Backpacking Injury Recovery:
Injury Recovery Basics

Injury Recovery Basics

Getting Started:
Frame of Reference

You are in the Injury Recovery Section: I

Getting Started, Coming Off the Couch, & Recovering from an Injury

This injury/fitness recovery section is a subset of the fitness section. There are three more injury/fitness recovery section pages that follow. These pages are listed as Sections II, III, and IV in the index below.

Last: Physical Fitness Index              Next: Beginning an Injury Recovery Program

Fittness Recovery Section

Section Index

This page and three more composes the Injury Recovery Section

Section I>
Injury Recovery Basics
(This Page)

Page Index

Getting Started - Purpose

Chronic Vs Acute Pain

Don't Rush It

Self-Guided Recovery

Successful & Unsuccessful Programs

The Bottom Line

Keeping What you got

Broad Physical and Psychological impacts

Healing Time is Vital

Drug Plan

First Stretching Video:
Introduction to Stretching

Real Lower Body Injury Recovery

Getting Frostbite

Evaluating the Extent of the Injury-First Response

Previous Injuries

Wound & Structural Treatments

Start Stretching & Walking ASAP

Drugs and Pain

Life is a long Trail

The Fundamental Skills of Physical Fitness

Injury Recovery & Beginning a New Fitness Program

Always consult with a doctor after injury and before beginning any healing, therapeutic, or exercise activities such as those reviewed on this and the following pages...then have the sense to know the bullshit from the bullion...

The following pages of this trail guide discusses the first stages, the most difficult stages, of recovering from a lower body injury and/or restarting a conditioning program after a considerable period of inactivity.

Consider Previous Injuries

Recovering from injury and getting an exercise program started are always the most difficult parts of restoring and maintaining fitness for me. The extra difficulty for me is due to my personal history of previous injuries. My previous injuries deteroriate during inactivity or when I've incurred new injuries. I have to pay particular attention to all of my previous injuries when I am sufficiently healed to restart my fittness program.

Our Goals

My goal on this page is to induce you to begin a regular stretching and exercise program suited to the status of your injury recovery, impart the sensitivity to recognize the warning signs of reinjury or new injury, manage pain, help you understand the vital role of rest in recovery, and manage the advantages and dangers of various pain medications in healing and recovery.

If you don't need this introduction to the basics of injury recovery you can head to the next page, Beginning a Fitness Recovery Program, where we actually begin to put the principals on this page to use by beginning a basic stretching and walking program. This program makes the transition to jogging as injury treatment and wound control progresses on the Finishing Your Healing Program page.

Following our injury recovery and the restoration of our basic abilities to walk and jog we will finally put together a regular schedule of jogging and aerobic exercises complimented by a program of lifting free weights. The final chapter of this fittness section is the catch-all Related Topics page.

Your Thoughts, Questions, Comments, and Experiences are Valuable

Each page in this Physical Fittness Section is linked to the Physical Preparation-Mountain Conditioning Forum, where you can post up your comments or questions about this Introduction to Injury Recovery page on the Injury Recovery Forum.

The Plan

#1: Injury Healing

The plan is to first heal the injured part sufficiently so you can begin restoring the flexibility and strength necessary to begin a light exercise program. The first stage of injury recovery is allowing the injury to rest and heal properly. The injury must be sufficiently healed and ready to begin range of motion, stretching, and light exercise to avoid the dangers of reinjuring or prolonging the injury.

Each injury requires specific treatment, as well as a specific period of rest and recovery, and a properly tailored approach to recovering range of motion, flexibility, strength, and endurance.

#2: Restore Your Capability to Exercise

Over time we will gradually increase our basic flexibility and strength work until we are capable of beginning a regular aerobic and lifting program. From that point we should be past the injury/recovery stages of the injury, and we can begin to establish a regular aerobic and weights programs.

From the first small steps of healing and range of motion exercises we will again gradually transition our range of motion exercises to walking, then on to jogging while lengthening the distance of our route. Our plan is to gradually develop the strength and endurance necessary to get backpacking again. The first goal of our program is to heal the injury, begin stretching and walking to begin builing endurance and to restore our health, then we will begin to jog parts of our walks as we increase our overall distance and restore our fitness.

#3: Develop Consistent Exercise Program

Once we have rehabilitated our injury we will expand our recovery program into a full-blown exercise program. This can be harder and take longer than you might expect. Be patient.

So far we have been decreasing our exercise loading in the face of chronic pain, and ending exercise with the advent of acute pain during our injury recovery phase. We will maintain the same approach as we expand our exercise program. Even though the injury may have properly healed, it may take some time to bring it back to full strength.

Making the transition from stretching and light exercise to extended workouts may take some time.

You may find that your bad knee or hip acts up during extended runs. You may well have to back-off, reduce your distance, reduce your speed, or take other measures such as anti-inflammatories to reach full strength.

An important part of regaining fitness is going to be doing the basic "roadwork," spending the time and putting in the miles necessary to build endurance. You are not going to be able to do this all at once. Each run will give you more strength and endurance, and each subsequent run will be built upon your previous work. My goal is to gradually "stair-step" my exercise sessions up until I reach my seven mile goal.

We will walk-run the 3.5 distance until we are comfortable moving it up to 5 miles, and then up to the 6 mile distance as we gradually restore endurance while maintaining a consistent level of pain in our previously injured parts. When the chronic pain begins increasing we will reduce the workload until it is back under control, then we will again start pushing up the distances.

