Monday, July 28, 2014

Stress fractures: A guide for backpackers

I have been off the Pacific Crest Trail for the past 6 weeks healing from a stress fracture in my foot.  I still have a week left before I can slowly return to walking and to backpacking.

I didn't know anything about stress fractures before it happened to me, so I want to inform other hikers and backpackers about them.  It is important to be able to identify a stress fracture and distinguish it from an injury you can hike on so that you don’t cause more damage and you can heal faster. 

I've compiled the information that has helped me to understand the causes of stress fractures and the most helpful guidelines I've followed for physical and mental healing.  Some of it is from articles or websites (see references below), but most was advice given by my friends and the backpacking community and from my sports medicine doctor and physical therapist.
I got my stress fracture in the Sierra. Photo by Arizona.
Story of my stress fracture
The individual circumstances around a stress fracture and which bone is affected contribute to variability in the severity of the injury and duration of healing.  I felt the injury all of the sudden on Muir Pass in the Sierra at mile 840 of the PCT, postholing in snow.  I felt a stabbing pain at the top of my foot that didn’t go away even with a maximum dose of ibuprofen.  The pain only lessened when I was going uphill or when I rested.  While backpacking, I had to concentrate on every step to avoid the shooting pain that felt like a stake was being driven through my foot.  Because I changed my gait (i.e. hobbled) to avoid putting more pressure on the ball of my foot, I got several bad blisters.  I didn’t recognize this as a stress fracture and instead I kept backpacking for another 100 miles through the snow and rocks of the Sierra.  It wasn’t getting better on the trail so I got off the trail at Tuolumne Meadows (mile 940).  My injury wasn't diagnosed as a stress fracture of the metatarsus for another four weeks.

What are stress fractures?
Stress fractures are microcracks in the bone and are often considered overuse injuries.  Bones get broken down during activity and are constantly being rebuilt.  When there is too little rest they can’t rebuild fast enough and are weakened.   Fatigue contributes when the muscles get tired so do not lessen the shock on the bone due to repeated impacts. 

What causes stress fractures?
Stress fractures are caused by a variety of factors including increases in distance, weight, speed, or internal factors like inadequate nutrition or hormone irregularities.  I believe mine was due to a combination of factors acting together including the sudden increase in pack weight (bear canister, microspikes), altered stride due to walking in snow, increase in pace (due to wanting to get up the passes quickly before postholing conditions worsened), and my change in shoe size (up 1/2 size) at Kennedy Meadows (mile 700)  that led to my feet slipping around in my shoes.
Changing to a larger shoe size in Lone Pine/ Kennedy Meadows- big mistake!
Important things to know about stress fractures
-Diagnosis of stress fractures is tricky.  The tiny cracks of a stress fracture do not show up on x-rays right after they occur.  Only when they start healing can they be seen on an x-ray.  The first doctor I went to took an x-ray, didn’t see anything, and then didn’t diagnosis the stress fracture.  Then my insurance company spent 2 weeks delaying the MRI which could have shown it.  Finally I went to a doctor that deals with athletes and got a second opinion and diagnosis.

-Stress fractures are surprisingly common among runners and backpackers.  When I started asking around, I learned that some of my fellow backpackers have recovered from this type of injury.  Hearing their personal stories has been incredibly helpful in coping with the pain and frustration of being off trail.

-Rest is required to heal a stress fracture.  This is not an injury that you can hike through.  If you keep hiking you could break it completely or it could cause other injuries and delay healing for months or even years.  I had never heard of stress fracture and was in denial of the severity of the injury.  If I’d gotten off sooner, it would have healed faster and I’d likely already be back on the trail right now.
Healing in the redwoods and wearing the boot.
Physical healing 
There are several things you can do to promote the physical healing of the bone.  Obviously, follow the advice you get from your medical doctor.  These are the steps I've taken:

-I rested my foot.  It was extremely difficult to go from being on my feet for 12-14 hours a day to the level of rest required to heal the stress fracture.  On the trail, rest meant sitting for 15 minutes every few hours.  After the injury, rest involved staying off the foot 23-24 hours a day and wearing a “walking boot.”  The boot took pressure of the injury to speed up healing.  I avoided walking even in the boot as much as possible.

