Broken femur - anyone with experience?

[Ogresse]

A little graphic here...don't read if you're squeamish! Also, I apologize for the length. I'm just really hoping one of you lovely ladies has had a similar experience (not that I'd wish this injury on anyone, of course!) and can offer some words of wisdom.

I bumped a wheel and fell over onto pavement at slow speed at a feed zone last August and squashed my left trochanter (dumb, dumb, dumb!). It cracked into a bunch of little pieces and - somehow(?) - my femur also displaced inwards and well up into my pelvis. Needless to say I was doing Lamaze breathing ex. there on the pavement while waiting (45 minutes!!) for the ambulance (which arrived without any morphine on board), imagining myself on a Carribbean island, etc. OUCH. The surgeon tells me that I was one of his top 10 worst fractures for 2006 (yippee).

The "short" story is that after surgery to implant a compression bolt, plate, and 5 screws through my femur I was on crutches and then a cane for nearly 5 months. When I was finally able to walk on my own I quickly discovered that my broken leg was now about an inch shorter, leading to pelvic tilt and back pain. The new leg length discrepeancy has been confirmed by x-ray. I now wear a lift in my left shoe and have a pair of expensive orthotics that I use for long walks to ensure that I'm 'even'. They work great and keep the back from getting sore. I don't wear orthotics when I ride...more on that coming up.

From week 6 post-op I rode indoors on my trainer for rehab, and also did dozens of PT exercises. I'm reasonably well recovered, though I can't run comfortably (and who likes to run, anyway?!). My endurance is great and my HR zones all bumped up 5-6 points this year with increased fitness. So that part is good. Sometimes there's some spasming in my inner thigh - a lot of things about this injury just feel weird and I can't begin to figure out what the problem is.

From March - present I've ridden outdoors 150+ very hilly miles per week, on average. Despite stretching and PT, my IT band snaps loudly over the bolt (I know, ew) when I rotate my leg but is not painful. On PT's advice I visited the surgeon's physician's asst. last week about the popping (x-ray shows that the compression screw has been backing out! Frankenscrew!) to see whether the surgeon would recommend bolt removal. The surgeon was not crazy about that idea but we didn't have long to talk about it. He was more interested in my x-ray, which showed, for the first time, a fairly rapid onset of arthritis at the ball and socket. My last x-ray was in June and there was nothing arthritic there (i.e. the culprit is most likely the biking). He scheduled me for a CT scan but the tech there felt I should go to the scanner in another town that takes many more images per millimeter. We need to inspect the bone and tissue in the arthritic area really carefully and see what's up.

I use Speedplay cleats and had HAD knee problems in my left leg that are now gone!! You know that surgery they do if you have a tight IT band, where they slit the ITB near the knee so it tracks correctly? That's effectively what the joint repair surgery did for me so at least the knee tracking problem is no longer an issue! I still use the Speedplays - love them - but my left one is stacked an inch high (with the help of an expert cleat placement/bike fitter). The other day the whole thing disintegrated while riding - the screws just weren't long enough to keep all the shims and extra plates in place. Now my cleat specialist friend recommends going to a shorter crank for my injured leg and leaving the good leg on the original length crank. This way we can use fewer shims. I'm 5'2.5" with 28.5" inseam...they SAY (and this is a whole nother topic) that I should be on 165s rather than 170s, anyway. I've just bought a 165mm compact and we'll do the "bike surgery" in the near future.

So - whew - a lot to this story, I know. Has anyone ever gone through anything at all like this? any part of it? I'd really, really appreciate hearing from you if you have. It's been quite a long road to get back and it looks like I'm still on that road, so to speak.

Thanks so much for reading....
O.

[LBTC]

O, first, ouch, ouch, and way to recover

I have not experienced this, and can only say, it seems like you're following all the right ideas for recovery, regaining fitness, etc. That's a lot of miles you're doing, girl!

