So you think you know everything there is to know about stress fractures after reading "No Reason to Stress," which discussed what a stress fracture is, why we develop them and how we can treat and even prevent them from catching up with us? Think again!

For this installment, I was lucky enough to catch up with one of triathlon’s most hardcore, talented and determined professional athletes, Hillary Biscay. First of all, to understand how fierce of a triathlete Biscay truly is, just take a look at her race résumé as posted on her website, HillaryBiscay.com. Staggering, I know, and to think that the sport of triathlon was a mere hobby after 15 years of competitive swimming is even more impressive. Not to mention she is a Ph.D. candidate in African American Literature. But Biscay has put her academics on hold to live the dream of being a professional athlete, getting paid to race and do what she loves, Ironman.

But it wasn’t too long ago that Biscay’s promising future suddenly didn’t look so rosy. In 2004, Biscay suffered what could have been a career-ending stress fracture in her hip at Ironman New Zealand. After undergoing extensive surgery that had doctors putting three titanium screws in her femur to encourage healing and enduring two months of intense of physical therapy while not being able to walk on her own, the always-optimistic Biscay made a full recovery to resume her pursuit of Ironman titles.

While getting ready for January’s Challenge Wanaka triathlon in New Zealand getting ready for The Wanaka challenge (at which she finished second—a “fun training day,” according to Biscay), I got a chance to talk with the Tucson, Arizona, resident about her injury, how she dealt the hiatus from training and racing and how she stays focused when things get tough.

“Looking back, trying to finish that race was crazy, said Biscay, referring to that painful day at the 2004 Ironman New Zealand. It was at this race that Biscay was forced to take her first and only DNF—and with good reason.

She had suffered a stress fracture so severe that the femoral neck had cracked, leaving her at first dragging her leg behind her on the run in attempts to abide by her “no walking” rule and eventually being pulled off the course by the race doctor once the pain became so intense that she couldn’t even stand up. She remembers feeling, “a popping—like two bones were separating then coming back together while my leg swung forward,” explained Biscay.

An injury like Biscay’s poses a serious threat to athletes and non-athletes alike, since this region of the hip has a very intricate supply of blood vessels. Even a successful surgery can lead to a Avascular necrosis, a condition with which the blood vessels fail to adequately nourish the bone, thereby leading to bone necrosis or even death. This can be a nightmare, as running—let alone walking—may become all but impossible. Patients often opt for getting an artificial hip in hopes of regaining some level of activity.

Luckily for Biscay, none of these grave scenarios would befall her. She underwent extensive ORIF (open reduction internal fixation) surgery with three titanium screws being used to hold the femoral neck in place. The surgery was a success. She began physical therapy almost immediately but didn’t walk for two whole months. Keeping with her tough mental attitude, Biscay was back to racing Ironmans just eight months later!

Some obvious questions arise in regards to Biscay’s case, such as what caused her injury and what she has done to prevent an injury of such epic proportions from happening again. As for why the injury occurred, Biscay told me that, while her training regimen leading to the 2004 race was tough, it wasn’t anything that her body hadn’t been accustomed to from previous training. Nor did she up the ante too quickly in training volume or intensity. In addition, she had always been very in tune with her diet and caloric needs, so she feels this wasn’t to blame.

So what did cause such a misfortune? Biscay remembers having some misconceptions about her running style at the time, which very well could have played a hand. “I was perpetually trying to run like a pretty, proper runner while running high relatively high mileage,” she explained. “And given that I'm not naturally a runner, nor do I have that body type, this probably wasn't the best form for me.” She also feels that switching up her running shoes may have been a contributing factor.

As discussed in “No Reason to Stress,” improper running styles, wearing improper footwear or changing up one’s shoes can all prove to be stressful to the body and perpetuate the onset of such an injury. Any major change during training needs to be approached with caution, especially when the stakes are so high. In Biscay’s case, with her high physical demands, rigorous training schedule and need to be well recovered and ready to go for each workout, something like a change in her stride length or foot strike could have put her at risk.

Biscay has since worked on her running form under the tutelage of coach Brett Sutton, who had her shorten her stride, encouraging a more midfoot to forfefoot landing pattern, and increase the cadence of each foot contact. In time, she became more comfortable and her new running style became her biggest asset.

There was also a question of leg-length issues, as addressed by her therapist at the time. Determining whether there was a structural or functional discrepancy would help unveil whether or not a lower back, pelvic or sacroiliac joint contracture or tilt was throwing her out of alignment, thereby putting much stress on her injured side.

After a full evaluation of body structure and alignment, strength, flexibility and her individual biomechanics, Biscay began a more-advanced stretching routine and paid more attention to how she felt during her workouts. So far, this has all paid off, as her running has only gotten better and she hasn’t looked back since. With a full schedule of races this season and a sound understanding of her body and its mechanics, Biscay will surely continue to set PRs and course records alike!

When asked how she was able to stay focused during her downtime and not get discouraged by the tough uphill battle she faced, Hilary responded, “There is no bad event or even bad race. Keeping things in the right perspective can always help you learn something.” The perpetual optimist who has said, “If you race enough, disappointing results are inevitable,” has proven that even when things look bad, there is always something to be gained. Spoken like a true student of the sport. It is this attitude that has enabled Hillary Biscay to look adversity straight in the eye and only see the good at to ultimately stay at the top of her game. Her determination and love for the sport runs deep. And it shows.

Expect great things from her Biscay year, as that is all that she expects from herself, no matter the circumstance.

Dr. Dan

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Dr. Dan Geller is a member of the American College of Foot and Ankle Surgeons, runs a private practice in Manhattan and is an attending physician at the Department of Surgery and Orthopedics at St. Vincent's Midtown Hospital. He is the preferred doctor for the New York Road Runners Club and the Triathlon Association of New York City, as well as the doc of choice for members of the New York City Ballet.