I consider a step-up to a longer distance successful when I maintain the same level of pain during the longer run as I experienced running the shorter distance.

From there our program will serve to maintain our capability for Long Distance High Sierra Backpacking.

#3: Add Trail, and Hike!

Thus this fitness plan is different from any other. It has a long term goal. It constitutes a long term physical foundation for a naturally engaged lifestyle. We have two practical ongoing goals: First, to recover fitness after injury or inactivity. Second, to be well prepped for regular long distance backpacking.

Maintaining the capacity for deep engagement with wild places by maintaining our mountain conditioning when we are out of the mountains has many other benefits. Our regular flexibility, aerobic, and strength training exercises also offers a wide range of positive effects for the mind and body.

Good for Everything

Besides being good for your heart, lungs, blood sugar, brain, attitude and digestion, finding a beautiful place for the walking-jogging aspects of your fittness program really relaxes your mind.

I make sure that my aerobics program (walking-jogging) brings me though some beautiful territory who's natural beauty and wildlife deeply refreshes me.

Strawberry Canyon

As soon as possible after any injury I begin walking up and down the fire roads and trails in UC Berkeley's accidental Natural Preserve located in Strawberry Canyon in the Berkeley hills behind the UC Berkeley campus. These walks are a prelude to, and preparation for jogging them. I'm lucky to have this expanse of grass, forest, ferns, and redwoods laid across out across a tasty complex ridgeline a short hike from my place.

I strongly suggest you find a natural space that chills you out for your walking and jogging.

Strawberry Canyon is full of critters of all types, from rattlesnakes to occasional mountain lions, with big bucks, turkeys, coyotes, hawks, owls, and house cats all thrown in for good measure. Pretty amazing diversity for being next to a big nasty city.

The terrain surfaces are generally soft, which eases the stresses of impact on injured joints. The exercise "experience" through this terrain both delights and sharpens my observation and engagement skills while rebuilding my physical capacity.

I suggest that you find a beautiful place for your walking and jogging that is as stimulating for your spirit as it is good for your body.

Every location in the world has areas that typify its terrain and flora. Find that place in your location, and refresh your spirit where you work your body.

	Hiking trail up through a fine redwood grove.				Soft trail through temperate forest ferns under the Redwood's canopy. Easy on the feet and knees.
	The nature of the terrain demands observation as well as work. Engage your mind and body!				The beauty of the terrain engages and soothes the mind as the difficulty works the body.
	Looking at Berkeley and the San Francisco Bay through Strawberry Canyon. Angel Island sits bordered by light. Marin in background.				The Golden Gate Bridge beyond Alcatraz Island.
	700 feet of elevation and 1.75 miles of work are rewarded with this fine view.				You exercise should be in a place that refreshes your spirit as well as your body.

A Well-Rounded Program

You can heal from serious injury and recover from sustained inactivity to achieve high levels of fitness, but if you are not properly geared-up and experienced enough to properly use your gear in wild terrain, all is for naught.

As we heal, control inflammation and pain, and steadily continue the slow process of strengthening ourselves into a regular fitness program, I am going to encourage you to build up the backpacking gear and the trail and camp skills that will be necessary to practically apply your increasing fitness to the trail. As we recover from injury and build fitness we'll do a series of backpacking trips of ascending difficulty to compliment your improving fitness with parallel development of your trail skills and gear.

Our goal is to reach the level of fitness necessary to support and compliment a lifetime of really rewarding long distance backpacking. The level of fitness you maintain off the trail as a normal part of your life will determine your access to, and even how you experience life on the trail. Poor fitness applied to difficult conditions creates pain. We are going to minimize, if not avoid that fate through regular exercise.

I'm not going to get you to walk and stretch, then jog and lift without a grander goal than fitness itself. Fitness without application is like a compass without a needle. There is a point to having bodies and minds designed such as ours, and my plan is to put you into position to find out exactly what that purpose is. I'm going to get you into shape so you can use that body of yours to safely and comfortably travel in nature.

That's the natural canvas for backpackers. What you paint upon nature's canvas with your footsteps will bring out, and is determined by, your character and values.

The rewards of making nature the standard and goal of your exercise program, and a part of your life, can profoundly change your mind and body.

Once you get comfortable with working your body, working your gear, and have some trail time under your belt we will focus our efforts on completing my favorite hike. We will hit the trails for the hike from Lake Tahoe to Mount Whitney. I've hiked this route four times, and I'm looking forward to the fifth.

I see more things each time I hike it.

Reaching this goal may take a while, depending on your injury, healing, fitness, funding, and time constraints. I'm planning on having all these factors lined-up for my 5th Tahoe to Whitney backpacking trip during the Summer of 2012. You may want to set yourself a series of reasonable long term backpacking goals as part of your fitness program as well.

Always consult with a doctor before beginning any exercise or therapeutic activities such as those reviewed on this and the following pages...then have the sense to know the bullshit from the bullion...

We all gotta start somewhere...meet you at the bottom...

Purpose

This "injury recovery" section is written for those of use who are coming off of extended stays on the couch from a lengthy period of sedentary lethargy, be it caused by injury or just plain old physical disengagement. This section is designed for those of us who are once again taking the very first steps towards beginning the long process of recovery from injury or inactivity.

Beginning an injury recovery program and starting an exercise program are two of the most difficult phases of getting back into backpacking shape. Great care to avoid re-injury and new injuries is required. Thus our program starts out with range of motion, stretching, and walking. Once we get back in shape it will be much easier to stay in shape than it was to get into shape. So hang in there, because the rewards of getting into shape get progressively better, and the costs progressively lower.

