Reflections on my stress fracture

It's definitely important to reflect on the mistakes you have made and make every effort not to repeat them. With regards to my running, the stress fracture that I suffered in late July has been perhaps the biggest running-related setback I've had, and one well worth avoiding in the future. It hasn't all been negative though, and I have learned much from the past 12-14 weeks about myself, running, and triathlon training. 

My stress fracture was located in the base of my 4th left foot metatarsal, or one of the long bones of the foot. The base of the 2nd-4th metatarsals are actually common areas for runners to develop stress fractures, although anecdotally, there may be a greater incidence of tibial and hip stress fractures. The symptoms I developed were classic for a stress fracture - an insidious, dull pain which was very hard for me to localize, starting off with a very mild sensation of soreness which gradually worsened as I continued training. I did not suspect I had a stress fracture until the pain had worsened over 3 weeks, and even then, I was able to run 20 mile runs without problem, so I continued to doubt the possibility of a stress fracture. Unfortunately, the days AFTER the run presented with great difficulty, with increased pain. I finally realized I was looking at something more serious than a strain when I noticed that I was starting to have problems walking without pain. And even then, I didn't really believe it, since I was still doing intervals and distance as fast as I had planned.

Stress fractures are caused by overloading the bone. It is generally a combination of chronic repetive low-medium grade forces, as opposed to a sudden high-intensity burst (which would more usually lead to an acute fracture.) Diagnosis can be difficult, as the pain is often dull, and hard to localize. Even with repeated self-physical exams, I swore that my point of greatest pain was the base of my 5th, not 4th metatarsal. It was not until weeks of recovery that the general soreness decreased to the point where I could clearly push on the toes and deduce that indeed, the pain was at the base of the 4th. 

Diagnosis of stress fractures is usually by MRI or nuclear bone scan. In most cases of stress fractures, x-rays will be completely negative. If you have radiographic findings of a stress fracture on xray, you have had a fairly significant one in that a gross bony fracture likely occurred. In contrast, my stress fracture was the more typical type, in where the xrays look completely normal, but there is true microdamage to the bone which can be detected by more sensitive (and expensive) imaging studies. My MRI demonstrated a very, very small "crack" in the base of my 4th metatarsal. The defect was so small that it would have been easily missed if I hadn't been specifically looking for it (I am a radiologist.) However, the various imaging data all correlated with each other, and after a few weeks, my physical examination completely matched the study, with focal pain exactly at the location specified. I was lucky in that my 5th metatarsal was spared - those often require surgical fixation since they do not heal well on their own. The pain I was feeling in the 5th MT base was due to the pushing of the 5th bone on the 4th as I pressed down on my foot.

Recovery from stress fractures is generally 12-16+ weeks, depending on severity and location. The type I suffered almost never requires immobilization or surgery, and in fact, it is recommended to continue non-weightbearing exercises such as cycling and swimming to maintain fitness. I was hoping that I would heal faster since my fracture was so small on imaging, but indeed, it took a full 12 weeks just to get back to running 1-2 miles without pain the next day, and will likely take 16-24 weeks to get back to no pain at all. I tried several times to make an earlier comeback, and ran 1-2 miles at a time to "test" out the foot, but on the 3 separate occasions where I tried this, I suffered recurrent pain the following day, indicating that it was not a good time to restart. I now can run 10 miles at a time without pain the next day, but I do have definite persistent soreness in my foot if I massage the area, indicating residual injury. I've decided that it's better to be safe than sorry, and I will not plan to race the 26.2 again until I can run and walk completely pain-free. 

In terms of the cause for my stress fracture, I think there were 2 main reasons, both of which are equally important:

1) Neglecting recovery weeks of low mileage after the San Diego Marathon

2) Adding steep hill running too quickly

I felt so good physically in the week after the SD marathon in July that I decided to continue training and possibly shoot for a 3:10 8 weeks later at San Francisco. I actually think this would have been a completely doable plan had I not increased my training volume with hills, and there are many marathoners who do back to back and more hard training after big races. Still, the undoubted reality is that running a hard marathon does a lot of microdamage to the bones and muscles. The muscles may bounce back in weeks, but the bones definitely need more care. Even if you have no bone problems whatsoever postrace, I would serious warn against increasing training volume in the 6 weeks postrace, as this is a prime time for these sorts of stress injuries.

The real killer for me was my addition of very steep hill runs. Since my quads were my limiting factor at San Diego, I switched both my midweek long runs AND my long 20+ mile weekend runs to all off-road climbs in the Santa Monica mountains, where the average uphill incline can equal 11% for miles at a time. While a few percent incline is close enough to normal flatland running that the risk of injury is lower, severe inclines and declines impart a whole new load pattern on the feet & legs. My stress fracture seemed to correlate with this exactly, in that I had difficulty reproducing the pain while running on flat surfaces, but once I put my foot into steep angle climbing positions with lots of loading on the distal toes, I developed maximal pain. Thus, the combination of a weakened foot from the marathon coupled with an unusual loading pattern, led to an unusual stress fracture. Remember that I have run 80-100 mpw for months at a time, and I was only running 65-75mpw postmarathon, so the sheer volume was likely not the culprit, but rather, the strange angulation I was training on.

I know those who have been reading along may wonder "it must have been those Payless shoes!" I know for a fact that this was absolutely NOT the case. I used my last pair of Payless shoes in training about 6 weeks prior to the SD marathon, and was using all Brooks Adrenaline GTS 7.0s in the remaining weeks prerace as well as postrace. I had purchased 3 pairs simultaneously, and even swapped out 2 new sets in the final weeks prior to the marathon. I did have one active pair that was 600ish on the miles, but I doubt that shoe condition was a factor at all here, as the other two pairs getting equal use were in the low 100s and 200s after the SD marathon. Still, I'd advocate for people to make sure that they're not logging ridiculous numbers of shoe miles in the postmarathon phase where risk of injury is perhaps highest.

From a mental standpoint, as much of a letdown it was to be knocked off training for 12 weeks, I really believe that for my highly self-competitive drive and personality, it was a necessary stage in my running development. In the past 2 years, I have found that with careful training and planning, I have pushed far beyond any physical running limitations I previously had. Part of my progress involved taking real risks, such as going a lot faster, farther, and longer than I ever believed possible. Training to the point of this stress fracture has made it clear that I have been able to mentally drive myself to my physical maximum, and thus cannot blame any limitations of progress during the last training cycle on any lack of motivation, or subconscious fear holding me back. Even if I never fully regain my prior ability, I will always look back on this period of maximal training with self-respect, in that I was willing to put it on the line and go all out for my goals.

In terms of future races, I have nothing planned in the near future. I would love to do a triathlon in the next 3 months, but tri season ends for the winter, and racing does not start until late spring. There will be no fall/spring marathon for me, as I will not be in form to restart a full training cycle until at least early spring. I will however, be doing smaller races, possibly 5ks and 10ks here and there just to get slowly back into the groove of the race (without overdoing it), and I did sign up for a spring half marathon in Washington DC where I will be for a conference in March. Despite this lack of race focus, I've been training fairly hard for triathlons, with 4-5 swims per week, fairly fast runs, and strong bike efforts for 1-2 hours per day on average. Plus, I've been lifting weights again, and have regained 5 lbs of muscle and most of the strength that I lost over the past 2 years. I'm going to try and enjoy the next few months of open-ended triathlon-style training without a definite goal and enjoy the opportunity to take the sporadic random day off here and there as need be. But have no doubt - the moment that the body is ready and willing, I will be ready to return to my unfinished business with the marathon, in full force.