The Injury Commandments

March 6, 2021

This article was originally posted in August 2017 by Chaski Coach Amelia Boone here.

While it’s not something I’m exactly proud of, if there’s one thing I’ve become well-versed in this past year and a half, it’s been dealing with an injury. And not because I’m the master of recovering and returning to the sport in record time, but because I failed hardcore at it. I screwed up injury recovery in pretty much every way possible, and I paid for that. I’ve spent a lot of time this past year writing about the mental side of injury, yet haven’t touched much on the nitty-gritty of rehab and rebuilding, for two main reasons:

(1) I made a lot of really foolish mistakes

(2) I’ve been afraid of jinxing myself (seriously, I’m superstitious like that)

Yet, like with all the writing I do, I always hope that my blunders, screw-ups, and errors can hopefully help someone else, so I figured it was time to nut up and admit all the things I did wrong, the (few) things I did right, and the things I wish I had done differently (#nojinxnojinxjnojinx).

DISCLAIMER BECAUSE I’M AN ATTORNEY AND REALIZE THAT THESE DISCLAIMERS DON’T WORK ANYWAY: Please realize that this list is personal to me and based on my experience. I’m not a doctor, nor do I play one on a 30-minute sitcom (though I always liked to think that Elliot from “Scrubs” was my soulmate). These are simply things that worked for me: take what you want and leave the rest.

1. Be careful with cross-training

The minute an athlete receives a diagnosis from their doctor or physical therapist, the next question is always “ok, but what CAN I do?” (Bike? Swim? Aquajog? Errr…“deep water run”). It’s natural. We are endorphin junkies, and we are afraid of losing our fitness.

Built-in crutch-holders…safe Amelia, real safe

I did it. I fractured my femur, and the next day, I was in the pool, swimming with a pull buoy between my legs for as long as my bored mind could take staring at the line on the pool floor through my tears. I started Assault-biking with one-leg and arms only and ski-er-ging sitting down (which I did for sometimes an hour-plus, every day). I did sets of pull-ups until failure and push-ups on one leg. I clung to fitness in every way possible. And it worked. When I came off of crutches from the femur, I was rearing to go: my fitness was there, but my muscles, tendons, and bones were not ready for the impact yet. And within 3 weeks, I was down again with a second stress fracture – this time in the sacrum.

With the sacral stress fracture, I tried a different approach on the advice of Mario Fraioli, who was kind enough to speak to me about his experiences with multiple sacral stress fractures.  Guess what he recommended?

My unpopular opinion: aqua jogging is BS.

No cross-training. Rest. Completely.

I instantly balked, but I saw the rationale: while cross-training may help your mind, when done to an extreme like we obsessive compulsive athletes are prone to do, it can actually create more issues and imbalances in your body.

It’s for this reason that I see more and more doctors (and more and more professional athletes) following a progression similar to this after an injury (specifically, a bone injury):

For a month after the initial injury, nothing. Complete rest. From there, start light cross-training (swimming, biking, etc., depending on injury). But that first few weeks of complete rest at the outset of the injury is SO crucial to jumpstart the healing process. I wish I done that the first go-round, and it’s a model I’m seeing more and more professional athletes follow. Sure, you may lose a few points off your aerobic fitness in those few weeks, but it will come back, I promise.

Two things, however, that I wish I had done but didn’t. First, keep up with your mobility (within safe boundaries). When you have a major injury, your body is going to learn new compensatory behaviors, and those are hard to break. For me, I spent 4 months on crutches hopping on one leg with the femoral stress fracture, yet I never considered the ill-effects that could have on me. Second, keep up with all the body care/soft tissue work. I told myself that I didn’t need bodywork because I wasn’t training, whereas the opposite was true. That down period was my time to take care of long-standing issues and soft tissue adhesions that were causing problems. Further, when your body is protecting an injury, your other muscles clamp down and compensate to protect it, leading to even more imbalances and restrictions. Yet because I felt like I wasn’t training, I didn’t feel “deserving” of massages or other work. Bullshit. Injury is the time to take care of all of those full-body imbalances. Use that time.

2. Eat. More.

This one is counterintuitive. When you go from 100-mile weeks to…nothing, the temptation as an athlete is to cut way back on intake because you are no longer putting in long training days. We all fear weight gain with an injury. What I wish I had known, and what I wish I had realized, is that it’s greatly beneficial to actually gain a bit of fat and weight during injury. My coach, David Roche, uses the term “get squishy” – not only can the extra food and weight help with healing, but it also helps reset adrenaline and hormones that are probably beaten down from months and years of hard training. Use injury as a reset.