It's like planting a garden. You gotta dig hard, get dirty, and nurture the soil for a long time before the flowers finally grow. Then you can enjoy that garden you planted.

My wide range of trail and non-trail related injuries have demanded many long periods of inactivity, slow recovery and gradual rebuilding. Those of you who have gone through the cycle of training-injury-recovery-training know how difficult this can be. Don't give up hope. We're going to do this. Again.

Take Charge of Your Recovery

Though your situation in the wake of injury or inactivity may be bleak now, during this period of low fitness and injury your perpetual pursuit of full recovery over time will either restore the capacity you still have, or show you the next medical or surgical step necessary for recovery.

Sometimes finding relief is as easy as suspending the exercise program to take more rest, to allow an inflamed joint to chill out. Other times recovery demands that you walk miles with chronic pain to restore circulation and strength to a fading knee. Sometimes the only way to treat a chronic joint pain is to work it out. Other times an inflamed joint must be rested.

You need to know the difference.

Your injured part's responses to the stimulation of stretching, range of motion, and light exercise are going to determine if you should proceed with exercise, increase the exercise, or if you should diminish the exercise to continue healing through rest. To make this call you are going to have to learn to differentiate between the different types of pain you experience and what each type of pain means to your healing and strengthening processes.

This awareness is vital to exactly determining how your injured parts are responding to work, so you can adjust the work load accordingly for your injury.

This section assumes you have incurred a lower body injury, consulted a doctor, and have now healed enough from the initial injury that you are ready to start putting together a range of motion and stretching program to begin restoring flexibility, strength, and some endurance to the healing part.

A Hard Section on the Long Trail

Getting started and keeping on a recovery program can be very difficult. Especially if the injury has laid you out for a while, and has degraded your overall fitness. Controlling pain and inflammation while building capacity can take a long time, but is well worth the effort.

The pain generated working an injury back to fitness is very real, but the physical capacity this work restores will actually reduce overall pain in the long run. My approach to recovery is to see recovery as just one part of a lifetime of physical engagement where pain and pleasure rise and fall over time with the demands of the situation.

The Dilemma

One thing has become very clear over my life: Inactivity after an injury's basic healing is complete ultimately brings greater pain than wise activity brings. Some of you may be aware of the horns of this particular dilemma: pain increases with inactivity-pain increases with activity. Going with the activity side of this equation ultimately brings reduced pain for greater capacity, and eventually will allow you to diminish the amount of pain you experience from greater amounts of work.

This "Recovery" part of life, though difficult, is the first and very necessary step you must take towards building or restoring a regular flexibility, aerobic, and weight training program tailored to begin, restore, or maintain a life of High Sierra backpacking and wilderness travel.

Though sometimes long, difficult, and painful, regaining access to your fundamental physical resources is the gateway not just to nature's beauties, but for you to access your fundamental physical capabilities. These capacities will allow you to access nature, which will also allow you to access elements of your character and capacities suppressed within urban society.

The program that follows emphasizes a slow, steady progression of range of motion, flexibility and walking exercises that must be carefully maintained within the limits of your injury's capacity. This program requires you closely observe and analyze your injury's responses to increasing stimulation.

The goal is to gradually build physical capacity through each stage of rehabilitation to full fitness without re injuring or injuring yourself.

Why We're Here

This following elements of this page means to give you a frame of reference for assessing the pains your upcoming range of motion, stretching and walking efforts are going to initiate, how to identify the types of pain you are experiencing, and how to ascertain what each type of pain means to your recovery. You are going to learn to gradually stimulate your injured parts with stretching and light exercise, observe their responce to the activity, and modify your program to suite your injured part's responce.

Along with careful analysis of how your injury responds to stretching and light exercise, we are going to examine how to properly use medications to accommodate the trajectory of your recovery.

Next page:
Beginning a Recovery Program

Chronic vs. Acute
Pain

You are going to have to differentiate between what I define as "chronic" pain, such as the pain of moderate arthritis and the natural muscle tightness, stiffness, and soreness you experience during the late stages of healing and recovery after bone breaks, sprains, and tears from the "acute" pains, which are the pains informing you that your are actively damaging or inflaming, rather than strengthening your injured parts.

Acute pains require ceasing exercise. Chronic pains are generally "workable," with proper warm-up, care, observation, and feedback.

Acute pains are the de-habilitating pains, generally "sharp" or "flaming" in nature, that accompany increasing inflammation and while damaging tissues. Chronic pains are generally characterized by dull aches, stiffness and low to moderate grade pain. Chronic pains can build-up to an "acute" level during and after exercise, requiring a cessation of exercise or extended recovery time.

When to Start and Stop

Our goal here is to first, carefully work up the flexibility and range of motion of the injured parts, then add some strength through walking. We will then build up our walking distances and pace to eventually build up the endurance of the areas afflicted by injury and chronic pain. We are aiming to do this without sparking acute pain or actually re injuring the part. This means knowing when to stop exercising is as important as knowing when to start exercising.

Rest is as Important as Work

First and foremost, make sure you have allowed the injury to properly heal and rest after the injury. Not letting an injury heal properly before starting exercise is a recipe for long term chronic pain. Bone breaks, sprains, and every other injury have pretty well established 'average" required times of healing and rest before physical therapy can start. Consult your medical professional for average healing times for your specific injury. Healing times can vary considerably between individuals. Consult your doctor for the proper time to begin range of motion, stretching, and light exercise after an injury.

