TFL Trigger Points and Iliohypogastric Neuralgia

On Friday, October 13th, I noticed that my right hip was aching while climbing stairs. Ever since then, my hip has been the bane of my existence! 

All-brick boardwalk in Miami Beach

I'm going to include the timeline of the injury mainly so I can remember it in the future and for anyone else who has a sudden hip issue arise. But it will be quite boring for anyone who isn't me or anyone not suffering from a hip injury. So feel free to skim through or breeze past it to the next section. (Even the title of this blog post is boring in order to be searchable by anyone else suffering!)

Friday, October 13:
In the morning, I ran 8 miles on the all-brick boardwalk in Miami Beach. I was in Miami getting ready to board a cruise in the afternoon. We had flown in Thursday night so we'd have a night to "chill" in Miami before heading out the the Caribbean. 

I met up with another Instagram runner, Stephanie (@stephpiruns), for an 8-mile run. Originally I had put 18 miles on the schedule as my last long run before MCM. But then I decided to back that down to 14-16 given the heat. And then when the actual forecast came out for it to be unseasonably warm and humid even for Miami (dew point of 82) I backed it down even further to just 8 miles. 

The run felt great from a hip perspective, although I was absolutely drenched by the time we were finished. 

A few hours later, we boarded the cruise ship and then ascended a few flights of stairs to our room. It was at that point I noticed a slight ache in my hip. Something that I had not felt at all during the morning run or at any point in my training. When we got to the room, I moved my hips around and felt a deep ache when I moved my hips to the right. Weird!

Saturday, October 14
The next day, I foam rolled and did some gentle stretching before starting my treadmill run. I only made it
about two miles when I realized this might not be a good idea given the state of my hip. I felt it with every step. And even though it was only a 1.5-2 on the pain scale, it was one of those "I have nothing to gain by doing this but a lot to lose" moments with the marathon just two weeks away.

October 15-October 18
The cruise was a nice distraction from the hip. I was able to keep a positive mindset and enjoy the cruise with minimal hip obsession. I was comforted by the fact that I didn't "do anything" to injure my hip during that 8-mile boardwalk run, unless the brick surface really irritated something. 

In the mornings, I would do foam rolling and gentle stretching and a lot of Googling to figure out the source of the pain. Initially I thought it was an IT band issue, but towards the end of the cruise I had settled on TFL strain. I did not run on Sunday. I did 2-mile runs on Monday and Tuesday, both of which confirmed the pain was still there. On Wednesday I rested it again and that was the day we disembarked and flew back home.

What did this feel like at this point?
For anyone experiencing a similar pain, it felt like an extreme tightness and deep soreness all around the Iliac crest (pelvis bone that juts out). Both in front of the bone and behind it. The way I felt this pain was by putting all my weight on my right foot and cocking my hip out to the side/back. Otherwise, I had no hint of any issues at all. I had zero pain at rest. Zero pain walking. Mild pain while running. And a deep pain with that one motion. 

Thursday, October 19
I was miraculously able to see both my doctor and my physical therapist on my first full day back home. Usually my doctor has a 2-3 month wait, but he recently switched practices so his patients probably don't know how to find him! He's an amazing doctor and has a reputation for being one of the best in the area for sports medicine. 

He diagnosed me with "TFL Trigger Points" which are spasms at the muscle fiber level. He treated it by performing wet needling with an ultrasound, showing me where he was releasing the muscle. He also injected cortisone to near the surrounding nerves. He told me I should be 100% by the following Monday and if not, I should go back to see him again.

Saturday, October 21
This day was when the freakout finally happened! I had been calm, patient and positive up until Saturday. But when there was seemingly ZERO improvement on a 2-mile test run, I found myself down in the dumps. I threw myself a huge pity party. The sulking lasted all day. The doctor thought I would feel much better by Saturday and yet nothing had changed. Thus, I was discouraged. Defeated! DEFLATED!

I did not run on Sunday but tried again on Monday, because Monday was supposed to be the 100% day. The first two miles were mostly pain free but after that, there was no denying that the pain was still there. 

