Fecal matter happens…and I’m not talking about BM’s. I’m talking about injuries. Many of these tissue-damaging events can be prevented through proper training and sound judgement, but despite our best efforts, injuries happen. And they are going to keep happening. But how we deal with them makes a huge difference in how rapidly and to what extent we come back from injury.
This is Part 1 of 2 in the Dealing With Injury discussion, and today we are going to focus on acute injuries. Without doubt you have familiarity with these things. There are innumerable scenarios but I’ll illustrate a few. You are cutting, running, jumping…you take a step — and suddenly you feel and hear a pop somewhere in your southern hemisphere. You are bending, lifting, or twisting…and out of the blue there is a snap as you immediately seize up with back pain. You are moving quickly, explosively, or unexpectedly…and you are met with a tearing sensation in a muscle, joint, or other tissue. All of these occurrences are known as acute injuries. They happen emergently and are largely accidental or inadvertent in nature.
We need to look at these acute injuries on two planes. The first is the physical, or biological nature of the injury itself, and the second is the psychological impact of the event. Let’s take a few moments to look at each side of the injured condition.
On the physical side, and in the most basic of analogies, we need to view an acute orthopedic injury on the inside of the body just like a cut or laceration which we have all experienced on the outside of the body. When we get injured, a tissue inside the body has been torn or damaged just like a finger that we accidentally cut during a kitchen knife accident. This may seem obvious but the healing process is virtually the same, inside or out. It’s how our bodies deal with injury.
If we simplify the injury healing mechanism to some degree, we can divide it into three basic phases: bleeding, scab, and scar. There are more “official” terms for these phases but I prefer to use these because they are easy to comprehend.
Bleeding represents the initial tissue damage or insult, and the body’s emergent or first-phase reaction. We respond instinctively to immediately arrest the bleeding and to position the injured area as far away from the mechanism of injury as possible, or in the least aggravating position we can find. On a cellular level, the body is mobilizing a variety of repair-related molecules, cells and organelles, and is building up a cloud of inflammation under which all these functions operate. Our innately brilliant body utilizes strong pain signals to remind us that tissue is damaged and we need to be vigilant in supporting this initial response of stopping the bleeding and setting up the emergency zone.
Think of this scene as a burning building. The fire department responds to the alarm to put out the fire, cordon off the area, and utilize the technology necessary to ensure that the damage is both contained and eventually reduced to a smolder. In the human body, the time frame required for this phase depends upon the severity of the injury and the health of the individual, but in most cases this takes about 3-5 days. Protection and containment are the primary objectives in this phase.
The scab phase that we recognize easily is that time period when the pain, heat, redness, and swelling is significantly reduced (although not eliminated). The injured area starts to progress from a raw, bleeding, and quite fragile state, through a gelatinous initial repair substrate (granulation tissue), and finally to a hard, dry scab. This is where the body gets serious about repairing and rebuilding the damaged area. In our burned building analogy, the demolition crews come in and get all the debris cleaned up as the construction workers begin to focus on framing and rebuilding the structure. Just as in the first phase, this second period of injury management can be quite variable in time. In most cases this is a 1-4 week process.
One important point to keep in mind is that each phase of injury recovery is blended into the other one, just like a construction jobsite does with various processes. Rarely are the phases entirely distinct or absolutely precise. It’s a dynamic management system that represents an artful balance or dance that our bodies automatically coordinate.
The scar phase is generally known as a tissue remodeling or refinement period. Just as an external scab tends to dry up, fall off, or disappear, the internal injury goes through a similar process. The body attempts to reduce the volume of the healing area and restore to the best of its ability the original cellular matrix of the tissue. The major goal is to minimize the total amount of scar present in the tissue, and to make the scar tissue that does remain as functional as possible. On the jobsite, this is where the finish work is emphasized — paint, trim, fixtures, interior decorating, landscaping, and final cleanup. Restoring that once-burned building to a properly-functioning home (or office) is the dedicated pursuit. For minor injuries, this can take as little as 2-3 weeks, or as much as 6-12 months in more catastrophic cases.
What’s really important to understand here is that injured muscles, tendons, and ligaments (as opposed to bone, skin, blood vessels, and some nervous tissue) heal largely via the process of repair as opposed to regeneration. This may take some explaining. Badly bruise or break a bone, and you notice it heals with a lump or bump in most cases. This is known as a bony callus, and it represents the body’s laying down of new, additional bone to fortify that area as a safeguard against future insults. That’s regeneration and then some.
Muscles, tendons, and ligaments, and joint capsules don’t recover in quite the same manner. They utilize scar tissue, and you can think of that as duct tape, glue, patches, or other “fixes” that shore up a damaged structure. And scar tissue is neither as elastic as original tissue nor is it as strong. This means that scar tissue doesn’t quite stretch as well as what it replaced, and it usually doesn’t have quite the absolute strength, or yield limit, either. Our bodies are incredibly efficient at healing, and they always do their best to reduce scar tissue down to the absolute minimum. But a repaired muscle or intervertebral disc, just like a repaired wall in a building, is rarely completely as good as the original. It might be very, very close, but even when we feel like an injured area has healed to 100%, it’s probably only 99.7% (or some other number) in structural quality. Don’t get bummed out about this…just keep it in mind.