Starting a therapy program after injury is almost always painful and will generally spark some degree of swelling and inflammation. Anticipate that your injured parts will over-respond with pain and irritation when you first start working them. Start slowly. Carefully monitor the injured part's responses to your first application of range of motion and light exercise.

Note the role and effectiveness of anti-inflammatories when starting stretching and light exercise. If you have reduced pain and anti-inflammatory use prior to beginning stretching and light exercise, note any changes or increase in pain and inflammation caused by the new activities.

You have two options to treat increased pain and/or inflammation. First, you can cease, reduce the exercise/stretching, and increase the time between exercises. Second, you can increase anti-inflammatory use prior to and after the exercise/stretching session.

My point here is that sometimes slowing or stopping exercise sessions, or increasing rest between exercise sessions will get you to your goal quicker than pushing on. This is just as true when you are healing as when you are hiking a long difficult route.

Needing extra recovery time can be especially important when you are just beginning work on injuries and recovering fitness. Our goal is to use range of motion and light exercise to gradually diminish the amount of pain we experience for a given amount of exercise, though we may have to deal with increased pain and inflammation for a while before we actually achieve a decrease in pain for a given amount of work.

The exercises that are required to strengthen you also require recovery time.

Ignoring acute pain and trying to work through acute pain can be a recipe for physical disaster and long term disability along with perpetual extreme pain. The key is knowing when to strategically back-off and allow your healing injuries to rest and recover, and when it is safe to push your program harder.

This is why developing the experience and self-knowledge to differeiante between an acceptable level of chronic stresses and strains produced by your stretching and walking program from dehabilitating acute pains the risk further injury and disability is so very important.

If you have been sendentary while healing and recovering, or if you have just been sedentary, you are also going to have to deal with the metabolic stresses and fatigue that the trajectory of this program is going to cause.

Be prudent. Understand that rest is just as important as work during the healing and recovery process. Heck, healing and recovery from your exercises themselves is required. Your critical job is going to be properly judging whether work or rest is approiate for every particular situation.

Anticipate Changes

For me the important changes are marked by the points where chronic aching pains start sharpening up into flaming acute pains. I can generally anticipate that transition before it happens, as the chronic pains begin to sharpen, which allows me to moderate the exercise to prevent chronic pains from going acute.

Don't let you enthusiam hurt you. The whole point of these exercises is to make you stronger. If you work your injured or lazy parts beyond their capacity, you are risking serious long-term injury, and risk making yourself weaker for a very long time.

This means that you are going to have to carefully monitor your pain responses to stretching and exercise and be sensitive enough understand, to feel, when your chronic pain is transitioning to acute pain. Then you must be smart enough to stop or moderate the exercise sufficiently to prevent the onset of acute pain to prevent further injury and prolonged disability.

The key to success is sensitivity and experience applied consistently over time. Focus your enthusiam into a dicipilined schedule moderated by accurate self-analysis. You must learn how to accurately identify the type of pain you are experiencing, and feel when it is deteriorating so you can slow down or stop your activity. You must prevent injuring yourself further and/or experiencing extended and painful recovery periods between exercise sessions.

There is no reason to rush. When your injured parts say NO, no means no! You just need to be able to properly interpret your body's language of pain, and be able to differentiate between the normal pain of beating yourself back into shape from the acute pains caused by overworking injured parts.

Managing Chronic Pain

The goal is to build strength and flexibility while maintaining steady, if not decreasing levels of chronic pain for increasing amounts of work. Chronic pain is not uncommon after injuring a joint. Persisting chronic pain following severe injuries to ankles, knees, hips, backs, and shoulders can be managed through flexibility, aerobic, and strength exercises.

Chronic pain must be monitored and exercised within limits. The limit is when the pain starts transitioning to acute pain. Your initial judgment, to continue or stop, will be validated by two aftereffects. The first effect is the level of pain that endures after exercise is stopped. Second, and related to the first, is how long this elevated level of pain persists after the exercise is stopped.

How the injury responds after the exercise session is telling. The maximum effects will generally manifest themselves the next day after your walking and stretching program. This is a vital signal of its condition. If the pain has substantially increased, or even gone "acute," then your judgment of the levels of chronic pain you experienced during stretching and exercise was incorrect, and you over-did it. Now you must rest and recover until you have reduced the acute pain back to chronic levels before restarting exercise. Anti-inflammatories may be indicated before and after the exercise session to maintain reasonable levels of pain during the exercise and to keep both inflammation and recovery times down.

Recovery sometimes demands stopping all exercise. Sometimes it demands starting exercise. Only you can accurately identify the proper balance between exercise and rest to build flexibility and strength by judging the type of pain you are experiencing, and how the level of your pain is being influenced by stretching and exercise, and how long it takes you to recover from a given amount of exercise.

The key is going to be working out a schedule that strengthens your injured parts without re sparking the injury, and triggering extended increased pain after exercise. Professional consultations between you, your doctor, and a physical therapist can be productive in working out a program schedule.

Rest and Recovery

The fact is that Rest and Recovery from exercise are just as important as the exercises themselves. My "standard" interval between all exercise sessions, be it aerobic or weights, is one day working, one day off. The off day from running is the weight training day, and the day off of weight training is the jogging day. This is my goal and schedule during periods of optimal conditioning.

When restarting an exercise program or recovering from an injury I may require two or more days off between exercise sessions to allow the inflammation and pain to recede back to my current level of base-line pain. The interval of time it takes for your injury (or your body) to recover from an exercise session sufficiently to begin another exercise session is your Recovery Time.