Tuesday, October 24
I returned to the doctor and he said that while there definitely were trigger points when he had seen me the previous week, he thought there could also be a nerve issue. He identified the nerve as the Iliohypogastric nerve, which runs right over the iliac crest. It was time for more injections! This time the goal was to get cortisone around that specific nerve at the specific spot where it was most painful. The nerve he targeted last time was a different one. Using an ultrasound, he found the nerve, I told him where the pain was most intense, and he injected it. 

The doctor was confident in his diagnosis and treatment and confirmed that the bone and tendons were in

The red arrow is where the nerve hurts!

good shape. We just needed time for the cortisone to work around the nerve. 

Per his direction, I rested on Wednesday and Thursday, making sure to ice the hip on a frequent basis.

Friday, October 27
With the doctor's green light to resume running, I tried running again today. And it was not 100% pain free, but the pain had changed quite a bit. Previously while running, there was a large area of soreness and tightness all around that TFL. Now, the area of pain was a quarter-sized area, concentrated right over the bone of the iliac crest. 

Imagine you bang your hip on something, it bruises, and whenever you touch it, it feels tender. That's what running felt like. Every step I took felt like I had a bruise that was being poked-- right over the bone. 

The good news is: 

• The area of pain is smaller
• The area of pain is quite superficial (close to the skin)
• The pain didn't seem to worsen over the course of 4 miles 
• The pain was never more than 1.5 out of 10 on the pain scale
• I had no pain after the run, and I walked a full pain-free mile afterwards

The bad news is:

• I am not 100% pain free
• I am not sure what would happen if I did a long run or speed work
• Definitely no Marine Corps Marathon (although would I have run it anyway in the 70-degree heat?)

What next?
In a situation like this, the only thing I can do is take it one day at a time. The doctor did a thorough exam and an x-ray and was confident in his diagnosis, so I have to believe it's just a nerve that needs to calm down and the cortisone will start to kick in over the next few days. 

In terms of running, my rule of thumb is to never let it go above a 2 on the pain scale. If it starts to do that, I will stop immediately and walk home or call Greg. 

I am eying Richmond and Philadelphia as possible backups. If I don't end up doing either of those, then I am not sure I want to keep marathon training this season. I'll just have to see how I feel.

I ended my pity party with acceptance, so now that I have reached that stage I am mentally handling things pretty well. I have accepted that a fall marathon might not be in the cards. It's frustrating and disappointing, but it's all part of running.

Boston Marathon Controversies Galore!

Last week the B.A.A. announced that 11,000 qualifiers would not be admitted into the Boston Marathon. The qualifier field was limited to just over 22,000 runners and the race had 33,058 applicants. Anyone who did not run at least 5 minutes and 29 seconds faster than their qualifying standard was denied entry.  A week later, Tracksmith announced that their BQ singlet would only be available to those runners who had been accepted (22,019 runners), not to all qualifiers. 

Everything in the above paragraph caused quite a bit of controversy. I'll provide an overview of the controversies along with my take on each.

Are the women's qualifying standards "softer" than the men's? I've heard this claim quite frequently: It's easier for women to gain entry into the Boston Marathon than it is for men. Support for this argument is that if you compare elite men to elite women, the top men are less than 20 minutes faster than the women. Instead of the women's qualifying standards being 30 minutes slower than the men's times, they should only be 20 minutes slower. 

There's no data to support the claim of the women's times being easier. Most notably, the Boston Marathon accepted 12,535 male qualifiers and 9,440 female qualifiers. If the B.A.A. made it harder for women to get in, there would be even fewer women in the race. 

