2 weeks of rest.
How many times have you gone to a doctor with an injury sustained during activity and been told to rest it for 2 weeks? It’s pretty much the instantaneous canned response you’re going to get from someone who isn’t going to take the time to physically assess you and maybe write you a prescription for some painkillers.
While I most definitely can’t tell you to ignore the advice of your doctor or other medical professional, I can most definitely tell you that it’s worth finding one that takes more care in their diagnosis, and tell you how passive recovery loses to active recovery in almost every case.
The Four Most Powerful Things That Movement Does For Injured Tissue:
• Movement brings blood and site specific growth factors to injured tissue
• Tension is an anabolic signaller – stressing the injured area within its structural tolerance sends signals to the brain to continue to heal at an accelerated rate and to grow tissue stronger
• Tissue adapts to force lines – applying tension to soft tissues helps align the new collagen (scar) tissue to handle the types of forces it will see post recovery
• Movement creates repeatable patterns – Learning how to move well and support the injured tissue is a skill, and this skill is developed by repeated practice
If right now some of those points seem like they’re written in Latin, let’s take a closer look at each point and examine how they fit into the recovery puzzle
1 – Blood and Site Specific Growth Factors:
As you start to move an area of your body, the mechanical sensors within your muscles send signals to your brain that an increased demand for oxygen is being created within that specific tissue. The brain responds by relaxing arterial muscle and “opening up the gates” for increased blood flow to that area, but it’s not just oxygen that comes with that increased blood flow: amino acids, growth hormones and other growth factors are delivered to the area at an increased rate over resting tissue. Both the building blocks and the biochemical signallers for tissue regeneration are delivered via the blood to the site of injury. This is one of the reasons why we recommend aerobic/cardiovascular work for those dealing with injuries even if *gasp* they are purely strength or anaerobic athletes. The efficiency of this blood delivery is going to be a significant factor in the rate of which you are able to repair injured tissue. Simply by moving the site of injury with enough repetition to create an oxygen deficit is enough to stimulate this process of increased blood flow, and this can be done with loads far lower than what would normally be considered an effective strength training method – more on this later!
2 – Tension is an Anabolic Signaller:
Anabolic signaller is a fancy term for “request to build tissue stronger”, and applying tension to a muscle is the most reliable way to signal to the brain to build new tissue. There is currently quite the debate about which mechanisms are responsible for anabolic signalling, but there’s not currently much debate about which one is the strongest: it’s applying tension – simply applying tension to a muscle in a passive (aka you just sit there) stretch has been shown to grow new muscle and connective tissue. Before you get all excited and think you can just stretch your way to injury recovery, it’s worthy to note that these stretching studies involve holding a forced stretch for 30+minutes at a time at around 7-8 pain threshold. Fear not, you can apply tension in a much more enjoyable and efficient manner via targeted strength training and achieve equal or greater effects, and also without having to apply a stretch to a degree that would almost undoubtedly cause further injury.
3 – Tissue Adapts to Force Lines:
Left to its own devices in a state of rest, collagen (scar tissue) will lay itself haphazardly in all directions over the site of injury, which is likely to create future problems. You’ve probably heard these two things before and perhaps wondered how both could be true: 1 – scar tissue is stronger than the tissue it heals, 2 – if a muscle or other soft tissue tears once, it’s far more likely to tear again. If scar tissue is so much stronger, why do muscles tear again so frequently?
Imagine we take a blanket and rip a hole out of it, but we keep the piece we ripped out. Now we decide to sew the piece back in with kevlar thread, but we stitch in all directions over the tear – this is very much like the way scar tissue would arrange itself at rest. Imagine after the repair we decide to pull on either end of the blanket and apply tension until it rips, where is it most likely to rip? It’s unlikely the actual stitches will rip as they are many times stronger than the blanket, but rather it will rip right beside the stitches, as the stitches have created a stiff stress point in the blanket. But what if instead of randomly stitching across the tear, we could align those kevlar stitches in the direction we were going to pull the blanket? We’d still have a section of stiffness, but those kevlar fibres would more evenly distribute the pressure into the repaired piece of the blanket in the direction of pull; this is essentially what applying tension to a muscle during the phase of collagen proliferation (scar tissue development) can do for you. Almost all tissues, including bone, adapt to the force lines they see the most, since the force lines within a muscle are fairly predictable (they pull from point A to point B in a straight line) simply choosing an exercise that applies tension to that muscle in the early phases of recovery will help to align the collagen fibres in the direction of pull, and reduce the loss of flexibility associated with tearing, as well as reduce the incidence of re-tears by more even distributing the tension along the force line of the muscle.