The goal is to gradually bring our Recovery Time between exercises back down to one day, while gradually increasing the duration and difficulty of the exercises back to our normal high level of fitness.

The key to identifying the proper decision between rest and exercise is going to be based your understanding of the meaning and consequences of the pain messages and information your body is sending you, as distinct from your personal desires and goal of working a successful exercise program. You must know the differences between chronic pains that are workable, and acute pains that are not. You must have the discipline to stop working when your body requires rest.

This understanding can be built thorough carefully monitoring of your level of exercise in reference to your body's immediate and medium-term responses. The pain of overworking a healing injury can continue to intensify the day following the overwork. In this case you may want to increase the recovery time to two days between exercise sessions, and begin decreasing the intensity of the exercise session until only one day of Recovery Time is required.

Don't allow your desire to get back into shape overrule your body's need for rest, recovery, and proper healing time. I have seen as many people prolong injuries through overwork as through under work.

You are going to have to find the balance perfect for you.

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Pain Control

The most painful part of my most recent injury (frostbite) are the patches of dead, dying, and damaged skin with their withering nerves. On the other hand, re growing the skin has been as painful as feeling it die. This pain equals and ocassionally exceeds the various "class 10" pains I have previously experienced, both in intensity and duration. Serious pain control is required.

My secondary injuries are the insults to the bones, muscles, and soft tissues, composing the "structure" of my foot, caused by the same lack of oxygen that killed the skin on my toes. Overall, the "external" recovery of my skin has been about as painful as its death was. The "internal" recovery of the soft tissue, the healing of the bones, ligaments, tendons, and muscles in the front of my foot have a fierce dull aching pain similar to that I experienced during plantar facisits.

The damaged nerves in the skin are recovering sensation and growing as nerves do, through pain. The skin growth at the tip of my toe is interesting: I am growing skin with nerves and blood vessels. Quite interesting "sensations," unique variations on the theme of pain, for those you who are unfamiliar with nerve pain. Flaming, burning, and stabbing would be common adjectives.

The structural damage is reminiscent of the dull pains experienced while healing from a broken bone, much like the screaming dull pain of plantar fasciitis. This is a pain reminiscent of tissue being pulled off the bone. The nerve pains in my toes are similar to those produced by a herniated disc in one's back.

All of these pains are quite distracting during the day, and have made sleeping quite challenging. The exhaustion and psychological stresses of extended periods of constant pain are real impediments to healing. This wide spectrum of injured tissues and types of pain demands a well thought out pain control program.

Different Pains, Different Drugs

It is vitally important for both physical and mental healing to control pain. Extreme pain can significantly slow the healing process, and add extra dimensions of suffering to your injury from the resulting lack of sleep and stress.

The searing nerve pains from skin degradation on my toes are complemented by deep aching pains indicative of the"structural" damage done to the front footpad and toes. The nerve pain requires the strongest painkillers for extreme pain, while the "structural" pains traditionally respond well to anti-inflamatories and mild painkillers.

The multi-faceted nature of this injury requires that I track, treat, and medicate the different aspects of the injury as if they are different injuries, and carefully monitor the effects of the overlapping pain programs on each injury.

The extreme pain of nerve and skin degradation requires powerful narcotics. In my case I was taking 30 mg Morphine like skittles during the early phases of the injury, with days off to prevent tolerance and addiction. The structural issues, consisting of the soft tissue and bone structure problems, respond better to anti-inflammatories than pain killers.

During the initial stages of the injury the narcotics suppressed both the skin and structural pains. But as the healing progressed and I began walking on the injured footpad and foot structure, the nature of the structural injury indicated that anti-inflamatories would better address this injury than narcotics alone.

Both the narcotics and anti-inflammatories can be very beneficial to healing and recovery from orthopedic injuries, but each must be properly targeted to achieve the best results, and both narcotics and anti inflammatories have many drawbacks that require both be carefully monitored.

Great care and close monitoring of your injured part's responses to drug treatments for safety and effectiveness. Proper use of drugs can speed healing and aid your recovery of fitness. But you must carefully monitor the status of your injury without drugs to properly determine when you are actually ready to begin range of motion, stretching, and light exercise. You may feel like you can run far and long if you are all hopped-up on powerful narcotics when you should not even get out of your chair.

The onset of exercise must be carefully managed so you can get the most out of your exercises as well as your pain and inflammation control programs.

Drugs

Anti Inflammatories

The majority of backpacker's most common injuries involve sprains, tears, and a wide selection of soft tissue joint injuries. Many of these injuries can be treated on the trail with supplies on hand in a well packed first aid kit. My favorite on-trail anti-inflammation asset is the ice cold stream.

Ice cold High Sierra streams are excellent for reducing inflammation and swelling after injury. Immerse the injured part in the ice cold creek for as long as you can, then remove it. Repeat for as long as possible. Ice cold creeks are also good for sealing cuts. Just be careful not to fall in!

The cold water reduces swelling.

Soft tissue injuries also respond well to anti-inflammatories, but both of the classic anti-inflammatories, Ibuprofen and Acetaminophen, have serious side-effects, and these powerful drugs affect different people differently, so show caution when using these drugs until you know how they particularly affect you. This family of anit-inflammatories is known as NSAIDs.

Ibuprofen, Acetaminophen, and Aspirin are but a few of this large and popular group of drugs known as Non-Steroidal Anti-Inflammatory Drugs, or NSAIDs.

