What is the most common tissue injury or pain experienced during hiking? Perhaps you thought of an ankle sprain, muscle cramps, or back pain. Nope. Researchers clearly identified blistering as the most common medical complaint addressed in wilderness medicine. Adding salt to the blister, so to speak, is that you are 50% more likely to experience a significant ‘other’ musculoskeletal injury if you already have a blister. Think muscle injury, ankle sprain. Why? Because of your altered and inefficient walking pattern.
You can be powering along, feeling like a mountain goat with lungs of steel, and a tiny patch of skin on your heel or little toe can undo you. Suddenly, every step is less a “majestic wilderness stride” and more an “awkward hobble worthy of a zombie extra.” A blister might seem small, but left unchecked, it can turn a dream hike into a slow-motion suffer-fest.
That’s why blister management isn’t optional; it’s survival. Think of your feet as VIPs; they’re carrying you through forests, over ridgelines, and down rocky trails, so they deserve the red-carpet treatment. Proper socks, well-fitted boots, and a little preemptive blister education might save you hours of misery. Here comes the education…
Formation of a Blister
To understand management, we first need to dispel the myth that blisters develop because of heat, moisture, and friction. To assist me in explaining the science of blister formation and management, I would like to give a shout-out to my colleague, podiatrist and blister specialist, Rebecca Rushton, who is on a mission to eliminate blisters and provided the 5 Stages of Blister Formation graphic below.
Blisters form not from your shoe rubbing on your skin (this would be called an abrasion) but from the movement of your shoe/skin interface across the underlying bone. The movement tears tissue between these two zones. Another way to visualise this is that a blister occurs when bones move inside your foot while the skin/shoe surface remains stationary. Again, there is a relative movement between the skin (epidermis) and your bones, resulting in a tear = blister. A practical way to understand this is to place some steel wool lightly on the back of your wrist. Draw slow circles, and it won’t be long before the skin starts to flake off your wrist, resulting in abrasion. Now apply pressure so the steel wool stays in contact with the skin, and do small circles. There is now no movement between the steel wool and your skin, so there is no abrasion; however, the tissue deeper to the skin is being stressed. We call this a shear load. It is the shear load that causes tissue elongation and damage. You can read more about the underlying research here and here.
Researchers using slow-motion cameras measured a 15mm rise and fall of the heel relative to the shoe during walking. Multiply that by 10,000 steps a day, add a 10-15kg backpack, and the spice of uneven terrain, and it is a perfect recipe for blisters. The forces being absorbed by the tissue are logically increasing, which is why blisters on the heel are one of the most common sites.
5 Stages of Blister Management
According to the graphic, we need to determine the stage of blister progression to manage it effectively. And it all starts before your blister forms.
Blisters also need to be staged to determine their correct management.
- No blister
- Hot spot, point of irritation and pain,
- Mild swelling, intact roof
- Roof torn, blister leakage
- Deroofed
Stage 1: No Blister
Ideally, no blister progresses beyond Stage 1, which means it is worth doing everything possible to prevent a blister.
This involves;
- Correct shoe size and lacing design
- Managing the location(s) of blisters you have experienced in the past
While these points may sound obvious, even on the Larapinta, I met one person wearing second-hand boots that they had just bought in Alice Springs before heading out, and I tended to at least 5 hikers with blisters on the trail.
Correct Shoe Sizing
For this discussion on blisters, let’s leave out high or low ankle cut, heel drop and thickness of mid-layers, and focus on achieving a great shoe fit. That is shoe width, length, height and lacing design.
1. Width Test
Stand on some paper & draw around your foot. This is particularly important if you have had blisters or neuromas on your great toe or pinky toe in the past. We want to ensure there is enough forefoot width in your toe box. Place the innersole of your proposed shoe on top of your foot drawing. If you can see pen marks, then the shoe doesn’t have enough width for your foot. Remember, it will swell with hiking.
2. Length Test
Place your foot in the shoe and ensure your heel is firmly against the back of the shoe. When standing, check you have a thumb’s width between your longest toe (first or second) and the edge of the shoe. If the boot has a solid toe box and you can’t determine your toe position, use the same drawing from the Forefoot Width Test. Besides selecting the correct length, it is essential to keep your heel in the heel cup. A correct lacing strategy (See below) helps you achieve this.
