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.

11 Days To Boston: SI Joint Injury Update

I'm back again with an update, with a little more clarity than I had in my previous update.  I'll first provide a brief overview of the situation, then a detailed timeline (more for my own sake to remember how this progressed) and then I will do a little rant about of navigating the healthcare system. Feel free to skim, as this is admittedly a boring post. 

What I've learned since my last blog post:

• MRI showed healthy discs. I have minor bulging, but nothing that would cause this type of pain
  
• The root of the problem is very likely my SI joint 
• That said, I do have some tendinitis around the left hip and a tight Piriformis, which are likely compensatory issues from bracing the SI Joint pain. It's one big chain reaction.

Progress since last blog post:

• Walking is now pain-free 75% of the time, and during the other 25% it's slightly noticeable
• I was prescribed a 6-day course of MethylPREDNISolone, and I have no idea if the improvement is from that or from my time off running. I finished it today.
• I took 9 complete rest days from running, but I did do PT exercises and foam rolling
• I didn't try to cross train because certain movements aggravate the area that aren't running, like leaning forward. Healing was my top priority; not maintaining fitness.
• I received a cortisone injection into the SI joint today

Timeline
After seeing my doctor on Tuesday, March 29, I scheduled an MRI for the following Tuesday (which then I was able to bump up a day to Monday April 4). I wanted to rule out a bulging disc. 

March 30-April 3
I had zero change, zero pain relief Wednesday-Saturday, which was discouraging as I had stopped running entirely. My doctor prescribed a prescription for 1000mg a day of Naproxen, but that didn't help at all.

On Friday, I decided to get a second opinion from another doctor who ideally would be able to give me a cortisone shot, as I wasn't getting any relief with rest or with Naproxen or with PT/dry needling. This doctor was not at all helpful, but he did tell me to stop taking the Naproxen and instead start a 6-day round of MethylPREDNISolone. Those are steroids, which I started on Saturday, April 3 and finished today.

During this time I refrained from running and did minimal walking. But I did some light PT exercises for the hips and glutes, along with stretching and foam rolling. I also used my RapidReboot hip attachment for compression therapy. I didn't want to go too crazy with the PT exercises because I hadn't been prescribed any by my PT and I wasn't sure it was an SI Joint issue. I just did some common sense stretching and strengthening that didn't cause pain.

April 4-6
Monday was the first day I noticed some relief. Finally it wasn't painful with each step, so I figured the rest + steroids were working. Monday was also the day of my MRI. I actually somewhat enjoy having MRIs. It requires you to be alone with your thoughts; no distractions. A great mental toughness practice.

On Tuesday, April 5, after taking nine consecutive rest days, I decided to go for a test run. Pain with walking was almost entirely gone by this point. I ran with an SI Joint belt, which had been recommended to me by a few people on Instagram as well as a doctor friend. I don't think the SI Joint Belt helped, but I do like the support it provides while doing my daily activities. On Tuesday's run, I did a run/walk series, with the run portions getting progressively longer (2 mins, 3 mins, 5 mins, 7 mins) to see how things were feeling. Pain around the SI Joint kicked in about 15 minutes into the run. And then it quickly spread to the glute and hip and I ended up stopping at 22 minutes. This was extremely discouraging.

After the run/walk I foam rolled, stretched, used a massage gun, and took an epsom salt bath and things calmed down and were back to normal. 

I got the MRI report which I didn't quite understand, but my doctor friend told me it was all clear and that the pain was not disc-related. I have some slightly bulging discs, but they aren't causing me problems. 

My run the following day, April 6. was SO MUCH better! I ran for 4.4 miles, including a few short walk breaks. No SI Joint pain, but my hip did tighten up on me a few times, and I had to stop and stretch. This could be because I did not wear the SI Joint belt, and my PT told me later that day that I probably didn't need one because my pelvis didn't need additional stability. During our session he did an adjustment to help the hip, and he also performed dry needling on my back, glute, and hip. It was painful.

Later that evening, I had a virtual visit with my favorite medical provider, a sports chiropractor who recently moved across the country. He was my go-to for ten years and I trust his opinion entirely. I probably should have done this virtual visit two weeks ago, but I was skeptical that virtual would help much. In hindsight, I think he would have provided the clarity I needed sooner rather than a lot of the ambiguous answers I had been getting from other providers. 

This sports chiropractor has helped me overcome everything that has popped up over the years. Talking to him was very reassuring. I was on the fence about getting a cortisone injection and he was in favor of it. He told me what to expect, gave me some exercises and advised on how to proceed. 

Today, April 7, I ran 6.6 miles 100% pain free thanks to the PT session the day before. No hip tightening, no SI Joint pain. I ran it as a progression run because I had a ton of energy and threw in some strides. It felt amazing to be back out there again. I still decided to get the cortisone injection because I didn't want the pain to return, and today would be my last chance before my doctor left town. I learned that there are very few risks with cortisone in the SI joint, and the potential reward was high. 

I've had two cortisone injections in the past, but they were both somewhere in the 2007-2008 timeframe and not for my SI Joint. One was the ankle and I think the other was the knee, but it might have been the hip.

My plan is to take a rest day tomorrow to recover from the injection, do a short/easy run on Saturday and then attempt a longish run on Sunday. I'll have to play it by ear and see how everything feels, but that's the plan for right now. My doctor actually cleared me to run tomorrow but in general I feel like she allows me to run when I really shouldn't! 

Venting Frustrations
I think I would be much better off if I had a cortisone shot last week; but my doctor didn't have any availability on the schedule until today. I tried to get one at my initial appointment on March 29, but she said that she didn't have time during that appointment. I wish I would have pushed harder to get the shot right then and there instead of waiting 9 more days. Then I wouldn't have had to mess with the medications or the MRI. SI Joint injections are used for diagnostic purposes because if the pain goes away, then it was definitely SI Joint.

Instead, it was a roller coaster of trying different medications, scheduling an MRI and trying to get insurance to approve it (they did not), and not really knowing what the issue was or if I was going to be able to finish Boston. And it took a full week since my initial appointment to get real pain relief. 

I've spent so much time on the phone trying to schedule PT sessions, trying to get an earlier cortisone shot (without success), working through the MRI scheduling and insurance, trying two different prescription drugs. Basically feeling helpless, frustrated and uncertain!

It's much easier when you know what your injury is, how long it will take to recover, and clear instructions on how to proceed. (Like a stress fracture, for example). It's also easier when it doesn't pop up three weeks before the Boston Marathon. So while I handled Covid pretty well, and while I handled my groin injury pretty well, I really struggled with the uncertainty on this one. It was difficult to stay positive.

BUT, I think I am finally coming through to the other side and I'm done with the worst of it. I have the cortisone shot, I have two PT sessions set up for next week, I know I'm not dealing with a disc issue, I have guidance on how much to run and what PT exercises to do, I'm no longer taking medications, and I had a 6-mile pain-free run this morning! I had none of this on Monday of this week.

My primary goal is to get to the start line feeling good so I will prioritize that over trying to salvage my fitness. At Boston, my main goal is to finish the race and ideally be able to walk when I am done (or at the very least, to be able to walk later that day!)  I've already been to the Boston medical tent once and I have no desire to return. I also want a good finish line photo. I haven't been happy with my finish line photos from my previous Bostons!

If you read all of this. . . you're a real trooper!