I can comment on the 165 cranks. I am 5' 1.5" with a 28.25" inseam. I have 165 cranks on my mountain bike, and love them. I wouldn't go longer if I could help it (the new carbon road bike I'm picking up tomorrow will have 165's too.) DH has read a bit of Andy Pruitt's info (the ultimate word in bike fit - I would *LOVE* to go to Boulder, CO and have the real thing done all the way). Long story short, Andy says to shim the cleats, do not use different sized cranks. I'm assuming there is a lot more to it than just changing the reach for one leg or the other, since the shorter cranks affect acceleration, etc.

By all means read up on it, but it seems like you're better off to get longer screws.

Good luck with your scans and the next phase of your recovery! Sending you loads of healing and helpful butterflies,
and hugs,
~T~

[Eden]

oh - like LBTC said ouch! I'm also a 28.5ish inseam currently with 165's and my fitter figures I could even go less than that if they were readily available.... (there are smaller ones - my kids cross bike has 150 somethings, though the quality is not tip top, and there are some specialty places that better ones can be found)
There is a person on this board who has two differently sized cranks. (I think it might be Triskeliongirl??? - you could try a search and see if you can turn up her posts about it, but that one would be tough to find I bet) Hopefully she will see this and give some input.
I've never had any major injuries, but I still have a pile of cleat shims in my left shoe - nothing like an inch, I would suspect, probably more like somewhere between 1/8 and 1/4 inch of difference in all. I've also got an extra insole in my left shoe give it a bit of extra height too, so that's something maybe your fitter could think about doing in place of a shim or two.

[mimitabby]

Yes, I'll send her an email and she'll probably post her. Triskelion.

[DebW]

I have a friend who broke his femur skiing last winter. Spiral fracture of the lower femur, repaired with a rod inside the bone (took 2 surgeries to get it done right) and hip/femoral neck fracture. He's been plagued with a number of screws loosening/backing out. Had the ones in his knee removed, but the doc refuses to removed the screws in his hip until at least a year post-op. He's got the same sort of tendons snapping over bolt head thing. He's been riding a bike on a trainer, says that's better than walking because the hip angle keeps the tendons off the bolt heads.

I've seen Triskeliongirl's crankset. It's custom made. Even the pedal is custom in order to rotate properly with the crank arm. I'm sure she'll give you the details if you ask.

[Eden]

Long story short, Andy says to shim the cleats, do not use different sized cranks. I'm assuming there is a lot more to it than just changing the reach for one leg or the other, since the shorter cranks affect acceleration, etc.

I wonder if *where* you end up with the discrepency wouldn't make a difference to how you would want to solve it. It would seem like cleat shims basically add length to your lower leg, so if your length difference originates in the upper leg, while shimming would make it possible for the shorter leg to reach the pedal when the longer leg is at an optimal saddle height, you would still have an imbalance. If you had a crank set designed to accomodate the length discrepency it might be better since then you are working with the hip to knee length rather than the knee to foot one. For most of us, the difference in our legs isn't enough to worry about something as involved as working out how to put two different cranks on the bike and still have it work properly, but it sounds like Ogresse not only now has a pretty large difference, she also races, so she needs everything to be as optimal as possible.

Only a little related - oddly enough my shorter leg (and I don't know if its an actual length discrepency or just a functional one - maybe I should try to measure some day) is the stronger one, and also my dominant leg? Go figure

[mimitabby]

you can pm Triskelion but this is what she told me in an email:

Please let here know she can PM me after Nov. 20, but that in the meantime she should know that I solved the problem with a custom crank set featuring a dropped pedal I got from Tom Slocum at High Sierra Cycling (mine is 3 cm). She can google him and phone him to discuss. Lennar Zinn's latest book also has good advice on this problem.

[Ogresse]

thanks for the butterflies, T. It was a relief to get the fitness back (though it took some time!). I really don't deserve any extra credit as I had no choice but to be on my bike for rehab - walking was out of the question - but it was so ironic to ride everywhere and then need my cane to walk the bike to the car! I have a long way to go before my legs have equal strength again.