-Pain meant the stress fracture was getting irritated.  This prevents healing.  I DID NOT do any activity or intensity level that caused pain.  I struggled with this mentally since I always used to increase my activity until I felt pain and therefore had exercised enough.  I used to enjoy post-exercise soreness.  Now I am really careful not to do any activity that hurts.  And if I do overdo it, I take the next day off and avoid that activity.

-I followed my physical therapist's suggestions about other forms of activity to keep up my strength and cardio that avoided direct pressure on the foot.  I lifted weights, spent hours on a stationary recumbent bike, used an arm bike, and swam with my feet immobilized (using a pull buoy between my knees).  Keeping up my cardio and getting my daily endorphins was key to maintaining my sanity and hopefully will allow me to transition more easily back to the trail.
Sweating at the gym.
-Ice often.  I iced in the morning, mid-day, evening, before working out, after working out, and lots of times in between.

-Physical therapy may help treatment.  Be sure to find a hands-on PT who has experience working with athletes.  I had ultrasound and joint mobilizations.  It calmed me to talk to the PT about the healing process and to get encouragement from them that I was doing the steps I needed to take to heal.

-Consider stopping taking anti-inflammatories (ibuprofen) which may interfere with bone healing.  I followed the guidelines given by my PT.

-I ate really well and completely shifted my diet compared to what I’d been eating on the trail.  Veggies, fruits, dairy, lean meats, and a high variety of fresh foods really made me feel better.
High variety of food does NOT mean different flavors of ramen.
Mentally healing
Being off the trail and dealing with an injury that forced me to be sedentary have been the most difficult things I've faced on my journey.  It was agonizing to be away from the trail.  I wasn't mentally prepared for leaving my friends or the awesome life I'd found on the PCT.  I felt like a failure.  I had to mentally prepare for the possibility that I might not make it to Canada this year.  It took a lot of work to view the injury as an opportunity rather than a huge setback.  This is what I have done to avoid falling into depression and to mentally heal:

-I had to accept that I couldn't run back to the trail and needed to be off trail for a long time while I healed.  6-8 weeks seems like forever to a long-distance backpacker.  I needed to change my mindset to take a long-term view.

-Accept that nothing is going to feel as good as backpacking.  I missed being outdoors and being separated from the trail community.  I didn’t have a plan for where to go or what to do with myself.  To cope, I used the opportunity to find other things- I’d never swam for fun or thought that I might enjoy meditating among the redwoods.  I found joy in connecting with the trail community in other ways.  I also connected with people beyond the trail using the same openness and curiosity that made connections happen so easily on the trail.

-Realize that you are not alone.  Do not keep the injury or your frustration to yourself.  Sharing your story is a powerful part of healing and will keep you connected to the backpacking community.  A stress fracture (or any injury) does not make you weak.  How you cope and what you learn from the experience shows your strength.

-Learn to be patient.  Diffusing the pent up energy I had and being still was agonizingly difficult.  I wanted to throw the f**king boot down a cliff.  I had to confront the anger and hurt.  To heal, I needed to shift mentally from “how do I get back to trail quickly” to “how do I heal completely and avoid re-injury in the future.”  I had to make peace with stillness.

-Maintain a positive mental outlook.  I was constantly assessing what activities and mental practices made me feel stress and what gave me peace.  Meeting friends on the trail was uplifting.  But being further from the trail most of the time made it easier to stay still.  But I also thought about my foot and bones healing, and visualized myself back out on the trail. 
Visiting Renee/ Pathfinder at Barker Pass.  We hadn't seen each other since Wrightwood.
-Redefine your notions of success.  I was devastated when I mistakenly thought getting injured meant my hike was unsuccessful.  I had to repeat to myself that “the journey is the reward” and I had to expand my notions about what the journey meant.  It isn’t just about getting to Canada, or even just about hiking.  It is way bigger than that.  It is about life, both on trail and off trail, and it is about recognizing the many aspect of that make a journey.