Stuff your face like you are mid-100k race

I did not do this. In fact, I actually lost weight during the injury because of my inability to use my legs (and later, my upper body). I’ve always built muscle really quickly in my legs, and it came off just as quickly. With the sacral stress fracture, I had to stop lifting anything heavier than a box of Pop-Tarts, so my upper body atrophied as well. I should have welcomed some extra fat, but instead, I just…withered.

Therefore, in rebuilding, I also had to be conscious to gain weight while starting training again. And I've successfully put back on the weight, but it’s a difficult balance where I have to be limited in miles and training because of my history of bone injuries and track my weight to make sure I’m eating enough to gain while increasing training and mileage. Had I adhered to Operation Get Squishy, this would not have been an issue. Even before the injury, I had hovered close to single digits in body fat, but I now realize that, especially for a female athlete, staying that lean, while socially applauded (insert eye roll and a whole different can of worms I’ll open some other time) only increases my propensity for bone injuries. With a bit of extra “trail padding,” injury risks substantially decreased.

So…embrace the squish during injury: it’s necessary for healing and durability.

3. Placebo can be a wonderful thing…for your mind

There’s a feeling of helplessness that’s associated with injury. Your body will heal on its own timeframe, and, as much as you will it to heal faster, in reality, there’s probably very little you can do that will actually move the needle.

That, however, did not stop me from trying. I tend to throw everything at my injuries: you name it, I’ve tried it (lasers, bone stimulators, e-stim, acupuncture, dry needling, magnets, herbs, poultices, the list goes on). Did any of them actually help speed the physiological process of healing? Probably not. Did any of them help the psychological process of healing? You betcha. With a long-term injury, it’s easy to lose hope. Treatments, whether they be placebo or not, can give you that sense of hope. And in a situation where you can start to feel very stagnant and helpless, being proactive can do wonders for you mentally.

4. Startup slow. No, even slower than that.

I finally got the a-ok to run after a clean MRI in December, and I plotted carefully the return (after failing miserably at “return to running” after the femur) with my coach, David Roche. After being off from running and any type of impact for 9+ months, we had to treat me like a new runner.

Holy shit, it sucked. The first glorious run back? 1 mile. Run 400m around a track at a 10-minute pace or slower. Walk 200. Repeat till I hit a mile.

And then, a rest day…you’re kidding, right?

No, no I’m not. For the first few weeks, runs were 1-2 miles, every 3rd day, then every other day. Paces were no faster than a 9:30min/mile. As coach reminded me, we are not “running,” we are getting the body used to impact again. Getting used to pounding. Getting the muscles and tendons and bones to strengthen and respond.

Mid-pre-dawn 3 miler

These runs weren’t glamorous. There were no epic scenery shots, no mountain summits. Most were done pre-sunrises, around a 1/3mile dirt track, barely breaking a sweat. But I had to trust the process.

It was maddeningly slow. And still, 7 months out, rebuilding still feels like a slow and never-ending process. But whenever I start to doubt progress, I take a look back through my training logs and remember that it’s always about baby steps. At the end of January, I was running 10-15 miles a week at a 9-10 minute/mile pace. Mid-April, I was hovering around 30mpw. And just the other week in August, I hit 60 miles for a week for the first time, including 10,000 feet of climbing. Building a base takes time, and the temptation to rush right in is overwhelming, especially if you are feeling good. But for me, that’s the beauty of a coach. I don’t need a coach to push me harder – I need a coach to rein me in.

(Side note: if you are interested in seeing my training logs in how I came back to running, let me know. Happy to share. UPDATE: I’ve received a lot of requests, and I realized I should have probably actually compiled them first…whoops! I will work on that and then find a way to share – thanks for your patience!))

5. Compensation is a Bitch

The great thing about bones and muscles and tendons is that they heal. The bad thing about the healing process is that you (mostly unconsciously) learn new movement patterns during convalescence to protect that injury.

Example 1: Being an Idiot. When sentenced to crutches for the femur, I didn’t exactly take it easy. I crutched up and down a mountain. I crutched all over the Western States (8 miles that day!), and I crutched everywhere I could “for exercise.” So no wonder, after being on crutches for 4+ months, I dealt with some serious imbalances (hello left calf twice the size of the right!). When I flung the crutches aside, I didn’t account for how the left side of my body had been bearing the brunt of forces for the last 4 months, hopping on one leg. And worse, I did nothing to try and unravel that. Needless to say, within 3 weeks of being back on two feet, I was hit with a sacral stress fracture. Guess where? The left side. Funny how that works.

