Part of being an athlete is understanding the inevitability of injury. Even if your form is perfect, your nutrition is impeccable, your recovery days are regular and your attention to joint mobility and soft tissue health is meticulous, you will have injuries. If you don’t you’re probably not training hard enough. Some of you may think you are bulletproof, but most of you probably know differently.
The injury you sustain most likely won’t be catastrophic if you’re monitoring your health, and the wonderful thing about these types of injuries is that they are self-limiting, meaning it’s very difficult for you to make it worse. The injury forces you to stop.
For the purpose of this article, we will leave those types of injuries aside and stick with the “tweaks”, “pulls”, “junky shoulders”, “business”, “heat”, “nagging elbows” and other injuries that can predispose you to severe injuries down the road. The kind of injuries that most athletes will work through, and the same kind of injuries that your primary care physician will probably tell you to rest and immobilize.
Before getting to the proper approach to managing these injuries we must first discuss the physiology of tissue repair. I refuse to say tissue healing because tissues don’t heal, they repair. We’ll keep this to a 101 level course and leave the intensive biochemistry out.
Every “tweak” is tissue damage. Every strain is a small tear in muscle or tendon tissue. A sprain is a small tear to ligament tissue. The severity of the tear correlates with the physiological response and the limitations you will experience. Tissue damage of all types creates an inflammatory reaction by the body that typically goes as follows:
1. Acute Inflammatory Phase: Marked by swelling, redness, warmth and pain, the acute inflammatory phase lasts about 72 hours. During this period of time, the body minimizes blood loss by activating the blood coagulation system; dilates the blood vessels so that repairing elements may be more quickly delivered to the damaged tissues; and removes debris which results from the damage to soft tissue cells.
2. Repair Phase: This phase lasts from 48 hours to 6 weeks. Early in the repair phase the body finishes the job of cleansing the entire area of the soft tissue injury. Next the body synthesizes new collagen fibers to replace the damaged fibers (scar formation). The new collagen is not, however, fully oriented in the direction of tensile strength.
3. Remodeling Phase: This phase lasts from 3 weeks to 12 months or more. During this phase, the body remodels the newly synthesized collagen in order to increase the functional capabilities of the tendon or ligament to withstand the stresses imposed on it.
In other words, YOU ARE ALWAYS REPAIRING!
It is important to note that normal tissues are composed of type I collagen whereas
damaged and repaired ligaments contain a large proportion of type III collagen. Type III collagen is considered an immature form of collagen because it is deficient in the number of cross-linkages between and within the collagen subunits. Experiments which have studied ligament healing in rabbits have found that 40 weeks after injury the collagen is still deficient in content and quality. The cross-linkages are of critical importance in determining the strength of the newly synthesized collagen. Over time, type I collagen replaces type III collagen during tissue repair. Factors that impede repair include:
- Extent of Injury - Swelling
- Hemorrhage - Poor Vascular Supply (Cartilage etc.)
- Spasm - Atrophy
- CORTCOSTEROIDS! - Infection
- Overall Health - Age
- Nutrition - Lifestyle (Smoking, Other Diseases)
In the case of more severe injuries, swelling will be present. When swelling is present, it is critical to reduce swelling because swelling increases pressure, causes pain and alters neuromuscular function. It slows the repair process and inhibits recovery.
Restricted activity is warranted for 24-48 hours in these cases, but controlled mobility of the area is superior to immobilization. This is crucial. Immobilization is only warranted in the most severe injuries. When instructed to rest, that only applies to the injured body part.
Cardiovascular fitness, strengthening and mobility should be continued. Ice is great for reducing swelling; however, compression is the single most important factor. Utilize elastic wrap to mechanically reduce the space available for fluid to accumulate (up to 72 hours in the most severe cases).
So that touches on the more significant sprain/strain injuries, but what about the more common factors pertinent to athletes. The presentations that sound like:
1) “Dude, every time I go overhead my shoulder feels like an ice pick is jabbing into it. I mean I can still lift it but I’m pretty sure something’s wrong.”
