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SAFETY and PREVENTION

        

Preventing Injuries From Falls in the Backcountry



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Though not something we often think about, our balance tends to erode with time. For weekend athletes, lost equilibrium can mean more spills on the slopes or wipeouts in the surf. For the sedentary, it can bring a surprise encounter with the sidewalk. Yet falls aren’t an inevitable consequence of growing older. It’s possible to regain equilibrium and compensate for permanent balance deficits.

Harvard Medical School Health Publications, 10.23.07

Central Issues Addressed in This Article

What kinds of strategies should be given priority for preventing tripping and falls? Which of the more controversial strategies are worthy of consideration? What long-term behavior changes will be most effective for me in a “falling prevention” program, especially if I am not super-coordinated?

Introduction

Falling (tripping, slipping, sliding) is arguably the most common cause of accidents suffered by backcountry travelers. Injuries to the lower extremities caused by falling (sprains, strains, tears, breaks) are common and something that is largely preventable. Many things contribute, directly and indirectly, to ankle, knee, hip and back injuries. Age and genetics are two causes we cannot do much about. But there is so much we can do. Consequently, this article identifies numerous prevention strategies. Some are common sense, but many are not. Some “common sense” solutions (e.g., wearing stiff, high top boots) turn out to be quite controversial. Some strategies are supported by the medical literature, but most are not adequately researched. Most of the strategies shared below are commonly found in the sports medicine community.

The strategies presented in the next three sections come from a variety of sources (e.g., books, Internet research, discussions with certified medical practioners, personal experience). They cover a wide range and are grouped into three categories: highest priority, second priority and controversial but worthy of consideration.

Highest Priority Prevention Strategies

Weight Reduction: Reduce weight wherever you can, but especially in three areas: body fat, what carried on the back and what is worn on the feet. Even if you are a big boned and heavily muscled person and can carry weight easily, the knees and ankles are still a weak link. Weight reduction is necessary to increase mobility, decrease risk of injury and decrease fatigue. A high priority in this context is reducing the total weight of your complete footwear system (shoes, insoles, socks, gaiters, strap on traction). Reducing the weight of footwear is usually the easiest of the three mentioned. The lighter the footwear, the easier it is to get accurate foot placement on uneven ground. The lighter the footwear the less energy will be expended. A commonly accepted rule of thumb is one pound on the feet is equivalent of 4-6 pounds carried on the back. A good compromise for many is a mid-height, lightweight hiking boot made of mostly synthetic materials. Not only is reducing the weight of footwear a good prevention strategy, it also makes hiking and backcountry travel more fun and enjoyable (light of feet = light of heart?).

Conditioning: Get in top condition, especially in the body core and lower extremities. Besides having the strength to avoid potentially bad situations, being in top condition will increase stamina and reduce common end-of-the-day injuries that happen when one gets over tired. When tired, it is well known that one is less coordinated and less likely to react to normal terrain obstacles. Personal experience strongly supports the relationship between conditioning and coordination. If I haven’t been out hiking for awhile, I notice a significant reduction in my coordination when traveling over rough ground. Combining good conditioning with weight reduction will greatly reduce the fatigue and lack of coordination factors. If possible, tailor your conditioning program to your specific types of outdoor recreation. A great book to assist in this is: Conditioning For Outdoor Fitness by David Musnick, M.D. and Mark Pierce, A.T.C. (2nd edition, November 2004). Better yet, hire a personal trainer not only to suggest the most appropriate exercises, but also to hold you accountable when your motivation is flagging.

Defensive Hiking: As defensive driving is used to anticipate driving hazards, defensive hiking can alert a hiker to potential terrain disasters. Be attentive; constantly and habitually scan the trail ahead, alternately looking out 10 or more feet ahead to pick out the best route and then looking closer for more precise foot placement. Minimize looking at the scenery while hiking; consciously stop and rest a bit when you want to look around. Defensive hiking will also include adequate rest stops, especially towards the end of a long hiking day. Defensive hiking involves a lot of self-discipline, but it is a mindset that will go a long way in injury prevention.

Pole Support: Use trekking poles for balance and stability. Two poles are best for many reasons, but one is still quite effective for the purpose of balance and stability. See the article “Four Wheel Drive—The Case for Trekking Poles” for detailed information on the many advantages of pole use.

Adequate Traction: Wear footwear that will give you adequate traction for the surfaces encountered. Have your boots resoled when they get worn down. Replace trail shoes when they get worn. Carry traction devices for especially slippery surfaces (i.e., strap on spikes, cleats, crampons, snowshoes).

Good Light Source: Avoid walking around in the dark or fading light without a good light source.