NSAIDs are very powerful drugs that can screw you up as easily as they reduce inflammation. Inform yourself about their side effects, monitor their effects on your system, and give yourself occasional sustained vacations from their use.

Ibuprofen must be taken with food to protect your stomach, and has a 24 hour limit of 2400 mg. It is very effective against low to moderate chronic pain

Acetaminophen is dangerous if mixed with alcohol, and is hard on your liver in any case. It is less effective than Ibuprofen for me.

More Information

This series of research articles contains important information about drugs, pain, and fitness. Check out the news and the health and fitness forums for many good bits of information.

Your participation is welcome in these forums.

Narcotics

High levels of two distinct types of pain caused by my frostbite require a serious pain management system. Both the high level of nerve pain and the intense structural pains must be effectively controlled for efficient healing and restoration of physical capability. The narcotics will cover all the pain with a broad brush, but the narcotics will not reduce the internal swelling of the foot. The anti-inflammatories will.

Narcotics must be treated with great care. Narcotics quickly lose their effectiveness as your body rapidly develops tolerance. For this reason I have a two part strategy for narcotic use.

Use

First, I use the minimum dose necessary to break the grip of extreme acute pain, and only when the pain is bordering on unbearable. My goal is to eliminate daytime use of narcotics as soon as possible, preserving the most powerful drugs for when I need them the most, which is generally at night for sleep, to rest. This reduces the daily dosage to night hours. This makes for some damn uncomfortable days. Such is the cost of maintaining narcotic effectiveness.

Second, I try to maintain a two-days on, two-days off narcotic schedule. This allows me to build up the level of narcotic in my blood by the second day of nighttime use to "take the edge off" of the extreme pain. The next day, the first day off the narcotics, is characterized by increasing pain, with the second day off of narcotics again revealing my true pain status without pain medication. From that point of assessment I monitor the pain trying to delay restarting the narcotics for as long as reasonably possible.

Early in the injury I restarted the narcotics immediately after the second day off. As the injury reached the healing stages I have been able to expand the narcotic-free periods up to 4 days before lack of sleep and extreme pain again clearly indicates narcotic use is necessary.

This strategy avoids developing a tolerance, avoids addiction, and avoids the exhausting effects extended narcotic use has on the patient's metabolism.

Misuse

If you screw up with narcotics they will lose effectiveness while simultaneously exhausting you. This will leave you fully exposed to extreme pain while dehabilitated by both injury and exhaustion, and no longer protected by the narcotic effect. I experienced this particular version of living hell while recovering from a herniated disc in the late '90s...it sucked so bad that it is hard to describe.

My point is that you must carefully monitor your drug use in reference to your level and type of pain. Take the proper type and amount of drug that properly addresses your injury. Stop taking pain killers as often as possible, and push your drug free periods for as long as possible. My drug free periods allow me to "clean out," and get a clear picture of my level of pain without narcotics, while helping to keep the narcotics effective for the pain.

Balance of Powers

My assessment of the different aspects of my injury requires that I constantly re balance my meds and exercises for optimal pain management as the injury heals. This assures that you do not over-rely on meds, which will keep them effective when you need them during the progress of your recovery.

My point is that if you only rely on drugs for pain management you are in deep trouble. This section on physical preparation is based on the fact that exercise and flexibility are the best pain management system of all. You will find that the amount of exercise you can perform at a given level of pain will constantly increase. These are simple facts about the brutal nature of healing. Though I'm vying to make this as "vanilla" of a backpacking site as possible, I've got to tell the truth about my healing, even if it's illegal and not politically correct. I owe y'all the truth.

During the two days off of narcotics I used "alternative" medicine that worked really well. Honestly, I used alternative methods of pain control to morphine that were truly amazing. Let me explain.

Morphine puts up a "wall" between me and the pain, but morphine never minimizes the pain. It's the same pain with or without morphine. I can still "feel" the full force of the pain on the other side of the "wall" put up by the morphine, and the morphine induced metabolic exhaustion makes the "morphine wall" both metabolically expensive and short-lived.

Short-lived in that the morphine does not last long,takes more and more morphine to maintain the wall, and therefore morphine must be stopped sooner than later to prevent ineffectiveness and addiction. Narcotics are great, but have serious problems and liabilities effectively moderating long term pain. I found something quite intriguing.

A friend of mine made this pot "elixir" shit (boiled down weed solution suspended in glycerin?) that actually reduced the frkn pain. This elixir did not just put up a "wall" against the pain, as does the morphine, but actually reduced the pain at its source. I kid you not. Nothing else has reduced the source of the pain, except time and exercise.

This had a series secondary benefits. When taking the pot elixir my morphine use was considerably reduced, and this reduction eased the drug load on my metabolism. If you have never done narcotics before, it puts a heavy load on your metabolism.

As the skin and nerve damage heals my narcotic use declines. Less skin and nerve damage means more and longer exercise sessions, which directly confronts and inflames the structural damage in the front of the foot.

The evolution of my healing trajectory has brought about greater stretching, walking, and finally I am throwing in bits of jogging. These changes allow reduced narcotic consumption but inflame the structural problems, the soft tissue injuries the frostbite caused in the whole front of the foot.

This requires I increase my anti-inflammatory consumption to accommodate the increasing stress exercise has brought to the front footpad's structural elements.

At the end of a day of exercise I find that the exercise seriously increases the pain in the structure of my foot, which is also accompanied by screaming pains at the dead tip of my toe. This confluence of pains resolves themselves quickly half-way through the day after exercise that triggered them, leaving me ready to repeat the exercise the following day. I am moving closer to an acceptable recovery time between exercise sessions.

