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.


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


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.

Wednesday, July 16, 2014

Foot injury- Stillness among the Giants

The largest remaining grove of ancient redwoods are around Humboldt Redwoods State Park in Northern California. The Avenue of the Giants is a scenic drive through the park and redwood groves. The trees are so massive and close to the road that you totally feel like they are hugging you.
Ancient coastal redwoods towering up to 350 feet.
Coastal redwoods are the world's tallest trees, and despite my passion for big trees (which gave me my trail name of 'Hemlock') this is the first time I've seen the redwoods.  I hadn't been planning on this visit though. But I am on my fifth week of recovery after getting off the PCT for a stress fracture. Steph suggested this trip because it is one of her favorite places (Thanks Steph!) and because I would be able to get outdoors without needing to walk.
Making peace with the boot.
Stress fractures are an overuse injury caused by doing too much activity, repeatedly, with not enough rest. So now I'm on a mission to learn patience and how to rest. Not at all easy for someone whose happiest time ever was hiking 12-14 hours a day, day after day.  I love to travel, to move, to explore, and to physically push myself.  I get antsy being still. But because I'm off the trail because of this, I'd better figure things out and learn some patience, so I can have a lifetime of healthy backpacking.
Redwoods fracture too.
At the Avenue of the Giants, Steph and I drive to one of the many pullouts along the road. I slowly hobble in my boot to a big tree close to the car, stretch out on my sit pad, and let my toes breath in the air. I touch the fallen leaves, feel the trunk against my spine, listen to the birds and crickets, and settle into the stillness.
It's been years since I've meditated but beneath these redwoods, the practice comes right back to me.  I let go of my longing to venture up the trail or down the cliff to the river. (but at first, oh how I long to go play!). I make peace with not seeing the end of the path, not looking around the next bend for a bigger and more wonderfully gnarled tree, and not turning over rocks in the river. I breathe.  I let all my thoughts go.

What if I can see everything I need to from right here? What if the tree I'm sitting against is just the right one. What if I can enjoy the stream without knowing if there are caddisfly larvae in it? What if its ok for me to just be here where I am?

I can hear traffic of the road and sense encroaching civilization.  But right now the forest is incredibly still, and bursting with life.

I lie sprawled out on the ground gazing upward at the soaring trees, my leg anchored by the heavy boot at a funny angle. Steph and I exclaim how wonderful the light is, and laugh at how child-like we feel goofing off in the woods.
Doubled over in laughter at being sprawled on the ground in my boot looking up at the trees.
I temporarily lost that which I believed defined me and the one thing I could always rely on to make me happy. My darkest fear has been loosing my ability to hike, and now that's happened. It has been like going through a divorce or loss of a loved one. But here in these redwoods, I am able to dig deep and see that the inner peace remains. Then I am truly free. Sure it's a different freedom than the one I so easily find on the trail but this is a freedom that glows within me and that external forces and circumstances can't touch. I will carry this with me when I leave this incredible place.
Picnic shelter in the Women's Grove.
Check out these awesome videos about the redwoods:
Tallest tree found in Redwood National Park (part 1) (part 2)

Wednesday, July 9, 2014

Foot injury- Still living the dream?

I just went to a sports medicine doctor who took another x-ray of my foot and showed that my injury is actually a stress fracture.
The halo around the third metatarsus indicates healing of a stress fracture.
This means my foot needs more time to heal. The doctor said three more weeks, on top of the four weeks I've already been off the PCT.  Being off the trail due to my foot injury is the hardest thing I have faced on this trip so far.   I ache to be back on the PCT, back with my wonderful hiking buddies, back where I had never before been so happy in all my life. I struggle too with thinking about why this happened to me. I have a million questions about how to heal, how to stay sane while staying off my feet, how to recover, how I can ever hope to trust my body again. ;

When things got really tough out on the PCT, I'd remind myself: "I'm living the dream.  I'm hiking the PCT." Saying those words out loud cheered me up.  It reminded me that no matter what I was facing, that hiking the PCT was exactly what I'd been wanting to do for years.  I've never been so certain I was on the right path.

Out on the trail, sometimes, it was still mentally difficult.  Like when I drank my last sip of water in the heat of the desert while I was still a few miles from the next spring. After that, it took me a long time to trust myself judging how much water to carry, and how to deal mentally with the uncertainty of how much I drank. Another example was when I was standing on top of snow-covered Glen Pass, unsure how I would get down the incredibly sheer slope, footprints going in several directions all of which looked like they would fall off the face of the earth. In those moments, I had to pull out all my techniques for believing in my abilities, and trusting that it would work out even though I couldn't see how it was possible in the moment. But I always kept going, I always ended up being surrounded by friends who helped me through it, and I always amazed myself that I COULD DO IT.

Those struggles are part of the experience of being on the PCT- it isn't all splendid scenic vistas and coolers full of trail magic.  Many of the experiences were achingly painful or just plain terrifying.  The PCT takes you to your edge, or drives you past it.  In those moments, instead of wallowing in self-doubt or being scared, I learned to step outside of myself for a moment.  I would remember that I was exactly where I needed to be.   I'd look around me and discover that the friends I'd met could teach me lessons to help me through. The really tough parts were my preparation for the the next section.  I accepted that all my experiences on the PCT- even the ones that hurt like crazy- were what I was out there for.  I reached new levels of self-confidence.  I was a bad-ass PCT hiker who could do anything that I put my mind to.  Having that realization felt life-changing.

This way of looking at and accepting hardships let me face my fears head on while I was on the PCT.  I trusted that I was growing and learning something about myself.  I remembered to welcome the ever-changing challenges, rather than experiencing them as something that sucked.