Now we can get to the psychological side of injury. One of the best ways to frame the impact of injury on our psychology is to use Elizabeth Kubler-Ross’s 5 Stages of Grief: Denial, Anger, Bargaining, Depression, and Acceptance. I’ll provide an example of how each stage typically occurs with an injury.
- Denial: “That didn’t just happen. There is no way I just injured myself and altered my course toward my goals. I see myself as a healthy, fit, capable person and I’m locked in on the path to peak performance. I don’t have time to be hurt and this just can’t be true.”
- Anger: “#$@!%&*!!…this hurts! I’m enraged that this has happened to me. I’m mad at myself and I’m mad at so-and-so. Why me? This wasn’t part of the plan. All my hopes and dreams are destroyed.”
- Bargaining: “Maybe I can tape and wrap this thing, and pound a bunch of ibuprofen, and miraculously get better in just a few days…and still be able to salvage my performance in the upcoming event. I will go on like nothing ever happened and still hit all my workouts and activities. I really need to execute my plans and I’ll just work around, through, and over this injury. There has got to be a way because I don’t want to face change.”
- Depression: “This sucks. Life is over. I’ll lose all my fitness, never be able to do anything again, and my existence is ruined. It’s not worth it to try to recover and I’m just not cut out to do anything athletic. I give up.”
- Acceptance: “All right, what’s done is done. I’m still disappointed by this injury but let’s get to work on the recovery. I’m going to need to reframe my goals but that’s not the end of the world. Oh well…onward.”
Obviously, the degree of each stage varies from person to person, as does the length of time required to get to Acceptance. And it’s normal to bounce back and forth a bit between the stages. But at some point, we need to recognize that the damage is done, the past can’t be changed, and it’s time to pull up our big boy or big girl pants and get to work on recovering from the injury. Sure, that’s tough talk and such a mindset is rarely easy to embrace. But it doesn’t make it any less true.
Now that we are aware of the effects of the injury on both the body and the mind, let’s look at how we can support the progression from injured to fully functioning. This comes down to what I call the series process of injury management. There are four key components in this sequence. They are healing, rehabilitation, training, and competition. And recovery works best when these four components are attended to in series fashion, as opposed to a parallel approach.
To clarify, we need to accomplish a significant portion of our initial healing before we progress to rehabilitation. Following rehab, we can get into more specific training. And ultimately, we are ready for return to competition. This is a series methodology and it differs from a parallel approach, when we might try, usually ineffectively, to do all four things at the same time. And as with all things biologic, there is room for some slight overlap, or back and forth movement as needed, in the series process. Everything blends together in a flowing manner.
In order to illustrate this progression, I will provide some definitions of the four parts of the recovery management sequence.
- Healing: Tissue repair and elimination of most pain. Incorporates all of the bleeding phase and the early portion of the scab phase. This can be supported with clinical modalities as indicated.
- Rehabilitation: The restoration of basic function such as range of motion, gait, and proficiency with activities of daily living. Correction of imbalances and compensatory movement patterns is emphasized. Completes the scab phase and initiates the scar phase. A plethora of clinical and self-help tools may be utilized.
- Training: Rebuilding strength, endurance, motor skills and conditioning. Begins with the scar phase in process, which concludes during training before progressing to competition. This is an opportunity for unlimited application of methodology in an individual manner.
- Competition: Participation in goal events such as athletics or high-level lifestyle activities (backpacking, gardening, etc.). Represents full injury resolution and maximum tissue durability/safety. When this journey is completed optimally, the endpoint may be at a higher performance level than the pre-injury baseline. Whether one competes in sports or not, this is the time to test the tissues, and to regain trust in the restored body.
Let’s drive that vision home again and appreciate the relationship between the phases of injury recovery and the series progression of management.
I simply can’t emphasize enough how important it is to understand and apply this sequence. The times are countless when I’ve had discussions about these mechanisms in the clinic with clients and patients, or very involved parents, who were immersed in the injury management situation. A guy with a partially torn achilles tendon asked, “I am signed up for a marathon in three weeks…what are the chances I’ll be able to do it?” My response: “No way in hell.” A mom whose son showed up with a Grade III ankle sprain on Tuesday said “Timmy has a game on Saturday…will he be ready to play?” I said “Only if you want him to have a lackluster and subpar performance, be in a great deal of pain, significantly delay his overall recovery, and probably do long-term, irreversible damage to his orthopedic health.” Because of those stages of grief we mentioned earlier, particularly Denial and Bargaining, many people need sincere professional help putting their injury situation into perspective. You really can’t cheat your own biology.
