How to get a Stress Fracture in your Sacrum

7/6 Edits Leg Length Measurement and MRI

5/4 Edits blood tests clear..

4/18 Edits (add Stats, leg length info and conclusion revision).

In the interested of clearing this white board in my office where I've diagramed and timelined and built a fault tree diagram to try and figure out what happen - I'm going to copy it all down here.

Stats:In a study of running related stressfractures (1978) 55% Tibia, 23% metatarsals (toe bones), 14% fibula (small calf bone), 6% femur (thigh bone) 1% ankle bones, 1% pubic arch bone and 0.1% sacrum. (Noakes - Lore of Running). (I suspect it was underreported back then with fewer means to detect - but still).

Not too common of a place to get a SFX but somewhat common for a high end distance runner from what I've found in my studies on it.........

Root Cause Analysis – Stress Fracture in the Sacrum.

Problem Statement – Injury in the area of my Right Buttock after the San Antonio Marathon caused an inability to race or even run for many months.

Timeline (blogger style – newest first – I wrote this chronological then decided to flip it around so I could add new stuff at the top as things progress – if anyone actually reads this it might be helpful to start at the bottom and go up - might flow better):

7/6 - CT Scan to measure leg lengths - waiting results but I got a copy of the data - by my measurement the the legs are very very close to each other - within a couple millimeters - we'll see what the doc says. Still waiting MRI results.

7/2 - MRI today - waiting results. Tech's words were getting better - not as good as all better but at least better than no change.

5/4 - received blood tests for samples taken 4/14. Apparently Vitamin D takes a while - not done local. Results came back all within normal limits. But just in case I've been religious about taking Ultra-bone vitamins I got at the supermarket for the last few weeks. All pain is gone and I'm walking normal with no limp. Still holding off any exersizing - I'm probably being a bit over cautious in cutting out the crosstraining I was doing but I don't really understand why 3 months between MRI's and the bone doesn't look better - doc seems to think it was the running but there was so little of that - just doesn't make sense to me - I'm thinking perhaps the crosstraining was a part of the slow healing so I'm holding off on that too.

4/15 - Dr. Visit to review MRI result and drill him with questions :). Made me feel much better about having some pain - most comforting words were a broken bone hurts for 4-6 weeks - I was very concerned that with each movement I made that had a little pain I was making the break worse and had lots of bad scenario's ringing around my head - very nice to hear some pain is just normal. Walking is so much easier today - still limping but not nearly so much - feels like the corner is turned :). The thought of a few months off gives me not the slightest disappointment (ok maybe slight) as long as it all heals up normal.

Currious thing - I was convinced leg lengths were the same but my wife assisted me in measuring up to the hip bone on each side and found a full centemeter difference with the right leg shorter - that could explain it all and so easy to fix with a shoe insert. I know someone else who had this same injury and she found the same difference in leg length. Doc's going to do a CT Scan to get an accurate measurement before I start running again.

4/14 - MRI Results - a crack (small line on right side of Sacrum) - treatment - 3 months rest - high likelihood will fix - no repetitive exersize - let the pain guide what's ok shortterm around mobility - maybe bike/swim after 6 weeks or so - depends - take new MRI after 3 months to be sure all is gone then can start running again. Prescribed to get bloodwork to be sure no underlying issue preventing healing. Checking if electrical stimulation makes sense (low expectations - expensive with questionable value and unlikely to be approved for something like this - still pursuing just in case might be helpful), Screw/pin - rarely used in this area - high risk - bone graph would be next option in the unlikely event just rest didn't fix. No mention of sports hernia on the report - I'm hoping this was a false diagnosis related to the abductor pain I had felt a few times only for about 1 week prior to the MRI - perhaps just a mild thing that needed a little healing time.

I was just happy he stopped using words like catastrophic making the healing process seem pretty normal. Although I thought I was being pretty cautious with this SFX over last few months - I can see looking back over this log I was not cautious enough - bone is a very different animal than soft tissue injuries - the slightest extra pushing can be very bad on bones. Seems most likely the crack came from running 3/28.

4/11 – Get another MRI…..awaiting results – bracing for a “crack” result – no idea what would be done for something that he says doesn’t heal – maybe a screw or a pin – who knows but it doesn’t sound like just wait “X” months……..We’ll see – I’m a little worried….

4/10 – progression is getting worse – buy crutches as now I’m limping most every step – the words of the doctor “Cracks in Stress Fractures don’t heal” are ringing thru my head.