3. Toe Box Height Test
With the two above features optimised, you are mostly home. People with a hammer, claw or an angled great toe will also need to consider toe box height. If this doesn’t make sense, it is because you don’t have these anatomical considerations to worry about. If you do, then you are already aware of selecting a shoe with a higher toe box or one made with flexible materials. The lacing designs (see below) will provide some modification to toe box height.
Lacing Design
There are three variations of the standard lacing pattern that are worth being aware of. These lacing designs help adjust your shoe fit to accommodate changes in foot volume (which increases with duration of hiking and temperature) and wetness (resulting in greater foot slippage) of your shoe.
Scout Lacing. BE PREPARED is the Scout motto, and using this simple modification across the top of your foot will help limit forward slippage of your foot on descents, especially if your shoes are wet or if your shoes are a big/wide fit.
Skip Lacing. This design is for individuals who find the top of their foot sensitive to pressure (fibular nerve compression) or who experience mid-foot compression problems, such as neuromas.
Heel Lock Lacing. This builds on the Scout lacing technique. Depending on your eyelet/speed lacing design, there are a couple of options. Again, the goal is to limit/prevent forward-siding of your foot in the shoe, which causes black toe injuries and blisters on the sole of your foot or under the metatarsal heads.
Lace Recommendation. One of the most frustrating aspects about hiking laces is how easily they fray and break, especially when they curl around a metal speed lacing hook. NO LONGER A PROBLEM! Even the laces on my Scarpa Delta GTX boots would only last 3-4 months before they started to fray. Perhaps I am overly rough, but since I have been using Lawson Technora Toughlaces: Thin 60″, I have had no breakages. I highly recommend this product.
Prepare your Shoe
If you have experienced blisters before, such as on the back of your heel or little toe, placing an Engo blister patch correctly on your shoe can significantly reduce the likelihood of blister formation. Remember, your foot is moving. I use large rectangular patches over my heels (and keep them in my first aid kit) and oval patches of different sizes for smaller areas. Aim to have at least a 10-15mm margin that extends beyond your blister site. Movement must occur between your shoe and your foot. Engo patches increase the slippage between your shoe and the patch/patch and your sock/skin. In this way, there is minimal shear between your skin and your foot bones, protecting the deeper tissue layers from shear.
Prepare Your Feet
With the busyness of life, it is hard to have the time to train your feet for a multi-day hike like the Larapinta. If you have common blister sites, prepare your feet before you head out. There are several strategies available, and you will need to test them out to find what suits your feet and your activity.
Applying tape (Hypafix 5cm is my preferred option as it is flexible and thin) over the skin so the rubbing interface occurs between your skin/tape and the shoe, rather than the tissues between your skin/shoe and the underlying bones
Creating a force-deflecting doughnut (using 3 or 5 mm orthopaedic felt or moleskin) that is applied around the blister site and held in place with Hypafix
Wearing gel toe sleeves. These work by creating a space between the toes (ideal for between-toe pinch blisters), creating a friction-reduced interface between the shoe and the toes (big and little toes), and providing a localised area of cushioning. If you already have a blister, avoid using a gel sleeve, as you need to follow the treatment stages outlined in Stages 2 through 5. Gel sleeves are a prevention tool. Likewise, if you have sweaty feet, they may not work for you as they are not breathable.
Wearing toe socks, like the Injinji hiking range. Like sleeves, toe socks create a space between the toes and add padding where there is usually none. Socks made with Coolmax or a similar material will help keep your feet dry and cool, thereby enhancing your comfort level.
You can reasonably test your shoes, feet, and socks in training, but unexpected things happen on multi-day hikes, which is why you need the knowledge and equipment to deal with blisters. We now proceed to Stages 2 through 5.
Stage 2: Hot Spot Formation
Perhaps it was wetter than expected, a longer day or more uneven terrain, but you have noticed a subtle warmth in a specific area of your foot. If it has reached a critical point or a painful spot, you have already progressed to Stage 3. If you are hiking solo, it is easy to stop and deal with this immediately, but in a moving group, you may not feel like calling everyone to a halt. The fact is that blisters don’t heal; they only get worse. This means that if not dealt with quickly, you will become an increasing impediment to your group the longer you ‘tough it out’.
Management: Take off your shoes and look. At Stage 2, you want to identify the cause. Why is that spot rubbing? A crease in your sock, an overlying seam of your boot, or the laces are loose, allowing increased foot movement. Determine the contributing factors, make necessary changes and activate your advanced blister program. By addressing all the contributing factors that cause blisters, you limit the potential for progression from transient awareness to a full-blown blister.