Example 2: Protective Mechanisms from Fear. With the sacral stress fracture, I was pretty much scared to twist/turn/lift – pretty much do anything that involved my back. If you’ve ever had the unfortunate experience of breaking your back, or a ruptured disc, or ANY type of back injury, you know how debilitating they can be, because EVERY movement involves your back. In an unconscious effort to protect that bone, everything else clamped down around it. Tight muscles impinged on nerve roots, causing radiculopathy down my sciatic nerve and my entire leg. When I finally started to move again, I had developed unconscious patterns of protecting my back, and sciatica and nerve issues continued well past the healing of the sacrum itself. Cognizant of not doing what I did with Example 1, I spent months in physical therapy, focusing on unwinding those protective mechanisms.

So how do you combat compensation? Once again, with two dreaded four-letter words: “rest” and “time.” Rest during the injury healing period to prevent yourself from developing new compensatory patterns (no crutching marathons!). And time to rebuild the trust in your body, and to break the habits.

6. Focus on strength first

This one is mainly directed towards runners: what’s the first thing you are itching to do when you get the all-clear from the doc?

Run. Obviously.

It’s exactly what I did, for two reasons: (1) I love running for the sake of running, and I hadn’t been able to do it for 9+ months; and (2) honestly, I was scared of strength work. It’s rather embarrassing to admit this, especially coming from a girl whose main training for obstacle racing for many years was CrossFit. But for whatever reason, the thought of squats/deadlifts, or hell – ANY type of weighted movement – was terrifying to me, while running (the thing that arguably injured me in the first place) was not.

So I started running and soon realized that simultaneously starting a (1) return to running program and (2) a strength-building weight training program was, well, a bit difficult.

What would have been smarter? Start with strength. When I was cleared for impact, ideally I should have started with squats, deadlifts, and plyometrics – the basics of a strength program. (Side note: I ALWAYS did my PT exercises, but those have been mainly unweighted and, well…PT movements…). And after getting comfortable with those and rebuilding that strength, then focused on running and impact.

PT is great, but I needed weight (both on my body and lifting)

6+ months out from the final negative MRI, I’m still struggling to find a balance between it all – I’m still well-aware that both my upper and lower body strength has not returned to pre-injury levels. Would it have come back quicker had I not jumped immediately into running? I can’t say for sure, but I think it would have been wiser.

7. Things aren’t going to feel right: Expect phantom pains and freak-outs that you’ve reinjured yourself

This is a tough one. When you first start back to training (and especially running), after many months off, you are bound to be hyperaware of every ache and pain. This is especially true if you are coming off of stress fractures. For me, ANY pain that I would get near either my sacrum or my femur instantaneously flung me back into a fear of another stress fracture.

The mind-body pain connection endlessly fascinates me, and it’s been increasingly evident to me in rebuilding from injury. I joke that the quickest way to get over an injury is to make something else hurt worse, but I firmly believe it’s true. You can really only feel pain in one place, and if your mind is hyperaware of a previous injury, you are going to channel ANY pain remotely close to the area into that one spot. It’s beyond frustrating because all anyone ever tells you to do is “listen to your body,” but when you go from being a person who feels NO pain at all to all of a sudden feeling EVERY pain possible, it’s difficult to know what to trust.

In these past 6 months, I’ve spent MANY days in tears and frustration that I’ve reinjured myself (something more than just a minor niggle requiring a few days off). People had warned me about phantom pains and I pushed them aside, thinking I’m smarter than that.

Real talk: nope, that shit is real.

I will sometimes be running and have a sudden flash of what I think is pain through the sacrum, and then it will disappear. Or through the femur, as I’m going down a steep descent. Is it in my head, or is it real? Honestly, I don’t know. But if it’s momentary and then settles, then I feel ok going on. The fact that they both seem to flare up before races also indicates a lot is in the brain.

Err on the side of rest

So how have I worked through this? Honestly, not well, but the number one thing I’ve found that helps is to log EVERY niggle and ache and pain during training. And if a niggle continues on for more than a few runs, I adjust and address it (often in the form of taking an extra prophylactic rest day or two). You won’t lose fitness from a few extra days of rest or cross-training, but you can nip niggles before they become nags before they become “break yo’ effin’ bones.”

