The climbs: long, sustained, and at altitude
The Elkhorns do not give you flat. The 50 Mile stacks roughly 13,400 feet of gain across the day, and a lot of it comes in long, sustained climbs up toward the 8,000 to 9,000 foot tops. This is where the race gets won or lost, and the move is patience. Hike the steep pitches efficiently, keep your effort even, and let the altitude set your ceiling instead of fighting it. Push the early climbs because they feel fine at 6:00 AM and you will pay for it deep in the back half.
You are up near 9,000 feet on the high 50 Mile sections, and that altitude makes every grade feel harder than the number says, especially if you live low. Breathe, settle in, and treat the climbs as the part you manage carefully rather than the part you attack.