Stage 3: Official Blister-Roof Intact
Your hot spot has progressed to pain and localised swelling. You now have a minor limp, and it is at this stage that people often acknowledge they need to do something about their injury. Remember, 50% of army recruits experienced a significant ‘other’ musculoskeletal injury when they already had a blister. Good blister management reduces the likelihood of a complicating injury.
Management: The key feature in Stage 3 is that with an intact roof, there is no chance of an infection complicating your blister recovery. If you haven’t already enacted your shear-reducing strategies, now is the time. If you have enough space in your shoe, you could cover the blister with an island dressing for protection. Activate your strategies for reducing shear loads, such as creating an island/doughnut using felt or moleskin, which will limit the direct compression of the swollen blister.
Stage 4: Official Blister-Roof Open
You arrive at Stage 4 through either of two pathways. Firstly, you were at Stage 3, and because of the blister’s location (e.g., heel or sole of foot under big toe), you needed to relieve the pressure, AND you could safely and cleanly do it. Or Stage 3 progressed to Stage 4 because of a lack of blister load management. With an open roof, there is an increased risk of infection, and this needs to be addressed before managing the blister loads.
Management: The goal is to maintain a sterile environment that allows the blister to heal and reduce the blister load. If you have decided to induce a Stage 4 Roof Open situation, swab the area with Betadine/povidone-iodine or a similar solution to remove surface bacteria. I prefer to open the bottom/lower edge of the blister with a scalpel. They are sterile and very sharp. Cutting the bottom allows all the clear fluid to drain, but leaves the rest of the roof intact, as it provides natural protection to the raw floor of the blister. If the leaking fluid is red, it indicates that a blood vessel was also injured at the same time. Not a problem. If the liquid is yellow, it is pus, indicating an infection. Gently push out all fluid, ideally with sterile gauze or cotton balls. Once drained, cover with a sterile island dressing and then add your blister load modifiers. These might include a felt doughnut and Hypafix, as well as an Engo patch on the shoe/inner sole. Monitor the healing process closely for signs of infection. If your blister is infected, apply an antibiotic cream, such as Neosporin, and change the dressing at least twice a day.
Stage 5: Official Blister-Deroofed
This is the worst outcome. See my picture at the start of this article. Avoiding a repeat of a Stage 5 blister motivated me to investigate the science and best practices for managing blisters. It is essential to know that, apart from the pain, there is a 4-6 week downtime from swimming (due to infection care) and being able to wear closed-in shoes, which severely limits your training options and work. Even when able to wear a shoe, it took a couple of months to fill in the blister deficit and rebuild a basic roof over the site, enabling activity participation again.
Blisters are something you definitely want to avoid if you enjoy training, running, hiking, snorkelling, and scuba diving.
Management: With a greater surface area open, the possibility of infection increases. Clean around with a Betadine swab. With the roof removed, we have a raw, exposed blister floor that needs to be managed. Applying a fluid-absorbing dressing (e.g., an island with gauze) can dry out the tissue, creating a scab that is rigid, inelastic, and prevents healthy skin from forming. The scab’s roughness will irritate the sensitive healing skin and, being inflexible, is easily knocked off. We require a strong, elastic tissue to form, and this is best achieved in a moist wound environment, just as burns are treated. In a moist wound environment (MWE), the fluid expressed is high in sugars, providing nutrition to new cells. Being a moist environment, cells can easily migrate around the wound. A MWE is achieved with a hydrocolloid dressing (e.g., DuoDERM Extra Thin, Compeed), which absorbs the fluid and creates a non-sticking gel layer. Gently apply the dressing over the wound, with a 1-2 cm margin, and avoid stretching it. Hydrocolloid dressings are permeable to air but not to water, dirt, or bacteria. Keeping the wound moist means no scab, no scarring and faster healing. Select a dressing that extends 1-2cm wider than the blister, providing a good wound margin. Keep the dressing in place for 5-7 days, or replace it earlier if the wound begins to leak. To do this, gently peel back an edge, remove the dressing and clean the wound. Then cover with a new dressing.
Summary
At the core, there are two critical aspects to blister management
The first is common to all stages, and that is to modify the blister-causing loads. Each person has a range of strategies to activate, and these are primarily dependent on the site of injury. The sooner this aspect is addressed, the less likely the next element will become an issue.
The second aspect relates to facilitating the wound’s healing and varies with the blister’s stage. This is on a continuum. Stage 1 is characterised by no wound, progressing to Stage 5, where a full-thickness, deroofed wound is open to infection.