Basic Ankle/Foot Exercise Program: My daughter, who is a certified physical therapist, recommended this exercise program. It is also the program I have used over the years to overcome a chronically weak left ankle. Using it, along with other strategies, has resulted in a personal reduction in ankle sprains and rolls to nearly zero. Besides the basic exercise program, Carla has made numerous other suggestions for improving this entire article. Following are two highly recommended areas of concentration:

Calf Stretching and Strengthening:

“The most important ankle muscle is the calf; this is what you use to take the weight off your heel and shift to the ball of your foot when your ankle starts to twist.” [Matt Mahoney, as quoted in Fixing Your Feet: Prevention and Treatment For Athletes, 4th Edition, page 250]

For stretching, use one bent and one straight knee, usually with both arms leaning against something. Alternate legs. For strengthening, routinely do calf raises in a standing position. For both stretching and strengthening at the same time, stand on some stairs with the ball of your foot and do calf raises (one leg at a time using arms only for balance); then lower your foot as far as it will go and hold for 15-30 seconds. Do both sides equally. Running barefoot in the sand is also good for calf strengthening, as is running backwards and sidewards.

Balance Training (proprioception exercises):

“Proprioception” is the feedback between sensory tissue, our brain and our muscle. By sensing the angles and forces in each movement of our feet, the brain can fire the appropriate muscles for stability and then movement. [Steve Gurney, adventure racer, quoted in Fixing Your Feet: Prevention and Treatment For Athletes, 4th Edition, page 247-248]

A relatively simple proprioception exercise is to stand on one leg while doing mundane tasks like brushing teeth or watching TV. Extend this exercise by looking up, down and side-to-side while on one leg. Another more challenging exercise is “stork standing” where you stand on one leg while on a soft and unstable cushion, bend over with the body and knees as if to pick up something off ground, and then straighten up.  Another is to practice standing on one leg with eyes closed (have a support nearby). Also good for balance training is hopping first on two feet progressing to one foot, up and down, backward and forward, side to side. There are many other balance type exercises. There are three major balance systems the help us stay upright: inner ear (vestibular), eyes, and sensation feedback from our feet and joints (Proprioception). Exercises like those above will improve balance by forcing one or more of the systems to work harder. Like when you close your eyes you the make the other two balance systems work harder.  If you want to hike at night, you will want to develop the other two systems by closing your eyes while performing balance exercises. Balance tends to take longer to improve compared to a strength-training program.

 Cartoon sketch about the season of falling

Second Priority Prevention Strategies

Pre-Trip Analysis: Check topography maps for steep and difficult terrain. Research guidebooks and other written descriptions of the planned area of travel for potential problems. Check that all party members have the appropriate equipment for the terrain to be traveled (e.g., internal rather than external frame pack). Check for weather conditions that might suggest problems with mud, ice, snow, blowdowns, lack of visibility, etc.

Review Prevention Strategies With Inexperienced: If you are a group leader or have inexperienced members in the party, review both the risks and prevention strategies before getting into difficult terrain. For example, set a realistic turn-around time for day hikes so that the group gets back to the trailhead before getting exhausted. Establish regular stops for hydration, nutrition and rest. Swallow your pride and abandon a route if it is proving to be too tough.

Stride and Pace: Shorten the stride, especially in rough terrain. At the same time, speed up the cadence for more efficiency and to maintain the pace. Keeping up a good, fast pace both on the trail or off trail will force you to concentrate more on foot placement and to hike more defensively. On a side note, consider that competitive cyclists and runners commonly acknowledge that higher cadence peddling and running is a more efficient energy output, and hence less fatiguing. 

Flexibility Exercises: Regularly do flexibility and stretching exercises so you can more easily respond to a fall without serious injury. Typical muscle groups that get tight are the Hamstrings (back of thigh), Quads (front of thigh), and lower leg musculature (ankle, Achilles, calf muscles). Active people tend to stiffen up more. The same happens as we age. Consider regular Yoga classes for a more comprehensive stretching program to help guide and motivate your stretching efforts.

In The Field Balance Practice: Travel off-trail regularly. Walk or jog on soft and uneven terrain even when an easier route will take you to your destination.

Off-Season Conditioning: In the off-season, participate in activities that develop strong legs and good agility and coordination. For better balance and whole body conditioning, practice Yoga, Pilates or Tai Chi.

Consult a Footwear Specialist: Buy footwear at hiking specialty stores. Call ahead to determine when their most qualified staff person will be working. Wear boots and trail shoes recommended for the specific kind of hiking you will be doing. Footwear for lightweight day hiking is quite different from that recommended for extended off-trail use with a heavy pack.

Orthotics and Inserts: Use a quality insert or orthotic (either over the counter or customized by a professional) that provides most or all of the following:

·      substantial arch support

·      well formed heal cup for stability

·      designed to correct any diagnosed foot problems

·      designed with a substantial “metatarsal arch” in the fore foot area to spread bones and toes to provide a wider and more stable platform.