Further, as the times get slower, the percentage of time difference shrinks. Here's an example. Let's say you have an elite male running a time of 2:05 and an elite female running a time of 2:25. That's a 20-minute difference, and 20 minutes is 16% of 2:05. So the elite female ran 16% slower than the male. Now let's look at an amateur male running a time of 3:10 vs. a woman running 20 minutes slower at 3:30. In this case, the woman has run only 10.5% slower than the man. The gap between a 2:05 and a 2:25 is therefore a larger gap than 3:10 and 3:30. If the percentage difference of 16 were to be maintained, the equivalent amateur woman's time would be. . . 30 minutes slower at 3:40.

So you cannot look at the elite field and say, "the men's and women's times are so much closer together than the 30-minute difference in BQ standards." It's true in terms of actual minutes on the clock. But not in terms of percentage difference. 

All that being said, it does "seem like" the women's times are easier. On a gut instinct level it just seems like it's harder for a man to run a 3:10 than it is for a woman to run a 3:40. And you could potentially say that there would be far more women qualifying for Boston if women trained as hard as men did. And that women, on average, do not train as hard because a certain percentage of them are pregnant or postpartum. But once again, all of this is based on gut feeling and I haven't seen any data to support this claim. 

To sum up, it may "feel like" the women's times are softer, but the data indicates that it is not easier for women to qualify for Boston than it is for men. And I believe the goal of the B.A.A. with their standards is to have a relatively equal number of runners from each group and not to make standards that are equally physically challenging. You'd almost never have an elite male beat the qualifying standard by over an hour, but there are older women who have beat their standards by over an hour.

Is the non-binary category fair?
44 non binary athletes were accepted into the Boston Marathon. I've heard all sorts of perspectives on this one. Before I get into it, the non-binary qualifying standards are the same as the women's standards. The B.A.A. says they do not yet have enough data to determine what the actual standard should be yet, so for 2024 they are going with the women's standards. 

At one extreme you have people saying that the non-binary category makes it easy for men to cheat their way in under the women's standards. And so the race is soon going to be full of men pretending to be non-binary. On the other extreme you have people saying that Boston is still not inclusive enough. I've also heard the argument "why do people care about the non-binary category-- it doesn't affect them." 

My thoughts on this issue are that it all goes back to the B.A.A. and their goals. If everything was 100% "fair" (which would be impossible anyway) then you probably wouldn't have a situation in which a woman in her 60s can beat her BQ time by over an hour but a young elite male cannot. With this non-binary category, their goal is to show inclusivity. The goal isn't necessarily to be fair, and that's their prerogative; it's their race. 

Remember the vaccine mandates from 2022? The goal was not to Covid-proof the race; that would be impossible. (There was no requirements for volunteers, etc.) The goals were to comply with local town ordinances and make runners feel safe. Many runners, myself included, didn't think the mandates were fair. But the B.A.A. is not obligated to be fair. 

To qualify as non-binary you must have qualified in another race in the non-binary category. Will there be runners who take advantage of this? Potentially, but that's really going to an extreme length to cheat your way into the race. What about the non-binary runners who have male genetics who can qualify under the same standards as the women? Yes, those runners have an advantage. The mere act of identifying as non-binary has not changed their physical abilities. 

The problem that the B.A.A. is running into is that they are trying to be as inclusive as possible while also being exclusive. And it's not possible to do both. And it's definitely not possible to do both 100% fairly. Someone is always going to have an unfair advantage.

The notion that they are going to look at non-binary data seems fruitless because identifying as non-binary has nothing to do with one's physical abilities as a runner. I am not sure what they are expecting to find. And even if they did end up making the non-binary standards the same as the men's standards, they would receive backlash for not being inclusive.

Finally, I'll address this position: "The non-binary category doesn't impact you - just focus on your own BQ." For the sake of one's own mental health, it's always best to focus primarily on the things you can control. But if everyone did that all the time on every issue, society would likely collapse. Healthy debate is good for all communities, including the running community. You don't want to be fully entrenched in social media debates about non-binary athletes running a marathon, but you also don't want to be completely blind and isolated from what is happening in the world around you. 

This debate should not be centered around the non-binary athletes themselves, but the policies of the B.A.A.

