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Injuries and Treatment

The Injury Games

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A look at how to cope with run-stopping maladies

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A now-healthy Anna Frost taking second place at the 2014 Mont Blanc Marathon 80K. Photo by Damien Rosso.

While Beverley Anderson-Abbs was recovering from surgery on shredded cartilage in her knee, she tried to maintain a stubborn resolve that she would compete strong in ultras again—no matter what. But as her recovery and hiatus from racing stretched past a year, the voices of doctors who told her she couldn’t run kept entering her head. At times, she felt devastated.

“I’d be sitting at my desk at work and have to close the door because I’d be crying,” recalls Anderson-Abbs of Red Bluff, California, a longtime top competitor who won last year’s Headlands Hundred and participated in each of the past three Barkley Marathons, arguably the world’s toughest 100-miler. Being injured “took away a huge chunk of who I am. There was suddenly this question of, ‘Who am I?’ Until that knee surgery, I was a runner. … To have that excised from your life is a hard thing to deal with.”

Eric Schranz’s calf injury was relatively short lived, but he too was emotionally wrecked when he couldn’t run for a month and had to relinquish his race plans for the season.

“I felt adrift and really disconnected,” says Schranz, host of UltraRunnerPodcast.com, of Sacramento, California. His strained muscle “took me from peak [training] to nothing. I had worked so hard to get to that point, and it was suddenly taken away.”

Schranz objectively knew that he would get better and that he should cross train to maintain fitness, but he couldn’t muster the energy to be productive. “In pretty much every area of my life, I felt off,” he says. “I found myself lost—that’s the best word I can find for it—and I did nothing.”

Except eat, that is. A month later, he had gained 14 pounds.

I can relate to such stories. When a doctor presented his analysis of an MRI of my foot, I wept as if a loved one had died. He said the stress fracture would heal, but the thrashed ligament looked “anatomically irreversibly pathologized.”

The diagnosis torpedoed carefully laid race plans that were months in the making. Fear, insecurity and grief over the loss of running—layered with a self-centered and exaggerated notion that “nobody understands how hard and unfair this feels”—pushed rational and positive thoughts aside. I packed on pounds from reduced exercise and, most nights, an extra glass of wine.

When you’re running well and training for races, “you take it for granted, and it becomes a part of your life,” says Western States 100-mile record holder Ellie Greenwood of Vancouver, British Columbia, whose racing season hit the wall in early 2013 when she suffered a stress fracture of the fibula, followed by a second injury of tibialis posterior tendonitis. She took the rest of the year to rehab and retrain.

“It’s not just about racing,” says Greenwood. “It’s also about traveling to places and having goals, so as soon as you can’t run and race, it’s like, ‘What do I do now?’”

Working through the Stages of Injury

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Anna Frost worked through injuries in 2012 and 2013, but is off to a great start in 2014. Photo by Damien Rosso.

Like two sides of the same coin, the moody injured runner who’s sidelined from a race seems as common as the elated runner who’s achieving a PR. Getting injured from time to time is such an ordinary occurrence in the sport that it seems as if we should take it in stride and quit feeling sorry for ourselves when it happens.

Why, then, is it so hard, particularly for ultra trail runners, to take a month or more off from running?

First, injured runners suffer withdrawal not just from the myriad physical benefits that a daily run delivers but also the mental and social benefits, such as time alone to think or time together with running buddies. They feel deep frustration after dedicating so many hours—often sacrificing family time or work in the process—to make athletic gains that time off will erase.

Beyond that, dedicated trail runners who register and train months in advance for ultra-distance races grieve the loss of those dashed goals. If they won a precious spot for a race entry through a lottery, then their sense of loss deepens when they forfeit that spot.

If you’re injured—or if you recognize that the odds are high you’ll have a physical setback at some point—then it’s helpful to realize that runners tend to follow a similar pattern of psychological reactions to their injury-induced reduction in training. If you’re aware of these reactions, you’ll be better equipped to move through them with less distress.

Several sports psychologists and coaches, such as Jerry Lynch and Warren Scott in their book Running Within, have drawn a connection between these reactions and the five stages of loss and grief identified in the oft-cited 1969 book On Death and Dying, by Elisabeth Kübler-Ross—denial, anger, bargaining, depression and acceptance.

Here is how those stages apply to us trail runners.

1. Denial

After winning The North Face Endurance Challenge 50-mile championship two years in a row, New Zealand’s Anna Frost struggled with a series of physical problems in 2012 and 2013 involving stress fractures, pain and general fatigue. In hindsight, she realizes, “I was basically denying how bad the situation was. I was in pain, but I was scared that if I didn’t run, then who was I? What would I do? … I was pushing and pushing, but pushing downhill.”

This first stage—denial—can be highly detrimental. Running through the onset of an injury usually makes it worse, ultimately requiring more time off. Denial also delays getting a diagnosis and beginning treatment.

Hard-core runners often deny the significance of their injuries, because they’ve been conditioned to run through low-grade niggles and fatigue. So, how can you tell the difference between pain that you should run through, and pain that causes or prolongs injury?