Two common problems are supinators who tend to have a high arch and roll to the outside and pronators who tend to roll to the inside. Orthotics and inserts, properly selected, can assist in correcting either of these problems. For an in-depth treatment of this subject, link to the article titled, “Orthotics and Inserts for Backcountry Travel.”

Controversial Strategies Worthy of Consideration

Even though this whole topic has controversial elements, this section includes  strategies that will often be seen as controversial. Some will contradict each other. I offer them with no attempt to evaluate their effectiveness.

Footwear With Maximum Flexibility: Instead of boots and trail shoes that have stiff “torsional” (side to side) stability (the traditional wisdom), it is better to have a running type shoe with maximum flexibility and mobility to develop leg and ankle strength as well as increase balance and mobility. Consider reviewing the article titled, “ Boots, Shoes, Sandals and Barefoot?” for a thorough critique of using hiking boots for ankle support and stability.

Stiff Boots: Wear stiff “off-trail” boots that give good ankle support. Consider adding elastic ankle supports (“ankle braces”) in the boots to allow for tighter lacing.

Thin Soled Footwear: Avoid footwear with thick or soft outer soles or insoles that can have a negative effect on balance. Gradually condition your feet to accept thinner and less cushioned footwear. Thinner footwear will also provide a better feel for the terrain. They will lower the center of gravity for your foot and will gradually strengthen the muscles of the foot and lower leg. Boots and shoes with an accentuated heel profile are to be avoided for the same reason.

Minimalist Shoes or Barefeet: Consider hiking in a minimalist shoe (e.g., Vibram’s Five Fingers, Nike’s Free shoes, sandals, racing flats) with only a thin outsole to protect your feet from the harsh ground or no shoes at all. In this same vein, Here is an interesting quote supporting this strategy:

 This lack of insole and other traditional shoe parts makes our lazy feet muscles and tendons actually do the work they were meant to do before we coddled them with amazing shoe technology. This is one of the reasons Kenyans are so seldom struck by running injuries, their feet and associated ankle muscles work correctly.

—David Thul, BackpackingLight.com forum

Practice Falling: Practice falling or rolling in ways that will minimize damage. Practice falling on soft surfaces and in different directions. Do not fall with your hands straight out (to avoid obvious injuries), but with more of a “tuck and roll” motion.

Slow Down: Instead of keeping up a fast pace, eliminate speed and pace oriented objectives altogether. Falls happen when people are in too much of a hurry.

Avoid Dependence Upon Supports: Unless needed because of injury or deformity, do not use canes, hiking staffs, trekking poles or other crutch-like devices. They gradually allow natural balance mechanisms to deteriorate.

Don’t Tape Joints: Taping the ankle has been shown to offer little benefit. Adhesive tape loses about 50% of its stabilizing power in the first 10-20 minutes of exercise.  [Dr. Bruce Beynnon, a biomechanical engineer at the University of Vermont]

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Adding these more controversial strategies to the mix should provide a more comprehensive understanding of the entire subject and provide more options to consider. I personally agree with some, disagree with others, and haven’t formed an opinion about yet others. What do you think?

Reader Participation: Potential Changes in Behavior

Many of the strategies presented in this article will be obvious to the highly experienced hiker. However, it is still a good idea to review them occasionally and acknowledge areas that need some attention. To assist in this process, first add any important strategies that have been missed. Second, consider circling a few of the presented strategies that you intend to focus on or experiment with for the next few hikes.

Final Thoughts

The primary focus of this article is on the prevention of more acute injuries caused by falling. It is not intended to provide strategies to deal with chronic and intermittent pain caused by such things as overuse, physical deformities, past injuries, ill fitting footwear, etc. For these types of problems, it is best to first consult with your preferred medical professionals (e.g., podiatrist, orthopedist, physical therapist, acupuncturist, chiropractor, massage therapists).

My strategy of prioritizing prevention strategies into three sections (Highest Priority; Second Priority; Controversial) is not meant to be the last word. This structuring will hopefully serve as a catalyst for readers to do their own prioritizing.

There are several situations that call for specialized strategies to prevent falling, tripping, etc. Four come to mind: high angle rock climbing; glacier travel; crossing steep ice and snow; river and log crossings. The first three involve mountaineering skills that are outside the scope of this book. Specific strategies for crossing rivers safely can be found in the book article with that phrasing in the title.

The critical issue in this article is not which specific prevention strategies are best (most are effective in different degrees), but selecting a small group of strategies and exercises and do them with regularity. Priorities are of little value unless taken seriously. Discipline is the name of this game!

 


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