Should extreme downhill races be allowed as Boston Qualifiers?
Extreme downhill races like those found in the "Revel" series are often blamed for the increase in the number of Boston qualifiers. Are these courses fair?

Having never run one of these courses I am not in a position to weigh in authoritatively. But this is my blog so I will share my non-authoritative thoughts. 

The only marathon I ever ran that had a net downhill greater than Boston was Sugarloaf in 2019. That was not one of my faster marathons, but I was also suffering from hypothermia at the end. CIM might also fall into that camp, but CIM is nothing like the Revel races, which have thousands of feet of elevation loss.

I've heard that extreme downhill races come with their own challenges like beating up the quads. Aerobically it might be a walk in the park, but you still need your legs to carry you to the finish line. All of that being said, the data shows that these courses are notably faster than courses with a net-even elevation. Does that mean they should be excluded as qualifying races?

If it were up to me I would institute a limit on the amount of elevation loss permitted. It might be fair to say the Boston Qualifying race cannot have a net elevation loss that is greater than the Boston Marathon's own elevation loss. Not to discount the achievement of runners who participate in Revel, but to level the playing field for one particular race, which is Boston.

The reality is that these races would have far fewer participants if they were not eligible for Boston. If Boston axed them it would potentially put these races out of business. Are they going to do that? Unlikely. Plus, these races are open to all runners. Anyone who wants the advantage of the downhill can run a Revel race. 

What in the world is up with Tracksmith?
Less than one week after the B.A.A. announced that over 11,000 qualifiers did not gain entry into the Boston Marathon, Trackmith added insult to injury by releasing a BQ singlet only available to confirmed entrants. They would not sell the "BQ" singlet to runners who actually did the thing that the singlet says! 

Now, if the singlet said "BQ - 5:29" then, okay. Or if it said "I was accepted into Boston 2024" then, okay.  But that's not what the singlet says. If it's a BQ singlet it should be available to all qualifiers. I applaud Tracksmith for celebrating the accomplishment of a BQ, but they undermined their own celebration by talking down to those qualifiers that were not accepted into the marathon.

The backlash on Tracksmith was intense because their post on social media was about much more than the singlet. It began with the quote "This isn't a jogging race," as if the 11,000 non-accepted BQers jogged their way to the finish line. The tone of the post was elitist in several ways and Tracksmith finally took the post down and issued an apology post the following day. 

This social media post raised the following question by many - is Tracksmith an inclusive brand? What exactly does it mean to be "inclusive" anyway? I'd argue that it's an ideal which is impossible to attain in reality. Featuring runners of diverse ethnic backgrounds does not automatically make you inclusive. Especially not when you charge $48 for a pair of underwear. 

Putting on my marketing hat, this is a huge gaffe. You do not post something that feels elitist to a large percentage of your customer base. Especially after these runners worked hard to qualify for Boston, only to be turned away less than one week prior! Issuing the apology was definitely the right thing to do, but it will not be 100% damage control for the brand.

Will I still buy Tracksmith? I have a love/hate relationship with the brand. So sure, I will still buy their stuff from time to time. Thankfully they apologized, but I was never 100% sold on their messaging to begin with. Something about the brand has always rubbed me the wrong way in terms of being borderline pretentious.

I have noticed a decline in their service over the past year. They used to ship their items out immediately and for my last order it took them 5 days to ship the order, plus additional time for it to be delivered. Their prices have increased but their processing speed has decreased. I much prefer rabbit to Tracksmith; rabbit is a feel-good, happy brand with fun colors and styles. California-based rabbit has much better options for summer running, but Boston-based Tracksmith has better options for colder months.

Final Thoughts
The common theme with my take on these controversies is that you cannot be "inclusive" and "exclusive" at the same time; that's a losing battle. The notion of 100% fairness is unrealistic, especially when "fair" isn't necessarily the goal. It seems like the B.A.A. is opting for equal representation across ages and genders instead of making things equally physically challenging across the board. Tracksmith will continue to face backlash. Feel free to disagree. These are, after all, controversies. All I ask is that you keep it respectful!