2) “When I hit the bottom of my squat I always get a sharp pain in my hip. It’s just for a second so I’m still doing heavy squat cleans, but I think I need to get it checked out.”
You get the point. These are not badges of honor by the way. These are warning signs that you should pay attention to. Your brain is significantly smarter than you could ever try to be and it will alter the way you move, even to the slightest degree, to adapt away from pain. Altered movement patterns reduce painful movement and predispose you to inefficient biomechanics and significant injury.
Nagging elements of an injury can be related to a variety of things. Typically athletes get stuck in a constant, low-grade inflammatory stage of repair. Don’t forget that all that lovely concentric and eccentric loading creates tissue damage leading to repair. This type of repair makes you beastly though, so don’t be afraid.
If an injured area gets stuck in an inflammatory stage for too long this can lead to the “-itises” of the world i.e. tendonitis, myofascitis, myositis etc. If allowed to persist even longer, tendinosis or other conditions indicating long-term irritation can manifest.
So what do you do? First of all, monitor all of those lovely items in the first sentence of this article. This will go a long way, and, truthfully, the rest of it is easy. Don’t be stupid! Being and athlete is a lifestyle choice. You are in it for the long haul. Don’t sacrifice your health now and set yourself up disaster later.
Let’s break that down and look at the “icepick shoulder” from above for clarity.
It hardly bothers you at all throughout the course of your daily activities, or maybe only in specific movements. It’s probably a little stiff or tight when attempting to stretch/mobilize in full range of motion, but isn’t really painful per se. While warming up (you better be) you notice some discomfort that improves the longer you go. Then you load up some heavier weight and press *&%!. What happened? The intensity of the load in that movement has exceeded the biomechanical threshold of the motor units involved. Say what? You shouldn’t do it! Crunchy, poppy, grindy and all of those other sensations are likely alright during movement. Pain is not!
Start with some focal ice massage for about 4 minutes to calm down peripheral inflammation. Mobilize the joint through passive and active movements (check with mwod, your coach, PT, Chiro, LMT or whomever). KEEP WORKING OUT THE REST OF YOUR BODY AND DO NOT IMMOBILIZE!
Give the shoulder 48-72 hours to recover and continue to self-treat with rest, ice and compression. Then test the waters again. Maybe apply some kinesiotape to the area to accelerate lymphatic circulation and repair. When you start back up, warm the area up a little longer than usual with dynamics, mobilization exercises, self myofascial work, foam rollers, sticks, lacrosse balls and all the other gadgets out there. Get the heart pumping and blood flowing to the entire body. Start with lighter loads and slowly work your way up.
After that listen to your body. Only you know the difference between hurt and harm. A little hurt is okay, you’re an athlete for god sakes (yes, even YOU are an athlete). Harm is another story. If there is pain, back off a bit, modify your plan, and continue to self-treat. If you are unsuccessful with this plan for a few weeks you may need some outside help. There are a ton of great tools and providers out there. And realistically, your PCP is probably not the best choice. A research study conducted a few years back revealed that 84% of family practitioners feel that their education does not adequately prepare them to handle musculoskeletal conditions (that’s a story for another day).
Dr. Kevin Kerchansky, DC, DACRB, CSCS, CICE
Dr. Kerchansky is the Director of Physical Rehabilitation at Triad Pain Management Clinic, a multidisciplinary, functional rehabilitation facility in Tempe, Arizona. He is a Board Certified Diplomate to the American Chiropractic Rehabilitation Board, and has been certified to testify in court as an expert in Clinical Biomechanics. Dr. Kerchansky is a post-doctorate educator at Northwestern Health Sciences University, currently conducting seminars around the country on the Functional Rehabilitation of injuries. His pursuits have also led him to credentialing through the NSCA, USAW, CrossFit, and various other sport systems.
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