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.