I'm familiar with Andy's book and his approach. Basically I'm not sold (yet) on either approach but with regard to the arthritis, I wonder whether a shorter crank would mean less stress on the ball? My cleat-fitter friend thinks Andy's work is a sensory/proprioceptive approach, where shimming (and also moving shorter leg's cleat back and longer leg's cleat forward, I believe) should make you 'feel' even so you ride more comfortably (a bit oversimplified but that's the gist). Having ridden this way for my first year back I'm really curious to try another approach and see how that feels and, most importantly, whether it will slow down the arthritis. That part is a big bummer.

Eden, does your bike shoe fit comfortably with the insert? My orthotics don't work with all my non-bike shoes - not enough room in there. The shoes with stretchy laces (a la Keen) do well. I have similar thoughts about upper to lower leg length difference. With the big cleat stack (and the 170s) my left knee ends up pretty high on the top of the stroke and not as far forward as the right knee, and I think there's more dead space in the stroke than in the right. So it will be interesting to see if the different crank lengths do help or at least what they feel like. And - a thought - maybe it's not that your short leg is "too" short...maybe your longer leg is "too" long?! Maybe that short leg's length just works better for all the levers and pistons at work. My left (shorter) leg pedals very straight whereas my normal leg needs canting wedges to keep it from tipping in toward the top tube.

Deb, your ITB snapping friend and I should get together and play some tunes . He sounds like he's much more uncomfortable than I am and certainly had a more complex fracture. Anything in the femoral neck brings danger of avascular necrosis which (like Floyd), if it occurs, means eventual hip replacement, and all that. I'm sure they're monitoring him closely.

Does anyone know how common it is for (uninjured) cylists to get arthritis in their hip joints? I always thought we were better off than impact sports people who primarily run or ski (other than getting bad marks for osteoporosis). In my case the femoral head is probably out of alignment so that it's rubbing in a way it didn't pre-accident.

Oh well, so much to think about. Thanks, everyone, for your thoughts. I'll be checking back!
O.

[Eden]

My shoes are standard Sidis - two velcro straps and a rachet. The insole isn't an orthotic - just your standard insole material cut to fit my shoe and give that leg a tad more height, so I don't have any problems with my foot not fitting anymore (come to think of it, most people including me have feet that are slightly different sizes and it definitely looks like my left is smaller - hah! I can measure my feet and yup - the left one is about 8.5 inches long at its longest, the right almost 9)

I just had her do my winter shoes (they are "touring" style shoes, with recessed cleats so they are somewhat harder to adjust). The shoe with the insole felt a bit weird and tight when I first put it back on, but after a few minutes with it on I didn't even notice the insole any more.

It's pretty well impossible for me to measure my own legs accurately, but roughly giving it a try I'd say my left leg is definitely somewhat shorter than my right or perhaps you are entirely correct, my right leg is longer than my left I do have one wedge in my right shoe to tip my knee in a little - there are 6 plus the insole to prop up my left!

This is all quite interesting - it makes me think of other things too. I've been doing step-ups as part of my winter training/core strength routine and I've noticed that I have a tendency to swing my my right leg out when I do it if I'm not paying attention - could very well be an unconscious compensation for that one being a little longer and hitting the ground sooner than I expect????

[Triskeliongirl]

No time for a lengthy response, but my LLD is 3 cm following a serious bicycle accident. You need to ring up Tom Slocum at High Sierra Cycling. While the custom 'systems' he builds are not cheap (he calls them systems not crank sets), it was the only way I could ride again without pain. My crank arms are 165mm (sized for my short leg), but then the crank arm on my longer leg side has a dropped pedal that rotates throughout the pedal stroke. The chain rings are also elliptical and off set, to balance the leverage and be gentler on my knees. His work isn't cheap, but its right on. I did have to fly to california for a personal fitting, but it was worth every penny.