But you can support it. The body is going to heal itself, and to a large degree, we can’t speed this up very much. But we can remove obstacles that impede progress. And certainly, there are a few things we can do to facilitate, and possibly slightly accelerate the process of recovery. But every good pyramid is built from the ground up with a solid foundation. Sleep and nutrition support health and healing. Anything else we do will only work if these critical foundational elements are in place. Whether you are a do-it-yourselfer or are utilizing the services of your friendly local physical therapist or rehab/fitness professional, making sure that the bedroom and the kitchen are optimally aligned with your recovering body is essential. There are many, many tools in the injury recovery toolbox. I’d like to simply make a few general suggestions as they relate to each of the injury recovery phases and also within the management progression we discussed.
Bleeding/Healing: Essentially, minimizing and eventually stopping the bleeding is key. While the inflammation process is our natural response to injury and the framework of healing, we don’t want to let this fire become excessive or prolonged. There appears to be some debate, and potentially confusion, on this topic recently. While it is quite true that we may not want to suppress the inflammatory response of exercise training in most cases (because this is how we make the most gains or adaptations), the same viewpoint does not hold true with an acutely injured tissue. Protecting and offloading the area for a few days, and utilizing ice, compression, and elevation, is still a valuable pursuit.
Early therapeutic movement can usually be initiated within the first several days of an injury, but this might require the expert assistance of a rehab professional…or at least your best and most cautious instinctive judgement. Protecting the injured area and getting the fire reduced to a manageable, and physiologically ideal level (as opposed to a raging, destructive inferno) is what we want to do here. Excessive inflammation leads to greater tissue damage, and eventually more scar tissue deposition (which we want to avoid). And remember, surgery is an acute injury as well. Post-operatively, the same rules apply. Various cryotherapy, pneumatic, and electrostimulating modalities are often utilized, as well as pharmaceutical agents. These can help with comfort and the management of pain and swelling.
Scab/Rehab: This zone represents a very broad middle region in recovery with much variance in length and application between unique individuals and different kinds and levels of injury. That stated, there are some general goals in this phase/sequence. The application of controlled, specific, and progressive therapeutic movement can powerfully affect the restoration of function as well as the minimization of scar formation. Any number of exercise and manual therapy applications can be effective. This is where the clinical tool box is filled with things like heating devices, ultrasound, e-stim, iontophoresis, implement-based tissue mobilization, diathermy, cold laser, and many, many more gadgets. In general these approaches have modest efficacy with the potential for powerful placebo effects. That’s not necessarily a negative, but self-mobilizing with various items like foam rollers and other implements, coupled with well-researched and applied exercise protocols, can be equally effective, as long as you have the expertise or have received the proper training from a professional.
Progress is rarely linear, as is consistent with the human condition. There will be ups, plateaus, and downs along the way. The main goal is to apply rehabilitation tools in a manner that allows the body to absorb and progress, as opposed to either not receiving enough stimulus to enhance function or having too much and aggravating the healing injury. Newer therapies are evolving, such as protein-rich plasma and stem cell injections, hormonal and androgen receptor therapies, and custom-designed supplement stacks (based in many cases on ancient wisdom). We will continue to see advances in medical science but I can’t reiterate enough that most injuries will heal just fine when you do the basics (correctly).
Scar/Training: Generally, at this point, the injured individual is relatively pain-free and functioning reasonably well in daily life. But rebuilding higher levels of strength, mobility, endurance, and other capacities is of great value, whether one considers oneself to be an athlete (you should in every case!) or not. And from the athletic perspective, there are always aspects of performance that can be developed and refined.
Progressive training also stimulates continuation in scar remodelling/minimization for potentially many months. Training increases physical capacity in all areas of life. It offers improved output in sports, higher fitness levels, and a degree of durability that can be protective against future injuries of the same type…or entirely new ones. This tends to be the most enjoyable portion of recovery for most people because there is a virtually unlimited amount of movement and conditioning that can be explored. The recovery goals can be achieved and often new movement paradigms can be discovered. It is entirely possible and actually quite common for an injured individual to come back with a better-functioning body than before, even if the injured tissue itself is a few percentage points less than original quality. This is because the well-trained body can correct movement deficiencies and increase power output, force absorption, and energy conservation, to name a few.
In summing up the injury sequelae, I’ll offer up some advice based on my experience over 35 years and working with thousands of folks in this capacity. Appreciate the underlying scientific principles of injury and recovery. Do your best to accept your situation and to optimally support and pursue recovery. Be conservative early (bleeding/healing) — your body knows what to do so make that a priority. Be aggressive late (scar/training) — get after it, challenge yourself, and reach new heights.
So that’s a decent overview of injury recovery with regard to acute episodes. My goal with this discussion was to provide you with some clarifying information, and a lot of reassurance in the process of recovery. It’s not always easy to be patient with these things, but if we are relatively accurate and moderately consistent in what we do, most injuries can be dealt with fairly expediently. I’ve heard it said “By the inch…it’s a cinch — but by the yard…it’s pretty hard.” Try to observe the steps we went over. Ideally, we hope to not have too many acute injuries, but they are an inevitable fact of life. Good luck!