Now that I am off-trail due to this injury, I try to tap into the skills I felt like I had mastered on the trail- that trust and assurance in myself- but it's not comming as easy as it did while I was on the trail.  Whenever the tears stream down my face, I attempt to say to myself "I'm a bad-ass PCT hiker and I can do this."  I only half-believe it.
Still a bad-ass PCT hiker, even in my boot.
 But then I think of myself on Glen Pass looking down those impossible slopes, how I took one careful step at a time, how I did that thing that terrified me the most and how awesome it felt to make it. This stress fracture will heal. I will figure out how this injury fits in with my journey. I'm going to do what it takes now so that I can keep hiking in the future. And when the time comes, those first steps back on the trail will be awesome.

Wednesday, July 2, 2014

Foot Injury- Update #4

After nearly three weeks off the trail, I haven't been cleared by my physical therapist to hike or backpack, but my foot hasn't been hurting so he says it is OK for me to walk a little.  As long as I'm careful and don't overdo it.

It was such a relatively small thing, and yet, it calmed my restlessness.   A night in my hammock at the Donner Pass trailhead on the PCT, dropping Arizona off after he took another zero day.  It gave me a new appreciation for everything I love about backpacking.
My happy place: my hammock.
Sometimes it is said that there are two types of backpackers- those that prioritize the hiking part of backpacking (and do long miles and carry fewer camp comfort items) and those that really like the camping part (and that roll into camp early and spend a lot of time in camp).  I always thought of myself as the former- I love to move and don't like to sit still much.  But this night made me realize how much I love the camping part of backpacking while I have been on the PCT.

I love the feeling of having everything I need on my back.  Being able to select my own spot for the night.  How the place is ever-changing, but it transforms into my home the moment I set down my pack.  Such freedom.

I delighted in the simplicity of camping.   I have learned an economy of motion in setting up camp from my time on the PCT.  I am quick and the setup is uncluttered.  Everything is where I need it.   Everything in my pack has a purpose. 

Just for the night, I attempted a few changes in my setup to see if I could save weight- including cutting down my foam mat/ leg insulation to 4 segments instead of 6.  I could tell it wouldn't work long-term- my feet stuck over the edge too much (oh darn it long legs!), so if it had been any colder I would have had frozen feet.  But it gave me a satisfying feeling to keep trying new things, to keep trying to optimize.

The last glow of evening light faded on the granite.  The tree branches were silouetted against the darkening sky.   There was a persistant hum of mosquitoes.  They were everywhere, circling and biting.   My heart filled with joy for being on the PCT.  Yes, I'd missed even these pesky blood-sucking beasts.

 I fell soundly asleep moments after zipping up my hammock and tucking my quilt around me.  The comfort and familiar hiker-funk smell of the hammock a huge reassurance, and sense of calm filled me.  I had that clarity that I am on the right path for me, that I will get back to the trail in due time.  That I will not take any part of this experience- the delight in making camp, savoring everything about night on the trail- for granted.
I am NOT backpacking. I am just carrying my pack very slowly a short distance to camp.
The alarm sounded even before first light. I fell into my morning routine, with the added benefit of enjoying it with new appreciation. Breakfast in my hammock. Then packing up in just a few minutes. Arizona's stuff was still all over the place. "What are you doing standing around with your pack on waiting around for me when you aren't even hiking?" It's not even 5 AM. My legs are antzy. My body thinks I am going hiking.  Instead I drove back to town in time for my physical therapy appointment. Arizona set off down the PCT.

Tuesday, July 1, 2014

Foot Injury- Update #3

Two weeks and three days since I've been off the trail for my injured foot.  I'm still on a roller coaster of emotion.  Today I went to visit Arizona at Donner Pass.  He wasn't at the trailhead when I got there, but I did run into Brett and Lee!  WOW hadn't seen them since Kennedy Meadows!  Met them at Mt. Laguna and leap-frogged with them for weeks.  Seeing them brought back so many good memories of SoCal.

I decided to walk south on the PCT to meet Arizona.  I've only been cleared by the PT to walk, not carry a pack and not hike.
Probably NOT what my physical therapist had in mind when he said I could go for a short walk.
The wildflowers were nothing like I'd seen since I'd entered the Sierra.  It was as if in these few weeks that I've been off the trail, everything has exploded in bloom.  And I'd been missing it.  I walked slowly, one careful step at a time, pausing to look at every single flower.
Yippee!!!  Thimbleberries!!  I haven't seen them in so long!!! 
Sitting on a cold rock at the end of a switchback (where I realized that I should not go any further even though I really adore climbing switchbacks- and no I'm not kidding), I wiggled my toes in the breeze.  My optimism slipped away when I realized this was the first day my foot didn't feel better than it had on the previous day.  Guess I over did it walking around too much the previous day.
Oh foot, why are you causing me all this trouble?
I sat on that rock for over an hour thinking.  Funny, when I was on the PCT, I never just sat and thought.  There was always something to do- eat, foot care, eat some more, look at maps, have another snack.  But now that I am off the trail, time creeps by so slowly.  I have more time to think.

I've been off trail for 17 days that have felt like the longest 17 days ever. And what have I done with all this time?!?!  I still don't have an answer for why this injury happened and how to prevent it from happening again.  I still have doubts about the diagnosis- is it really an inflamed joint (like my physical therapist says), or could it possibly be a stress fracture?  I'm incredibly frustrated trying to navigate the insurance and health care system.  And all I have to do with my time is to solve this problem, and I haven't figured it out and my foot still isn't better.

Finally Arizona rounded the bend and my downward hate spiral of self-loathing and despair came to an abrupt halt.  It was time for burgers and ice cream and laughing about this crazy life on (and off) the PCT.  I never expected my journey to be like this.  But I just keep on going, finding ways to stay positive.  Maybe after this is over, I will figure out what I am learning from all of this.