[Wahine]

Clinically, I would say that early onset OAS is more frequently seen in weight bearing sports and occupations. But I have seen it in people at a relatively young age that do not participate in high impact sport. For eg, last year I saw a 56 yr old male post bilateral hip resurfacing surgery (this is a technique to deal with hip OAS that is less invasive than a total hip and has a very good success rate in the younger population). He was a professional kayaker, still runs a guiding and instruction company. He was also a cyclist, both road and mtn. So no high impact sports, no major trauma. No clue as to why he had such severe arthritis at such a relatively young age.

I did find this excerpt from an abstract on The American Journal of Sports Medicine:

Men with high exposure to sports of all kinds com bined (in hours) had a relative risk to develop osteoar throsis of the hip of 4.5 compared to those with low exposure. Track and field sports and racket sports seemed to be the most hazardous to the hip joint. Men who had been exposed to high physical loads both from their occupation and sports had a relative risk of 8.5 to develop osteoarthrosis of the hip compared to those with low physical load in both activities. Potential confounding factors, such as age, body mass index, and smoking, were considered.

Long-term exposure to sports among men seems to be a risk factor for developing severe osteoarthrosis of the hip; this is increased when combined with heavy load from occupation.


In your particular case I would say that any alignment changes will result in faster degeneration of the joint. To the extent that you can decrease the forces going through the joint, you will decrease the pain and slow progression. A shorter crank arm would help significantly with this as it decreases the amount of torque required to turn the crank. In addition to this, staying in a gear that allows you the highest possible efficient spin would also help.

[Ogresse]

Hi Eden,

I bet it would be useful to have a PT or someone in the know spot you as you do your step-ups to make sure your knees are aligned properly. I have no training in this area - just a ton of rehab experience! - so it's a layperson's $.02. But if you're already wedged and canted as much as you are in the bike that might be a good thing to do (and consider orthotics which correct for varus/valgus and all that). As part of my rehab I treated myself to a superdy-duper (as my 7-yr old says) pair of trail running shoes. I tried to find the most stabilizing shoes possible and found an (expensive!) pair of Salomons that have helped me do lateral lunges and stuff like that without feeling like I'm going to fall into the refrigerator. Of course, I could always do them some place other than the kitchen...

Trisk - thanks for that note. I'd already seen that High Sierra site and eyed the one-piece wedges with great interest. I'll see how it goes with this next approach (I bet I'll end up with 165 on the right and 160 on the left/shorter leg - if it's even possible to find a single left 160mm Shimano crank!) and will definitely keep Tom in mind for a consult.

Wahine - thanks, also, for that info. I'll see if I can find the article you quote from. I've also heard about a surgery (osteotomy?) where they cut a deeper or different angle in the socket so the ball can rotate correctly once again. Lots of invasive things to do. Hoping to find something non-invasive (like maybe some kind of torture stretching device that can reposition my leg out and up!). The "funniest" ( ) comment I've heard so far is that if I do have to have a hip replacement, they can also lengthen my leg...

Hope everyone can get in a ride today! It's 40s and very sunny out here in New England and my legs are itching for it. Thanks for your help.
O.

[Triskeliongirl]

You don't need the wedges. Those are for folks with smaller LLDs. For small LLDs, approaches like blocks, shims, and creative cleat placement can work, but for large ones like ours, I believe that a dropped pedal is the best approach.

http://www.hscycle.com/Pages/cantsandwedges.html

While I had him build me an entire crank set, it may be possible for him to build you a single crank arm with a dropped pedal for your long leg size that would be comptable with any crank set.

[LBTC]

I have to say, not that I am a bio-engineer, or anything, but I think the idea of the dropped pedal on equal length cranks makes very good sense. This guy sounds like he really knows what he's doing.

Good luck, Ogresse.

Hugs and butterflies,
~T~

[Ogresse]

Trisk - I just sent an inquiry to Tom at High Sierra, so thanks for that tip.

It would help if you could, when you have a chance, describe how the dropped pedal works on your longer leg. I'm having trouble visualizing it.

Many thanks!