Once scar tissue has formed and matured it has limited to no ability to rearrange itself to force lines, meaning you have one shot at this, and it’s in the early phases of collagen formation.
4 – Movement Creates Repeatable Patterns
Although a bit chicken and egg, with injury often comes instability and poor movement patterns. Whether you’ve lost the ability to move well because of the injury, or the way you were moving created the injury, you’re going to need to relearn how to create quality movement with and around the injured tissue. Even simple movements take coordination from the brain to control contractions within the muscle and to work together as a system with other muscles around it, and the only way to get better at this is practice. If you wait until you’ve fully healed to learns these skills, you’ll have to tack on the retraining phase to the end of the tissue healing phase and lengthen the amount of time you spend not doing the activity you wish to return to
So in a nutshell, there’s the WHY to move in the early phases of injury rehab, but now we’re going to talk about why you can and should apply tension and movement FREQUENTLY, and as much possible without causing regression.
Chances are you’d like to spend as little total time in the recovery process as possible, and get back to doing the things you love. In order to return as quickly as possible we want to deliver as much blood and nutrients to the area, we want to constantly signal the brain to heal faster and stronger, and we want to develop the skills to move safely and efficiently while we’re healing so we don’t need to add an additional phase to the rehabilitation process after tissue healing has occurred. All this points towards strength training early and often, sometimes multiple times a day, which may seem absurd at first glance – you wouldn’t train a healthy muscle or tendon multiple times a day 7 days a week, how could you possibly train an injured area multiple times a day? It’s actually to do with the adaptation curves of injured tissue and the stimulus required to get a response from the body
Under normal conditions, you must create a fairly large stimulus to spur adaptation – in some way shape or form you must expose a tissue to a demand it was not adequately adapted to, but in injured tissue, it doesn’t take much stimulus at all to create a adaptive response, and because the stimulus is small, so are the recovery demands, and therefore the more repeatable the process is.
After disruption to the system (we’ve applied a small dose of repeated tension via a strengthening exercise) we get the anabolic signalling, we get the increased blood flow, we get the stimulus to align the collagen fibres in line with the force direction of the muscle, but because the dose that we can apply to the muscle is so low compared to what we would normally call strength training, these effects don’t last as long as they would with larger doses of strength training, so if we want to spend more time in the accelerated frame of healing, we need to apply tension more often.
How often should you train it? That’s a good question, ideally you should be working with a health professional who is helping you guide these types of decisions, and you have a high degree of body awareness. Different injuries and different tissues adapt at different rates, for example, muscle tissue is far more trainable than tendon tissue, but for entertainment purposes *note super lame disclaimer* I’ll give you some general guidelines that will help determine how much load and how often to apply that load. These guidelines are going to be aimed at muscle and tendon tears, and I’ll explain some modifiers for things like disc herniations and other passive joint tissues such as ligaments and capsules etc at the end
How to Choose Load:
The general guidelines for selecting the appropriate load for injured tissue is that the applied load can take pain levels up to about 3-4/10 scale during the exercise, but should return to baseline or a 1-2/10 within 30s to 1min of stopping the exercise. If you’re exceeding these thresholds, it’s likely you’re doing more harm than good by continuing to add load.