When I first set out on the PCT, my first long-distance hike that I'd been dreaming about and preparing for years, I knew it would change me.  I never expected that I would get an injury that would take me off trail.  I never would have imagined how being off trail has allowed me to learn so many lessons.  In many ways, I believe that this injury has facilitated the self-growth that I was seeking when I set out on the PCT.  Many of the lessons are still too raw to write about, but I am continuing to heal, and am learning to enjoy and appreciate this part of my journey.

Resources

Description of Stress Fractures by the American Academy of Orthopedic Surgeons
Runner's Guide to Stress Fractures in Runner's Connect

Shona Stephenson’s inspiring story of about returning to ultrarunning after a stress fracture.
Jen's story of depression after her stress fracture and about returning to running too soon.
DocSpice's stress fracture in the Whites that hasn’t healed completely in 6 months.

New Nomads on post-trail depression
Post-Thru-Hike- What was your Re-entry Experience Like? in Backpacking Light
How to cope with 5 stages of Injury Grief- from Active
Recovering from Post-AT thru-hiker depression- from Appalachian Trials

Acknowledgements

Huge thanks to Anna Huthmaker, Jan M., JJ, Farwalker, and Amanda for talking to be about their stress fractures or other injuries, and helping me stay sane.  Some of the best advice for healing was from Stacy Boone of Step Outdoors- thank you!  I'm grateful to Steph and Trish, and to Still Waters, for our conversations about the mental aspects of healing.  My PCT friends have been incredibly encouraging with emails and texts- thank you Pathfinder, Rewind, SlowBro, and MeToo.  Finally, I am thankful for having an incredible hiking partner in Arizona- especially for keeping up my spirits those last 100 miles hiking with the stress fracture (I have never laughed so much!), for connecting me with Steph and a home in which to heal, and for taking time off the trail to be there with me.

25 comments:

  1. Wow. What great words, Joan. Clearly not the journey of your choice but I'm glad you've found every single good thing that there is to be found in this experience. And I guess it's safe to say it is still an adventure of sorts. The knowledge you have shared will surely benefit others in the future. All the Ramblers are thinking about you and wishing you the best.
    Don

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    1. Thanks, Don! I'm finally figuring out how to view this part of my "PCT experience" as an adventure. Definitely not what I'd anticipated, but is definitely a broader experience. Give my best to the Ramblers!

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  2. Excellent article! Makes me think about adding a tab to my blog with resource links for trail injuries and illnesses. The emotional healing is such a bigger piece of a long walk than the physical one. As one who's been sidelined a few time with injuries, I have much empathy. You are a wise woman and I look forward to some shared hikes and friendship.

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    1. A resource link for more types of injuries would be most valuable for the community. Definitely a topic that gets overlooked.

      Meeting you really did a lot for giving me hope. I still think it's so cool you have the same bump on your foot where the stress fracture healed. Delighted to have a *stress-fracture sister* and look forward to seeing you again!

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  3. Such a great post. I've mourned for your injury (though I know I've said scarcely little about it). I, too, suffered from what I believe was a stress fracture. It wasn't during my PCT hike, but afterward. I was dancing tons and running tons, and ended up with some pain in the ball of my foot. Under-insured and unable to really get medical care for the injury, I just decided to take it easy. That is so much easier to say than actually do. It probably took me a full year to come full circle on the injury (though it probably would have been faster had I actually rested and healed!). Anyhow, your story, research, and perspective are a valuable, valuable resource to me, even now. Thanks for the post!

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    1. Oh my goodness- you too with the stress fracture! Sorry to hear it took you a whole year to get better. It is so difficult to rest, especially for those of us who are so active. Glad you found this helpful!

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  4. I am reading this post on the way back to Atlanta with a very large ankle and dr appt waiting. Perfect timing. Thanks for all the research and putting
    your story out for others. :)

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    1. Dang, sorry to hear about the ankle. Your photos make it look like you had a good trip. Hope you get a good outcome at the doctor's!

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  5. Thanks Hemlock = seems you are learning a lot.