4/9 – Visit a different doctor (orthopedic) – much more helpful than the last – goes thru the prior MRI with me and explains the injury better - I had somehow thought the SFX was a very small crack and I had squinted at that MRI trying to see it – he pointed out a whole section of the bone that was swollen from what he described as an extended period of over stress/micro fracture/heal – not like a single crack – guess that is what a SFX is and not a single crack – he explained SFX’s heal slower than a clean break – typically prescribes 3 months of no impact type sports (i.e. no running – biking and swimming are fine since they don’t impact). It’s nice to have a more helpful doctor. He was consistent with the other doctor in downplaying the significance of “Sports Hernia” impression from the radiologists on the last MRI – hope they are right. But he kept using words like “catastrophic” when we looked at the MRI and talking about the difference between a “crack” and a SFX – a crack in a SFX apparently will not heal.

3/29-4/11 – no exercise – initially no pain but progressively each day is a little worse than the prior from normal activity.

3/28 5.0 Ended quite disappointed that the pain in the butt was back and was definitely a building pain that was not going to go away with more miles. Time to stop running again – hopefully I didn’t re-injured by this run.

3/18 1.0/1.7,3/19 1.0, 3/20 0, 3/21 0.56 (after a bike ride – man that’s a tough transition), 3/22 2.6, 3/24 3.0, 3/25 4.6 – All these with minimal discomfort – I considered normal aches and pains of starting run after a time off although I didn’t like that that discomfort was in the area of the injury (clue?).

Running (5.5 weeks since the 5k, 10 weeks from prior “last” run)

3/21 56 (flying fast 21 mph average), 3/22 47

3/15-20 – skiing all week – no problems – a few short bike rides as well.

2/21 55 miles, 2/28 47, 3/1 36, 3/6 16, 3/7 33, 3/8 46

Biking (no pain from this activity around injuries)

2/9,2/16 – swimming lots of laps – much improved.

2/2-8 – 4 weeks off since last run – try to gingerly run (treadmill) – M 0.5, T 1.0, W 1.5, Th 2.0, F .57, S 3.1 (a local 5k I jogged very very slow – noted pain in the butt after 2.5 miles –should have walked the rest but didn’t).

1/26,2/2 weeks – learning swim strokes in the pool (Total Immersion).

Swimming (no pain from this activity around injuries)

1/19 week – nada

1/12 week – nada

1/9 – get MRI results – SFX in Sacrum Ala and Sports Hernia “impressions” (Doctor – orthopedic - unhelpful with any input whatsoever – just says to take time off – not even guidance on how long – so I go google)

1/2 – MRI

1/1 – 2.1, 1/2 – 4.8(upper thigh abductor pain), 1/4 – 5.6(upper thigh abductor pain), 1/6 – 4.25 (upper thigh abductor pain)

12/28 20 miles for prior week – Christmas Day up to 5-6 miles – No more pain in the butt but the upper thigh pain starts again then comes abductor pain shooting down the leg towards end of the run – walk home.

12/21 – no running – XRAY shows all clear – appointment for MRI keeps getting delayed thru holidays.

12/14 – no running

12/7 – 18 miles total – 5 mile max at once – expert massage – also using tennis ball for massaging – someone got me thinking toward piriphormis syndrome that seemed to fit the symptoms so I was self treating for this.

11/30 – 22 miles total for past week – pushed to 10/8 miles on a couple runs – still noted back of hip joint pain then upper thigh pain.

11/23 – tried a run on my own – ended up 13 miles with walk breaks every few miles I notice – I note symptoms of – back of hip joint pain than after a while upper thigh pain.

11/22 – Club run – 10 miles – first few pretty slow then 5 up to ~7mpm pace then dropped off pace of the others and walked much of the last couple miles back to the start as they went on a few more miles – I don’t recall the issues. When I got to the start I asked the club massage therapist for a massage (I’d never done that before) – I recall noted to focus on sore calves and SI joint area.

11/17-21 – M 5, T 0, W 7, Th 0, F 9 – all very slow running guided by – enjoy the run of whatever distance feel good – these post race runs after a marathon for me are much driven by the euphoria of the race and a reliving of dream kinda thing – no pressure to go farther or push any limits. No recollection of any issue abnormal on these runs.

11/16 – S - San Antonio Marathon – Don’t recall anything in the race. I did start the race with 2 IBP so it could be any pain I should have been feeling was masked. Finished race with lots of euphoria so perhaps wasn’t noticing any pain.

11/10 – bailed on a workout – noted in the log “hip pain”.
9/2008 – PT noted I have a weak right hip by having me lay flat and raise right and left leg as he pushed them back down . Along with this I had issues when not running balancing on left foot and raising right foot with pain around the hip.