How To Determine Dose or Number of Sets Per Session:
The pain threshold can be useful for determining set count as well, you shouldn’t run into a point where either during the set or in between the sets pain threshold is moving up, but ideally, you’d use around a 20% repetition loss as a marker instead, and this should occur before the pain scale moves up. Since the load is going to be fairly low, in general, the early phases of rehab are going to use higher rep methods to be effective, so say you’re able to achieve 20 reps on your first set, you could continue sets with full recovery until your rep count fell to 16 or less. Once this 20% repetition loss has been achieved, adding more work in this session is likely to spur further adaptation and could possibly be detrimental
How to Determine How Often to Repeat the Session:
There are a lot of factors that go into this, from the severity of the injury, to the type of tissue, the size of the muscle or tendon etc. but a general rule is if you can’t progress reps or load within your acceptable pain scale, you’re still adapting to the last session and you’re not ready for another one. In general, the earlier you are in the recovery process and the less load you’re using, the more often you’ll be able to repeat the session. This is sometimes multiple sessions during the day in the early phases, and as load tolerance increases will probably drop to a session per day, and finally return to the frequency of which you were training it before
What about disc/ligament/capsule etc injuries?
Although not universally true, injuries to the passive tissues of joints are generally a failure of the muscular system to adequately control motion at the joint. More often than not these are failures of the muscular system to produce enough force or apply that force fast enough and in a co-ordinated manner to stabilize the joint in reaction to the force applied, but it also can happen when an imbalance in muscular strength exists on one side of the joint vs the other (for example, extremely strong quads, and weak hamstrings affecting the tracking of the knee joint).
In general these injuries arise from lack of stability, or repeated wear and tear from poor movement patterns. The good thing is that most passive tissues are redundant – meaning that we have muscles that provide much of the same or identical support to the joint that the ligament or disc etc was providing, but you must teach the brain the skill to apply that muscular force in the situations you need it stabilize the joint in. As with any skill the more you practice it, the better you are a performing it, and the more you repeat the pattern the more likely it is to be retained. Once again frequency becomes our friend, but with a caveat, because these passive tissues heal at much slower rates, many of the sessions should be based around skill development without the need to overload the tissue, whereas 1-3 sessions per week can be aimed at loading the muscles (so long as they are not also injured) with the largest amount of load they can tolerate without putting undue stress on the injured joint tissues.
The aim of the initial phase of recovery is actually to have the active tissue take most if not all of the load – we have several people here at Blacksmith who have failed ligament surgeries or opted not to do them who have full function and return to sport. Those people have returned to sport through rigorous and graduated skill development that allows them to learn the abilities required to handle joint torque with muscle as opposed to relying on a passive ligament that not longer exists.
The biggest difference to note here is that skills like balance and control need to be developed more than tissues need to be built – quite often athletes will already have the requisite strength in the muscles to exert more control and balance than they are currently displaying, so the need for overload and tension come backseat to development of skill.
The “how much load?” becomes more dependent on joint stability and pain tolerance than muscle capacity, but the pain scale is still a good reference tool. The “how often to apply load?” becomes more in line with standard training protocols, 2-3 overloading sessions, and although the amount of sets and exercises is well outside the scope of this article, as a general guideline 1-5 exercises for 3-12 sets per session depending on the complexity of the joint and the amount of muscle groups acting on it (more exercises for shoulders/hips/spine, less for knee/elbow etc.). But the “how often?” for skill development drills – it’s almost impossible to overdo these. Small doses of frequent practice for balance and static stability drills can be done multiple times over the day as they require virtually zero recovery. Without a doubt people who have stability related injuries who practice their balance and stability drills more often will recover faster than those who do them less frequently.
Rest is for the Weak?
Rest is indeed an important part of the process, it’s during rest that you’re going to adapt to the load and tension you’re applying, but I can tell you without a doubt, those who are obsessive about every detail of both their rest and their active rehab processes will beat expected recovery timelines often by twofold or greater. If you’re as determined in your rehab as you are in your training or sport, you’re many times more likely to have both a successful recovery and spend less time on the IR than those who simply sit around and wait to get better. Ideally you’ll include one or more health care professionals who are familiar with people who push their bodies to the limits, and then take every opportunity to work on yourself throughout the entire process
Blacksmith Fitness 