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  6. Hey,

    We met in Glacier NP early in July. I was hiking with my dad and a friend on the PNT and had a chrome dome. I stumbled on this post Sunday night while googling "thru hiking on a broken toe" because I broke my toe on Friday and was trying to decide what to do amongst many tears of disappointment. This post, though about stress fractures was just what I needed to read! Thank you for sharing this difficult moment in your journey, but also sharing positive ways to embrace the bends in the road.

    Much love,
    Julie "Rainbow Brite"

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    1. Oh wow great to hear from you! I totally remember meeting you. How was the rest of your hike?!?! Such a sweet section up there, and you were lucky to do it before all the fires.

      I'm so very sorry to hear about your broken toe. It is so heartbreaking to have an injury that takes a long time to heal. Especially terrible to have to get off the trail. Wishing you all the best.

      I didn't believe it at the time, but this injury really did change my life for the better.

      Hugs!

      Joan

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  7. Great article. :)

    I'm recovering from a stress fracture from my hike as well.
    I was wondering what type of cardio workout did you do during recovery time?
    I need some suggestions.

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    1. Sorry to hear of your stress fracture.

      Not being able to exercise like normal is horrible. I had to stay off my feet completely and not put any pressure on them, so I begged my PT for cardio exercises. The arm bike did get my heart rate up OK but it was pretty boring. Swimming with the floaty thing between my knees kept my legs immobile-- never got my heart rate up as high as I would have liked, but at least I got to swim outside.

      Hang in there it'll get better, just got to be patient.

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  8. Hi there! I am recovering from my second stress fracture. I seem to get them each summer when I ramp up my hiking time. Do you have any recommendations for footwear? I am wondering if my choice of lighter shoes such as trail runners is contributing to my issues. Perhaps a beefier boot with a sturdier sole would offer more protection? I would love your thoughts!

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    1. I wish I had a simple answer for you!

      All the doctors I went to said that sturdy shoes with thick soles were important. That's what I wore right after my stress fracture and whenever I carry a heavy pack, even now. However, I still switch back to trail runners for high mileage days because the sturdy shoes all hurt my feet and give me blisters.

      When I hiked the Arizona Trail, I tried wearing trail runners, but when I had a few very heavy water carries, my stress fracture site hurt and I immediately switched back to the sturdy shoes.

      I guess it's a tradeoff between sore feet due to heavy boots and pain-free feet with higher stress fracture risk-- for me it all depends on pack weight and keeping the wear and tear down and rest up.

      Wish it were simple.

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  9. Thank you! I am hearing the same thing - go back to more traditional boots with a stiffer sole. I tried some this weekend and they sure aren't as comfy as my trail runners. Wah!!!! I will keep trying some different styles and brands until I find something that works. I have to remind myself that boots require break in time and aren't perfect right out of the box. My physical therapist even recommended going back to boots... ARGH!

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    1. The sturdier boots are terrible! I still haven't found any that don't hurt my feet. I have learned to wrap my feet to prevent blisters, and adjust my expectations in terms of foot pain.

      Hang in there and hope you don't get another stress fracture. Sore feet is at least better than having to stay off the trail for a fracture!

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    2. I taped my feet before when I used boots as well. May I ask which boots you are wearing now? I tried Vasques on at EMS this weekend. I haven't bought them. I also tried Salomon and they hurt my toes right away.

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    3. Keep trying a bunch of them on and find a good fit. I have bunions so the wider toebox of keens works OK. But they are hot and unforgiving. Ah well!

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  10. Thanks for the great story. Turned 50 and decided it would be a good idea to lose weight by reliving my glory days as a Marine and hike with a 75 pound vest for 5 miles a day for 2 weeks, after doing nothing but weight lifting for 25 years. After this stress fracture heals, I'll probably take it a little more slowly. :)

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    1. Yes, sometimes things like that seem like a great idea, until the body decides otherwise. :) Hope you heal quickly and can learn to slow down. (I'm *still* practicing slowing down every single day- maybe someday it'll get easier...)

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  11. Been using these: Danner Men's Crater Rim 6" GTX Hiking Boot:

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    1. I've got a pair of Danners I wear in winter- definitly sturdy and beautiful full grain leather that lasts forever. Still can't get used to them in summer though.

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