body work, single leg work and hitting unaffected muscle groups in the injured leg are all good targets. I regularly modify strength programmes for Running Buddy subscribers to help in these scenarios.
Put more energy into other aspects of your life. I've noticed it during tapers too but when the running schedule quietens down I'm blown away by how much extra time I have. I think something that challenges you here is a good fit. I started working with a business mentor recently and the action points from these meetings filled my free time nicely.
Be prepared for the drop off in fitness. You should definitely cross train and do it as best you can in terms of matching running volumes and intensities but your running economy will be reduced. I wasn't sure what to expect but my heart rate is still about 10 beats per minute above what it was for a typical easy run pace. It's a pain in the ass. You can see why people ramp up training quickly and pick up another injury, I'd like to avoid that.
The jury is out on whether this was categorically a bone stress injury or not, but either way, runners should learn about them. There are loads of good quality resources and this podcast is a good starting point.
For now I'm putting this behind me and enjoying the process of building my fitness back up. I hope you've taken something from this account of how uncertainty can be involved in a running injury. You have to manage injuries as they present and respect how your body responds during the recovery period. As much as I could have done without it, this was a good learning experience for me too.
Thanks for reading and if anything has caught your attention please get in touch through Instagram, Twitter or email (runningbuddytraining@gmail.com).
Patrick Carroll
Running Buddy