Elite-level coach and runner Ian Torrence, with McMillan Running in Flagstaff, Arizona, explains that “good” or “adaptive” pain is the beneficial soreness and fatigue we feel from hard workouts, to which the body adapts, getting faster and stronger. By contrast, “bad” or “restrictive” pain restricts or impairs proper running form. Examples of restrictive pain include swelling, persistent or asymmetrical soreness, sharp pain and chronic fatigue.

Restrictive pain is a trigger for or a symptom of an injury—so don’t deny it. Research the symptoms and seek medical help to get a proper diagnosis so you know what you’re facing and how to treat it.

Finally, Torrence advises, don’t deny the time it will take to heal. He sees too many runners try to run prematurely as soon as their symptoms feel better. Mere minutes into their run, they’re hurting again, and the damage is re-done. “Don’t go try to test it and reinjure it,” he says.

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After taking steps to address weaknesses and heal, Caitlin Smith makes a strong comeback at the 2014 Way Too Cool 50K, taking second place. Photo by Myles Smythe.

2. Anger

“When I first got the injury, I was just really angry—upset with everything and everybody,” recalls Caitlin Smith of Oakland, California, who felt shooting pains in her hip that forced her to drop out midway through the TransRockies Run stage race in 2010.

Smith, a 2:41 marathoner with many record-setting wins at 50Ks, was diagnosed with a stress fracture, which healed enough for her to race the 2011 Boston Marathon. But pain and biomechanical problems plagued her throughout 2012. Last year, she took steps to address these weaknesses and heal thoroughly, and then came back to place second in this year’s Way Too Cool 50K.

After the onset of her stress fracture in 2010, Smith says she was driven to get on her bike and do whatever she could to maintain her fitness—“I was so concerned I had lost something”—but at other times, she felt so frustrated, she wanted to give up entirely: “I’m like, ‘I’m never running again—I’m done.’ But if you get that angry about something, it means you love it.”

In hindsight she recognizes that she had been in denial about overtraining before her injury blossomed; during peak training, she sometimes would cry for no particular reason and frequently wrote “exhausted” in her running log. “You get in this mode where you feel you need to improve, and you ask yourself, ‘Is this even fun anymore?’ Then you have to take a step back and ask why you’re even doing it.”

Once an injury forces you to stop, Smith and others advise redirecting anger toward getting a clear diagnosis and developing a recovery plan, so you can channel the energy and passion you put toward training into healing. In other words, dedicate yourself to being the best patient you can be.

“You have to change your focus and apply your energy elsewhere in a positive fashion, instead of lamenting, whining and complaining. … Sometimes I want to shake my athletes and let them know they’re not the only one who’s ever been injured. It’s the better, more disciplined athlete who will overcome the injury and return to running better.”

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Geoff Roes. Courtesy of Geoff Roes.

Patience is the ultimate antidote to anger, says Geoff Roes, who in 2012 plummeted from his champion status in ultrarunning to being ill and incapable of running for a year and a half due to severe, systemic fatigue and other symptoms.

“Our bodies and minds have an amazing ability to heal, but when we become frustrated and angry about our ill health, we only limit this ability,” says Roes, the past winner of the Western States 100-mile Endurance Run and Ultra Race of Champions 100K. “Obviously, when you’re in the midst of the worst of it, this is a really hard thing to see. Try to think about the things you can still do, and not so much on the things you can’t.”

3. Bargaining

Schranz spent the week before his goal marathon “rolling, massaging, begging and pleading with the running gods to heal my stupid calf.” He knew he wasn’t fully healed before the start, but he gambled that he’d be OK. A mere quarter mile or so into the race, he realized there was no way he could run the distance—so he dropped out, bargaining with himself that the DNF would allow him to run two other races on his calendar: a 24-hour event, and the Lake Sonoma 50-miler.

A few weeks later, however, he accepted the scope of his injury and pulled the plug on plans for those other springtime races.

Injured runners typically bargain with themselves, promising to do X, Y and Z if they recover. Bargaining can be counterproductive if the runner promises a short-term, superficial change in the hope of a quick fix, such as, “I’ll take a spin class rather than run on Wednesday, so my foot can handle a long run on Saturday.” Such bargaining can contribute to a pattern of chronic injury or frequently feeling “off.”

A more healthy type of bargaining results in a change in behavior that promotes healing and prevents re-injury, such as, “If I can run again, I’ll spend 20 minutes three times a week on core exercises instead of using those minutes to run more miles,” or, “If my plantar fasciitis goes away, I promise to keep rolling the golf ball under my foot when I’m at my desk.”

The hard part is sticking to that good bargain post-injury, rather than lapsing into old bad habits.

“You need to remember what it was like when you couldn’t run, and how much you wanted to run, and if you can remember that, then doing the little things”—such as physical therapy exercises and getting enough rest—“is worthwhile,” says Torrence.

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Ellie Greenwood is having a banner year after recovering from an injury-ridden 2013. Photo by David Clifford.