The ultimate goal of this healing program is pain free fitness and exercise, which also means drug free. I am constantly moving towards this goal by increasing exercise while decreasing medication at every possible opportunity.

Exercise and Drugs as Pain Management Tools

This drop down in narcotic drug use was my response to the reduction in the duration and extent of the physical locations that I'm experiencing excruciating nerve pain. The reduction in pain was accelerated by stretching and exercise. Your recovery should follow the same positive pattern, independent of your level of pain and injury: when the injured part's inflammation and pain decreases you should increase the work load, decrease the medication, all while carefully monitoring the injury's response to the changing conditions.

Natural healing and reduction in drug use can be accelerated by carefully engaging stretching and walking therapies. Though starting physical therapy can be very painful, the benefits of engagement have again and again brought about an overall reduction in my pain and inflammation for increasing gains in strength, flexibility, and endurance. Less pain means more work, and more work for less drugs. Always follow this program when you are healing and recovering from injury.

The trajectory of healing can also go the other way. Inflammation and pain can increase during exercise, shortening the exercise sessions and calling for more anti-Inflammatories and pain meds. This brings out an important point: Always note the general "direction," or trend of your pain, endurance, and flexibility. If your pain during exercise is increasing, and your recovery periods between exercise are increasing, you may need to stop or slow your program down for a while. Beside carefully watching for chronic pain degrading into acute pain, increasing levels of chronic pain during your recovery may be telling you to slow your program down a bit.

Though the tips of my toes still go "off the hook" on a regular basis, the overall duration and extent of pain throughout my foot has diminished, especially when measured against my capability. I am aggressively using these healing opportunities to get reduce the morphine and increase the intensity and duration of my exercises. So I did. Reduction in nerve pain along with slow wound healing called for an increase in exercise. This increase in exercise triggered greater structural pain in the footpad, which required more Ibuprofen.

The structural pains consisting of the pains of the degraded muscles, tendons, and ligaments in the front of the foot (the front footpad) respond to long distance walking therapy (3 to 5.5 miles, hills) with extreme dull "chronic" pains. Treating these "chronic" structural pains with Ibuprofen has been quite successful. These pains are naturally receding more quickly after exercise sessions, and the pain experienced the day after the exercise session is diminishing.

As soon as I narrowed the recovery time to one day off between walking sessions, I began jogging sections of the trail.

Increasing Ibuprofen while reducing overall use of morpheme has been critical for to prevent and reduce inflammation during exercise, and has helped to shorten my recovery time between exercises. These chronic pain aspects of the injury require, and respond well to powerful anti-inflammatories. I have found that 600 mg of Ibuprofen before and after my exercise sessions has been working well. As I continue to "feel" better during and after turning my 3.5 mile walks into 3.5 mile jogs, I will reduce the "before and after" ibuprofen doses.

As I increase my mileage towards my goal of seven mile runs, I know this cycle of increasing and decreasing inflammation will continue. I will have to constantly monitor my body and alter my distances, recovery time, and drug regimes in response.

References

Fittness: Off the Couch, into the Mountains

Report: Exercise no danger for joints, Jan 2009.

Secondary Considerations

The inactivity and reduced activity caused by injury, in my case the first four months of almost complete inactivity following the frostbite injury, has the potential to reactivate and weaken previous injuries. You will find that new injuries can inflame old injuries, and inactivity degrades everything. This is the situation that confronts anyone who is beginning a fitness program after being sedentary for a considerable period of time.

In my case the extended period of inactivity caused by frostbite has really fired-up my previous knee, hip, and back injuries. You must consider your particular situation and previous injuries. The longer I sit static, the worse every old injury feels. Every day of inactivity is like having my knees, back, and hips beaten with a club. Add to these effects the loss of general fitness caused by eight months of inactivity, and these factors require a considered approach to restarting stretching and light exercise.

The good thing is that the irritations of these previous injuries are also addressed by the anti-inflammatories and pain killers.

Like me, you should be carefully monitoring the pain response of all my injured parts to my carefully applied stretching and walking therapy. I compare my "normal" baseline level of static pain with the pain caused by exercise and stretching.

I have noted a steady increase of strength and endurance for the same amount of pain as I continue to stretch and exercise my foot by walking.

I have been steadily reducing the use of narcotic pain medication as exercise increases, though my use of anti-inflammatories has increased.

So far, so good.

As the walking and stretching programs continue to make progress I will continue jogging longer sections of my walk, and extending the overall length and elevation of my walk.

We're on our way back.

Next we will begin to put together a well-rounded aerobic and weight lifting program that will ease our transition to carrying a heavy pack on steep inclines at high elevation.

See the Recovery Program Page for more on Pain and Pain Management.

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Don't Rush It

You must not overwork the injured areas or you will put yourself at risk from further injuries, as well as risking re-injuring the damaged part. Sometimes the inflammation from orthopedic injuries can take quite a long time to settle down enough so you can begin to work them back into shape.

I have experienced too many "false starts," where an exercise program following an injury fails in the face of sustained pain, to be overly-optimistic. I've thought my backpacking days were over a few times during my life.

After fracturing my Left kneecap into six parts in 1975, I refused the teflon kneecap replacement surgery the Navy offered me. It took nine years before I could finally exercise my leg without bringing on acute knee pain. Nine years after the accident I was finally able to maintain moderate chronic pain through sustained aerobic exercise, and not be crippled the next few days afterwards.

