Marathon Training – a pain in the arse…

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Week 9 of my marathon training has come to a painful end. Followers of my training so far will have read about a niggling left hip problem and how it settled nicely as my programme continued. I was beginning to feel really fit, no aches and pains, running well…then it all went a bit Pete Tong…

Firstly, let’s bring you up to speed…

Week 6 ended with a fairly comfortable 20 mile run along the seafront. Week 7 was a busy one, with my birthday in the middle. Thank you everyone for all my nice birthday messages on Twitter! I couldn’t fit every run in and had to replace one with a cross-training session – bike and gym with a jacuzzi after (always nice). I also had a lovely 6-mile walk to the pub for lunch (that counts as training doesn’t it?).

Week 8 was my best week of training so far. The left hip pain had completely resolved and the nice weather meant I could get up onto some of my favourite trails on the Downs – always a treat! It was a reduced mileage week too – 32 miles over 4 runs. Most were fairly slow-paced but I did enjoy a 1.5-mile hill interval in the middle of one run. Felt awesome to burn up “The Snake”, a winding hill climb that has slain me in the past! The switch from road to trail combined with a drop in mileage helped a few niggles disappear so as week 9 appeared on the horizon I felt the best I have done in training so far. Odd then that it all went wrong after that!

Week 9 started with a slow 8 miler home from work. I have to plan my week carefully to squeeze runs in. I often work Monday and Thursday evening as well as all day Monday to Friday so I usually use Tuesday and Wednesday for my midweek runs. Tuesday afternoon I sat at work and pondered how to approach Wednesday’s 10-mile tempo run. “I know” I thought, “I’ll carry everything I need to take home in my backpack tonight so I won’t need to carry anything on my faster run tomorrow”. So I loaded up the bag and slung it on my back. It felt ok but probably weighed around 5kg, nothing that unusual for me to carry. I ran with fellow Physio and guest blogger Andy “Coomba” Coombs and enjoyed a good natter on the way round.

Fairly early on though I felt the smallest of niggles in the back of my right hip. Nothing serious, just an ache. I completed the 8 miles comfortably and thought nothing of it. The next day it was still there, a little dullness in the background – nothing compared to previous issues I’ve happily run through. So Wednesday night I headed out for the tempo, 10 miles in total, 1 each for warm-up and cool down and 8 miles at sub 7mins per mile in the middle.

The run itself went well, the hip niggled a little but I did the 8 miles in 55:44. I didn’t realise anything was wrong until I finished the run about half a mile from home and started to walk the final stretch. I say “walk” it was more of a shuffle! The back of the hip hurt with every step. A sharp pain spread from the base of my buttock down into the back of the thigh. I went from RunningPhysio to LimpingPhysio (was even tempted to change the name of the site!).

As the evening progressed the pain got worse. Just lifting the leg to take my shoe off was sore. I hobbled around our bungalow wondering what I’d done and hoping it would settle quickly. Thursday morning it was a little better and so I started to puzzle out what was wrong with the help of Fabiano, a top Physio with a serious running shoe problem! You might have wondered how physios form a diagnosis so here goes…

Location of pain – deep ache in the base of buttock and posterior right thigh. Potential structures at fault, origin of hamstring muscles, gluteus maximus, piriformis dysfunction, hip joint, SIJ, bursa, sciatic nerve, referral from the lumbar spine, or bony stress response. (Note the left hip that niggled before is totally fine!)

Mechanism of injury – running with backpack or speed work – could result in problems in any of the tissues above. Fairly rapid onset after a lower mileage week might make bony response less likely, although extra weight from backpack could have increased bone loading. Lack of trauma makes a muscle tear less likely but tendinopathy or bursitis possible.

Examination findings – full pain-free passive movement in hip and lumbar spine (suggests both unlikely sources of symptoms). Pain on initiating hip flexion actively and slightly with resisted hip flexion although not consistently when re-tested. Negative slump and straight leg raise (suggest sciatic nerve unlikely). Hamstring and glute max tested isometrically at points through range – full power no pain, hamstring origin palpated with and without muscle contraction, no pain (hamstring/ glutes less likely). Palpation around ischial tuberosity and bursa – no pain. Piriformis palpation and stretch – no pain…

So, somewhat strangely, most tests were negative even though at times it hurt to walk! Physios reading this might be thinking “you should check x,y and z” and you’d be right there is more we would have assessed but time was limited. If you have any suggestions I’d certainly appreciate them in the comments section.