4. Depression

For Anderson-Abbs, discouraging prognoses from doctors and uncertainty about whether her knee would heal triggered terrible emotional low points. She fought back depression by being proactive in two ways: doing whatever cross training she could to stay fit, and trying everything medically possible to get better, including stem-cell therapy.

“The best thing you can do is stay positive, and as for the people who say, ‘You will never run,’ you’ve got to block them out,” advises Anderson-Abbs. “Keep working at it a little at a time, and try everything. Give it the time that it needs, and strengthen the rest of your body.”

She and other dedicated, goal-oriented runners also grapple with their identity and self-worth when injured. They confront the outsized role that running plays in their life—and the depressing, frightening void they face without it.

“Running was who I was,” says Frost. “I got to a point physically and mentally where I didn’t believe in myself—only as a runner.” To deal with that sense of emptiness and alleviate depression, Frost recommends cultivating other areas of your life that you might have been neglecting.

“It’s important to have other things that keep you challenged and interested,” says Frost. “It could be another sport, language, hobby—anything that you can direct your mental space to. Of course you might never entirely fill the gap, but if you can just keep fit and busy during the recovery time, then when you get back to it, it won’t seem so bad.”

Social isolation compounds the running-injury blues. Checking Facebook or Strava reveals all the happy miles that your running friends are logging without you, deepening your sense of loss and disconnection.

“Not being able to run had a large impact on my social life, as so many of my friends are avid runners and that’s how we typically spent time together,” says Roes. “It was also hard, because one of my symptoms has been difficulty concentrating and processing thoughts. I’m sure I was terribly boring and lame to hang out with, since it was nearly impossible for me to have a substantial conversation without feeling overwhelmed.”

If you really miss the social aspect of the trail-running scene, then Schranz suggests getting out to volunteer at a trail event. He likes to take photos of participants and cheer them on when he can’t run, because “going to races really inspires me to get better and healthy.”

5. Acceptance

Congratulations—you’ve reached acceptance, so you’re ready to get better. Only when you accept the fact that you’re injured, and understand it will take time to heal, can you properly treat and manage it.
Greenwood was able to process her eight months of injury and on-again, off-again running without too much dismay, thanks to a matter-of-fact attitude. “Everyone gets injured if you’re trying to run at your maximum potential,” she says. “You’ve got to deal with it and get on with it.”

The hardest part, says Greenwood, was accepting the need to be patient during her comeback period, after she could start running again. Returning to running in very careful, conservative segments interspersed by walking—what Greenwood calls “bumbling-along mileage”—can be more difficult than not running at all.

To avoid re-injury, Greenwood and others say you must be patient and not jump into too much running too soon. Greenwood’s patience paid off with a triumphant return to ultra racing last March, when she won the Chuckanut 50K. On June 1, she made headlines with a gutsy come-from-behind win at the 55-mile Comrades Marathon.

It’s normal to feel anxious mentally, and awkward and slow physically, during this initial comeback period. Torrence advises keeping up with cross training post-injury and gradually increasing the proportion of running.

During the first week back to running, for example, it’s reasonable to limit running to only 10 percent of your fitness time, with activities such as walking, cycling, pool running or the elliptical trainer filling out the other 90 percent. Carefully, over a period of several weeks, you can work back to the point where running takes up around 90 percent of your time and cross training only 10 percent.

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Meghan Hicks fast-packing California’s Tahoe Rim Trail. Photo by Rachid Dahnoun.

Silver Linings

Smith felt angry and depressed during her injury. “People would say, ‘You’re going to be stronger for this in the end,’” she says, “and I’d say, ‘Yeah, shut up, you’re running!’ But it’s true.” Being injured “gave me a new awareness of why I enjoy running, and also an awareness that my body does have limits.”

Being forced to stop running for a period can enhance gratitude and lead to a better balance between the sport and the rest of your life, even after you return to it. Seeing these silver linings can fuel optimism and help an injured runner move through the stages toward recovery.

Marathon des Sables 2013 champion Meghan Hicks, a contributing editor at Trail Runner, eloquently captured an injured runner’s renewed gratitude after she went on a short run in late March, following a couple of months of not being able to. “Recovering from injury, you can feel every single, pain-free step,” she wrote on her Facebook page. “You can feel each toe spread itself into your shoe. You can see the freedom of the open road. … After time away from doing what you love, all the senses are acutely aware, making the world seem so big again.”

An injury is also a great teacher, says Torrence. Learn from it, and do whatever you can to avoid repeating past mistakes in training. “I’ve learned most of my rehab skills from actually experiencing the injury and working with people who’ve been injured,” he says.

For Roes, not being able to run for more than a year ultimately “turned me into a more content and complete person. … As things have improved, I think I’ve been able to build to a life that’s more balanced and more sustainable.”

Sarah Lavender Smith is a contributing editor at Trail Runner who blogs at TheRunnersTrip.com. She battled the injury blues last winter by taking spin classes, studying Spanish and cleaning out closets.

This article originally appeared in our October 2014 issue.