Some of these injuries are quite scary. I popped a (tendon?) on the inside of my Right knee in 2007, and my lower Right leg swung outward perpendicular to the normal "forward and back" motion of the lower leg. Yikes. It took six months to just get the damn lower leg to stay in place, and another six months of careful strengthening work before again strapping on my heavy Winter pack.

When these knee injuries hurt today I fear they will cut loose again. The Right knee will not. Though sometimes painful, the pain is merely a remnant of the original injury. I gradually brought the joint back to full capacity with exercise and finally a set of backpacking trips of ascending difficulty. Though the Right knee joint has developed some chronic pain following its injury, its range of motion and capacity are again within operating specs. I have a high degree of confidence in my Right knee.

The Left knee operates with chronic pain that may become acute. I can feel the transition between chronic and acute pains. This knee goes "bad" every five or six years. My backpacking kit requires the proper first aid kit with good wrapping materials and drugging capabilities. By far the best protection on the trail for previous injuries is your physical preparation before hitting the trail.

Both of my earlier knee injuries demand a regular schedule of exercise and stretching to maintain strength and flexibility. When this schedule is interrupted by a new injury, both my knees begin to deteriorate.

Therefore my recovery program from any new or old lower body injury must take into account the status of my knees, and other earlier injuries. No injury stands alone. Each injured part affects the parts around it, as well as previously injured parts.

Proof of recovery for my knees was hiking 420+ miles between Tahoe and Whitney early in 2009 (I think I hit 450, but I've got to add it all up...) followed up by 181 miles on the Tahoe to Yosemite Trail without re supply in Sept of 2009. Good to Go...until this frostbite bit, and everything falls apart, again.

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Self-Guided Recovery

My point is that a self-guided recovery from many lower body injuries is not impossible for many injuries that the doctors would normally prescribe surgery. During my life I have refused two lower body surgeries. Both injuries have recovered superior conditioning than the surgery would have allowed. My rule is no replacement surgery until the body part is totally worn out or falls off.

The key to successfully preserving your parts is regular physical engagement expressed through regular practice of flexibility, strength and aerobic exercises while monitoring and understanding your body's feedback from these exercises. Proper rest and recovery from exertion is vital.

Since you are here, you are looking at starting your backpacking fitness program "at the beginning." The first steps after fundamentally healing the injury are to establish the fundamental basis of long term stretching and walking programs. The stretching is the permanent foundation of your fitness program, and backpacking is the constant goal.

Our means is our end.

Truth and Consequences
Base Level and Recovery Time

The application of stretching and walking will cause your freshly recovered parts to respond with pain. You must instantly respond to that pain by slowing, stopping, or modifying the stretch or walk as is necessary to prevent further injury, while carefully monitoring the effect of the exercise/stretch during the following 24 hours. Has swelling, inflammation, or extended bouts of increased pain resulted from the stretching and walking?

If so, but you are not re-injuring yourself, note the time it takes for the pain and inflammation from the exercise to diminish. This is your Recovery Time. Now we need to gradually work up to the point where you can perform your exercise and walking session without sparking a session of acute pain and inflammation.

Cut down the distance of your walk and the strain of the stretch on your injured part until you can perform each without sparking excessive inflammation. This is your Base Level.

Once we determine our repeatable Base Level we will now begin attempting to bump-up the difficulty of each exercise from our Base Level by small increments without sparking sessions of increased inflammation and increased pains which would call for extending your Recovery Time.

As we do this we will have to pay careful attention to getting the proper rest, drugs, and Recovery time between exercise so you can consolidate the gains of work without re-injuring or further injuring yourself.

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The Successful Program

A successful program will be characterized by shortening recovery times between exercise periods while increasing the time and difficulty of the exercise sessions. I try to keep the level of pain consistent: I want to experience the same moderate levels of pain, or even less overall pain, for greater and greater amounts of work.

The Unsuccessful Program

The unsuccessful program is characterized by quick onset of acute pain upon exercise, increased continuing chronic & acute pain after the exercise is terminated, causing extended recovery times between exercise periods. These symptoms indicate that you need more rest and a reduction of activity to suit your circumstances.

Even a basic stretching and exercise program cannot begin while you are still experiencing the acute and inflamed phase of injury healing, when the stimulation caused by movement itself still triggers acute pain and inflammation. If you are still experiencing acute pain moving your injured part after the injury is healed you must determine if the pain is a symptom of ongoing damage and disrepair, or is part of the natural process of injury recovery.

Some joint injuries continue to hurt bad after they are healed: Enduring Pain

This is a good time to consult the doctors. Their machines can peer into your body and determine the nature and extent of soft and hard tissue injuries. Sometimes the joint or tissue is just at the end of its life, damaged beyond recovery, and is beyond recovery.

Other times chronic pain is enduring, but the hurting part is still usable.

After unsuccessfully trying everything possible to self-restore the injured part there is a proper time for surgical interventions and parts replacements. But the time for surgery should only come after you have exhausted all other options.

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The Bottom Line

Pain is subjective, but the source and consequences of pain are not subjective. Either the pain is a sign of ongoing injury, irritation, and inflammation ("Acute," by my definition) which demands no exercise and plenty of rest, or it is a "chronic" pain. Chronic pains in many instances will haunt old injuries until you take your last step on this planet.

My goal is to eliminate or reduce acute pain so that exercise and stretching may be commenced on your injured parts. Once acute pain is under control we now have the task of managing chronic pain sufficiently while building greater strength and capacity to again make us capable of long distance backpacking in the difficult conditions of the High Sierra.

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