27 Feb Learn How to Exercise Safely When Injured
by Dr. Matt Fontaine
So Doc, Can I Safely Return to Exercising Now?
“Can I still exercise while I am treating and recovering from my injury?”
Every day in clinic I field questions like this? The conversation usually goes something like this…
At some point is nearly every new patient encounter the topic of conversation will turn to answering the question…
“Can I still exercise while I am treating and recovering from my injury?”
Here is how this conversation typically unfolds over the course of the first few treatments to first few weeks… and typically the narrative continues throughout the course of treatment.
Patient Joe Athlete: ” So doc, how does my injury feel? Is there less scar tissue? Are the muscles working better? Are my joints moving better?”
Doc: “typically over the course of a few treatments (in as little as 4-6 treatments) I will begin to see changes in tissue pliability (more free range of motion and sliding of the tissues). What this means is that some of the tissue adhesion (glued down repaired tissue that results from repetitive motion or overuse injury) has been released and some of the tissues have improved gliding, relative to one another as muscles overlap and must slide relative to neighboring tissues. ”
With regard to muscle function I tell patients that “Manual muscle testing provides a window into the nervous system to show us if a muscle is engaging or not. We test these daily as indicators of joint dysfunction. We know joint function will often dictate muscle function. Compressed or misaligned joints often cause a muscle or muscles to weaken.”
Patient: So, can I safely run, bike, swim , lift weights, etc. without causing more injury?
Doctor: ” That is the million dollar question. When dealing with soft tissue injuries, joint dyskinesis (poor joint motion), and faulty movement, it takes time to make changes. A fracture can heal typically in 4-8 weeks provided there are no complications. Soft tissues are more dynamic and because the injured soft tissues and fascia are rarely immobilized, they have to handle load and tension on a daily basis. During exercise, these not yet healthy tissues will have a decreased capacity to handle load under tension and further injury may result.”
Below we will discuss some guidelines and explanations on dealing with these issues.
When will I be free to swim, bike, run or CrossFit without limitation?
Lets talk Math: basic mathematical equation I= NF/AR
Injury (I) = Number of repetitions (N) X Force of repetition (F)/ Amplitude (A) X Recovery time (R)
This means that all load into tissues is cumulative, meaning tissue damage occurs overtime with repetitive movement.
Tissue load, over a certain threshold injury will occur. Going a little bit beyond threshold results in minor microtrauma the body can repair. Remember, the body repairs soft tissue with inelastic type III collagen and so some degree of adhesion will result. This type of collagen is fibrous and more prone to injury. Our normal healthy tissue is made up of Type I Collagen, which is elastic and absorbs shock and stress well. If the mild overuse is followed by proper rest, RICE, foam roller and stretching may in fact release the newly laid scar tissue and restore normal gliding.
It is important to note that sustained contraction or repetitive motion causes muscles to tighten. This tightness squeezes off blood supply, which causes hypoxia (decreased oxygen to the tissues). This hypoxia sets off the very same reaction that occurs in the body after an acute trauma. It signals the body to lay down fibrous scar tissue in the exact same way it does after a muscle or ligament is torn.
Beyond the threshold over and over and over may result in more serious injury, despite the lack of pain.
Let’s look at Injury Curves
The above figure represents decreasing threshold of soft tissues, fascia, and joints with cumulative training and repetitive motion. Overtime these tissues loose capacity, become weaker, inhibited and more injury prone. Overtime, continued training of tissues that have not fully recovered results in more trauma to these tissues. Eventually injury, pain and inflammation ensue.
How to Stay in the Game
One of the main goals when treating athletes is to keep them training and competing in their respective sport if at all possible. That may involve decreasing training volume to reduce the repetitive action below the threshold of further injury. In acute or severe chronic cases, complete rest from the activity or sport for a period of time may be necessary for complete recovery. After evaluation and initial first 2-4 treatments, the physician should be able to determine if the sport can be continued during treatment and rehabilitation.
It is important to note that with training while recovering from injury, there is a fine line between the volume and intensity that can safely be handled by one’s body and still make progress in rehab and recovery. Over that specific amount (training volume/intensity threshold) more injury can occur or at least create enough strain to prevent or slow recovery.
Everyone has different genetics and abilities that will make each individuals’ training volume/intensity threshold different from the next person. It often requires trial and error to determine an athlete’s or individual’s particular threshold. Once that is determined, he or she must keep training below that threshold during the rehab and recovery phase to allow the injury to recover.
What signs & symptoms should I look for so I know the injury is coming back?
If the athlete can do his or her sport, like swim, bike, run, CrossFit, Orange Theory Fitness type HIT training etc. without pain during the activity or sport, that is a good sign the activity can be tolerated without very much if any further injury. It is especially important to watch for pain and swelling the day or two after doing a run or lifting weights or playing a sport.
If the athlete has a lot of marked soreness and the injured area “feels raw and beat up” or has increased pain, this indicates the volume and or intensity of the sport or exercise was too much and overloaded the tissues creating further tissue damage.
During treatment and rehabilitation, it is imperative that we continue to monitor the athlete as they ramp up their activity for these signs of pain and swelling. As long as we can avoid the pain and swelling with a certain level of activity, say for instance a runner who can tolerate a 5K run without pain, then we can progress them to increase their running volume each week. Volume can be increased only as long as it is tolerated without pain and increased inflammation. If we reach a point of too much activity and overload, we can deload by decreasing the volume and or intensity of the activity or sport.
Pain: The Body’s Built In Fire Alarm. Usually the alarm sounds way after tissue damage has occurred.
As a physician, I often hear patients tell me that they have been playing a sport or doing an activity for years and never had a problem. the patient may say something like…
Patient: “Doc, I have been playing tennis for over 30 years and I never had any pain or injury until now. I don’t understand what happened.”
Here is my analogy to explain this: If you punched the wall over and over for 20 hours, what would happen? The first few punches may not hurt or cause injury. But the trauma to the soft tissues and joints is cumulative, eventually enough wear and tear causes breakdown to the point of pain. Likewise, if I drive my car over and over for years, I may not know there are problems lurking. Eventually enough wear and tear occurs and warning signs emerge (noise, black smoke etc.) For the body, it’s warning sign is pain, and although the presence of pain definitely indicates tissue damage, the absence of pain does not indicate the absence of injury, tissue damage or pathology.
By the time pain is evident, tissue damage has already occurred.
What to Do: Getting Proper Treatment
The first priority is to restore motion to the joints and the soft tissues. This is where manual treatments like joint manipulation, Active Release Techniques and Instrument Assisted Soft Tissue Release have their “sweet spot” in treatment. These are the best methods of treatment for joint and soft tissue dysfunction.
Once these issues are improved or resolved, then we can progress to balancing strength with exercise and progressing to sport specific improvement in strength and endurance.
The OVERALL TREATMENT PLAN MUST BE AN INTEGRATIVE PHYSICAL MEDICINE APPROACH- not just an exercise video- not just exercises to strengthen “weak muscles”.