8. There’s no such thing as a straight line

Rebuilding is going to be a maddeningly frustrating process of two steps forward, one step back (hell, sometimes it’s one step forward, three steps back). And there’s going to be a bunch of stops and starts. Since I was cleared to return to running ~8months ago, I’ve had at least 5 stints where I had to take anywhere from 3 days to 2 weeks off from running to address little injuries (fondly referred to as “niggles”) that popped up along the way. Each time, I would be thrown back into a pit of despair that I was once again broken for the long-term, that I was going to perpetually be THAT “injured girl,” and that what little fitness I had built was now wasting away.

Starts and stops with various foot freakouts and niggles

And it’s even tougher to look around at social media and at other athletes and think “hell, they NEVER get injured” or “they never seem to miss a day” (aside from a planned rest day!)…ergo “WTF IS WRONG WITH ME.” Whether or not it’s true, I’ve chosen to tell myself that hey – EVERY athlete has to take a few days off here and there to “get things right.” And in rebuilding, it’s probably going to be even more than normal. There is no straight line – just a messy, twisted, muddled path that we are all trying to figure out. Just remember that unplanned rest days and short breaks are part of the plan, after all.

9. Patience, young grasshopper

I’ve been running and training consistently, with some hiccups, for a good 6 months now. And I’m itching to get lost in the woods for hours every day and run ultras again, but I know that I still have to be cautious given my (now) history of bone stress injuries.  Honestly, sometimes it gets to the point where I feel like a caged animal, and I just want to be let loose.

I see so many folks around me ramping up mileage quicker than I did, or crushing ultras on just a few months of training. And my mind will immediately go to comparison: “why do THEY get to do x, y, and z?” “Why am I still struggling feeling out of pace and dealing with niggles and the never-ending ups and downs?” “When can I run for hours (or days) at a time again?”

But I have to remember that it took years of consistent training (which I was fortunate to have!) to build a base, and it may take close to that long to do it again. And while I had grandiose plans for 2017 of world domination, I’ve come to a place where I’ve accepted that 2017 is still going to be a rebuilding year and that the first thing that has to be set aside is the ego.

So I’ll bide my time. I’ll celebrate the little victories. I’ll avoid comparisons. And I’ll love the process.

10. The only way to overcome your fears is to face them

At some point, you will get back to racing. And you will get back to doing the things you did that (potentially) caused the injury in the first place. Your first time facing that is going to be beyond nerve-wracking. I’ll give you two examples.

Because of the sacral stress fracture, I feared pulling any type of weights from the ground. I feared deadlifts. I feared holding weight over long distances. So here’s something I’d never thought I’d say, and I’m embarrassed to admit: I was scared of a tire. The thought of reaching down to the ground to flip a 200lb tire sent phantom pains flashing through my lower back, through my previously broken sacrum.

And it’s not just the tire. I was scared of a bucket carry – of 60lbs of rocks up a mountain. How ironic is that? My very favorite obstacle, the one that I have become known for, was the one that has prevented me, along with said tire, from returning to run a Spartan Race.

That bucket scared me. But each time, it gets easier.

Or, let’s take the case of the femurs: one of the many contributing factors to my femur fracture was the number of steep descents I was doing (in preparation for the Western States, I told myself). So my coach (#SWAP4LYFE) and I have been limited my descending in these past few months because of the toll it takes on your bones and the impact forces it puts through your femur.

But to return to obstacle racing, I had to face both of those fears. In Monterey, I learned that I could flip a tire without breaking my back. In Palmerton, I learned that I could go run down steep descents without fracturing my femur.

It’s a process of learning to trust your body again. You have to face that fear, to push that boundary, and realize – hey, I’m not broken. Hey, my body still knows what to do. And the only way to get there is through time and repetition.

I’m not there yet. I still have a long way to go to trust my body again. Rehab, recovery, and rebuilding is a fine dance of pushing the boundaries, testing the limits, and then learning when to pull back. But I know now that sometimes you have to take that risk, and to face down that demon, to learn that you can come out the other side.

Finally, find what works for YOU, and ignore how others did it

Now that I’ve bored you for 3000 words plus, I’ll tell you to ignore all of it and do your own thing.

Kidding. Kind of.

Recovery from injury is a highly-individualized process. No two people are going to have the same exact injury or the same root cause of the injury, so no two rehab and recovery plans should be alike. I spent a year getting caught up in the depths of Google, figuring out how other people rehabbed and berating myself for not coming back as quickly as others or for not following their exact protocol. Time and time again, I had to force myself to step back and acknowledge that I am a different person, with a different set of injuries and contributing factors and root causes, so one person’s plan may not work for me. All you can hope to do is take helpful nuggets that you can use and leave the ones that you can’t.

Here’s to health, happiness, and the ever-constant pursuit of a pain-free run 🙂

— Amelia Boone

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