2/2008 – Groin Pain following a 5k race a couple weeks after the Houston Marathon (right leg abductor pain). Impacted running for a few weeks – I found I could after a slow and cautious warm-up I could run any distance or speed I wanted without impact. (Perhaps the Genesis of a Sports Hernia??)

Causes/Preventions for Next Time
Stress Fracture in the Sacrum causes (and preventions) from my studies are several – I don’t know my exact cause but have lots of risk factors that likely added up to the injury.

Typical Causes:
Quick ramp up in intensity – bones not stressed and strengthened to the new intensity level and vulnerable to SFX due to this low strength:

My Risk Factor on this – Only the San Antonio Race itself lends itself to this description of a quick ramp-up in intensity. In training I had 3x20 mile runs - fastest 6:40 average then going to 26.2 at 6:05 pace on race day (10% faster and 30% longer than anything in training) - perhaps too big a jump at once - perhaps should have had harder workouts in training to prepare the body/strengthen the bones for the raceday stress. Training in general was slower prior to this race than any other of the year due to the heat of the training months prior to the race. Race Day was accelerated over training speeds by the combination of a very cold day for the race and the extra benefit from what I’ve called the turbodrive routine I did prior to the race to give me a little extra race day speed.

Imbalances in running form – Leg length differences have been seen to cause this injury, also running on a slanted road, also an abducted foot (slanted out).

My Risk Factor on this – I run a large variety of running surfaces so the slanted road doesn’t seem to make sense for me. Haven't done the leg length measurement correctly yet but by home-measurements I do find my left hip bone is about 1 cm higher than my right. Also off the MRI laying on my back I found the top of my left femur to be 9 mm higher than my right on the film - need to get that measured right and consider a shoe insert.

An exagerated visual of the impact of leg length difference - extra forces transfered to the point of my stress fracture seems to make visually make sense:

Also I do notice on video footage I happen to have I do have an abducted right toe – I found a perfect scene in 2008 Boston video to see I’m running along the yellow line in the middle of the street where my left foot lands exactly parallel with the line but my right foot is slanted with my toe about an inch outward off center from my heel. I even have a certain whole body sway I see in all video’s I can find that seems to highlight a right side imbalance. I’m also noting nearly all my running injuries have been on the right side so I’m thinking this is root cause of lots of stuff. I do get the impression this is not hard to fix this with shoes and certain strength exercises now that I know to go fix it.

Mineral Issues – Low Calcium – This was apparently what happen to Deena Kastor who suffered a broken bone in her foot a few miles into the Olympic Marathon “I was doing a long run in Colorado while there for the Boulder Bolder, and drank out of a stream. Most mountain girls would know better, but I thought I was at a high enough elevation to quench my 15 mile thirst. I was really sick for 3 weeks (one of those weeks in which I ran the NY Mini 10K) until I finally took medication. In that time I lost 5 pounds that was difficult to put back on in marathon training. My blood was depleted of minerals so it grabbed the nutrients from my bones."

My Risk Factor on this – although I drink lots of milk I don’t focus much on vitamin intake and have never focused on taking Calcium but I do find listed as a preventative for stress fracture to take Calcium and Vitamin D – This is now and will continue to be a focus I will do once I get running again.

Weak Abdomen/Core – Stronger abdomen/core helps to stabilize the pelvis and put less stress on the bones.

My Risk Factor on this – I never did core work – definitely will be a focus area once I get running again and before.

Conclusion:

I don't really know what happen specifically but I did have enough risk factors that I was unaware of that in the end I think I was destine for something like this as I got faster - with speed comes harder pounding and with harder pounding comes higher stresses and a weak point is revealed. I suspect the a heal insert to even out the leg length delta, maybe fixing the gait issues (running form) as well as some core strength building and focus on vitamins could have prevented this - I got away with it at slower speeds but at some point I got fast enough that these weaknesses became important. Lesson learned for next time. One of the hazard of not being coached is I'm having to figure it all out myself where a coach probably would have pointed out some of these things that now seem somewhat obvious.

In hindsight recovery has been done all wrong - needed a solid several months off without impact sports and still haven't had it yet. All prior injuries were couple days off or run through and it gets better eventually kinda things - this was was clearly a different animal although it took a while to realize. Better listening to signals and responding could have made this so much less an issue.....probably most important lesson of all - and one I hope to never have to relearn ever.

John.

ps - been thinking of a new handle for my next running life - I'm hoping the comebackkid or some variant might work...