It is an odd presentation, the pain is in the back of the leg yet the most aggravating movement is hip flexion. It’s fine at end of range but initiating the movement hurts. If I repeat the movement it gets easier. I think perhaps the most likely source of symptoms is a bursa – a fat pad that sits between muscles and bones. Some of the bursae are quite deep and difficult to palpate. The painful arc of movement early in range could be where there is pressure on the bursa. Bony stress response is certainly possible but usually results in anterior thigh pain and I’d expect pain with impact rather than initiating movement (although walking can hurt I can hop and jog on the spot pain-free). Reactive hamstring tendinopathy is also possible although tests were negative.

What I can be reasonably confident of is that there is probably inflammation somewhere! My pain is fairly typical of an ‘inflammatory pattern’ – I’m stiff and more sore first thing in the morning and have a residual ache most of the time. Other issues can present in a similar way though and tendinopathy isn’t thought to involve inflammation but could result in similar symptoms.

One frustrating part of this injury is that it’s hard to know how to reduce symptoms where their source really isn’t clear. My first port of call was rest. If walking is painful it’s usually best not to run and even a short jog across the road hurt. I did some gentle stretching but couldn’t find a stretch that targeted the area. I’m taking anti-inflams but I’m not sure if they’re helping. Sometimes all you can really do is wait. Sometimes that’s all you need to do, the healing process does pretty well without us interfering!

Thursday was sore but Friday and Saturday felt a bit better although morning remained pretty tender. The problem is though I really wanted to run Sunday!…

A few months ago I chatted to @bryanwe about a few of us getting together for a 20 miler along the South Downs Way from mine to Eastbourne and today was the date we chose. I’ve been really looking forward to it. Nothing beats a trial run with nice people and stunning surroundings. I decided Saturday night, when the hip felt a little better, that I’d run the first 2 miles to take them onto the South Downs Way then walk home. But come Sunday morning a touch of runner’s madness crept in!

As the lads arrived in their running gear I found myself changing my mind. We were chatting excitedly about the route and temptation got the better of my judgement. Off we went and I set out just hoping to see how it would go, maybe I could do the 20 miles? We were planning a mixture of running and walking and a comfortable pace of 12-13 minutes per mile, it didn’t seem impossible that I might plod round ok.

As we broke into a jog it hurt straight away, my heart sank. As we continued through it settled to a manageable niggle and I thought maybe, just maybe…? The first 3 miles were ok but after mile 4 it got progressively worse. It wasn’t severe but it was clear continuing wasn’t the most sensible option. I stretched and rested at mile 5 but as soon as we set off again the pain kicked in. I reached the point where I had to make a decision – head-on and do all 20 miles or come off the route and head into Newhaven for a bus home…sadly I chose the latter and plodded a couple of miles down a bridle path towards the coast. I stood, frozen and disappointed, at the bus stop, desperate to be warm inside somewhere but knowing it was the right decision.

On a positive note though it was great to meet fellow runners @GrahamCarterGC @DanPark81 and @maximisemylife and good to catch up with @bryanwe. They’re all nice guys and have websites of their own that are worth checking out – Dan has http://dan-fattofit.blogspot.com and Max (who’s actually called Kevin!) has http://www.maximisepotential.co.uk . I’m really pleased they finished the 20 miles and enjoyed a bracing runout on the Downs.

So what’s next for LimpingPhysio? Well, my pain doesn’t appear to have reacted too badly to the run. It’s no more sore tonight than it was last night which is positive, although tomorrow morning might be another matter! The only solution really is rest. I wouldn’t have ran this weekend had we not planned something. I’ll rest for this week or at least until it’s pain-free to run. I need this to resolve for The Grizzly in 2 weeks and to be fine for the marathon in April. It’s better to arrive at the start line slightly undertrained and unfit than overtrained and injured…

…I’ll let you know how I get on….