Injuries happen. That's a fact when exercising or playing sports. But as a great man once said: "it ain't about how hard you hit, it's about how hard you can get hit and keep going".
Today, dear reader, I am going to teach you to keep going when you "get hit", by schooling you on how to recover from any musculoskeletal injury you happen to get.
Now, obviously I can't go into detail about every specific injury, not only would that take longer than anyone would care to read, but it also wouldn't be specific enough. Each individual is different and as such, requires different advice. Instead, today I'll be covering the general phases that each injury receiver should go through when trying to return to their sport, whether that be at the top level or just the local bowls team.
This is exactly the same information that I have been taught at a master's degree level for exercise physiology, but it is something that everyone can understand.
Without further ado, let's hop into the 4 phases of rehab everyone who has received an injury should complete:
Phase 1: Acute management
Goal: To reduce pain and swelling, and to prevent further injury. Best approach: Maximise pain-free range of motion (ROM) and minimise rest.
Exercises: controlled ROM movements, multiple times per day, with NO increase in pain.
Usual duration: 24-48 hours, can reoccur. Looks like: sitting on the couch with an ice pack on and taking your injury through gentle movements.
When to progress: full ROM is achieved with minimal pain.
The goal of the acute management phase is all about minimising inflammation and maximising pain-free range of motion (ROM). Most inflammation lasts 24-48 hours, however, some injuries can last longer or become re-inflamed.
Most people know the acronym RICE:
Rest
Ice
Compression
Elevation
But in recent years an increased focus on active rehabilitation and how much harm inactivity can cause to muscle tissue has produced a more relevant acronym, POLICER:
Protect
Optimal
Loading
Ice
Compression
Elevation
Refer on
The most obvious difference being that Rest has been replaced with Optimal Loading, which basically means to move the injured limb as much as possible without injuring it further. In general, if you can move the limb without pain, you should be moving it regularly to encourage healing and return as much range of motion as soon as possible.
A secondary goal is to improve proprioception and motor output, which both decline rapidly during an injury. This basically means understanding where your body is in space and being able to control it. Just like everything else in the brain this fades when not in use, but this loss can be completely negated by exercising.
To achieve this, the exercises are controlled. The amount of force is limited, and the position of the body part should be as supported as possible. A good way to ensure a body part is supported is to move perpendicular to gravity, not against it. This is so the load can be increased or decreased based on if there is a flare up of pain while going through the movement.
You can progress to phase 2 once you can move through full ROM with no or little pain while under no load.
Phase 2: Increase load, alter risk factors, maintain conditioning
Goal: Increase muscle strength, minimise overuse and compensation injury risks, keep the rest of the body fit. Best approach: Build joint stability and muscle size.
Exercises: Isometrics, basic strength patterns and cross training, 2-3 sets of 8-12 reps, 2-4 times a week. Stop if increase in pain 24 hours after exercising.
Usual duration: 2-8 weeks. Looks like: Resistance band or limited gym workouts, return to everyday life with careful considerations around use of injury. May flare up but the trend should be getting better.
When to progress: Functional tests should be passed with good form (no compensation).
The goal of phase 2 is threefold: increase load tolerance, alter biomechanical risk factors and maintain conditioning. To do this, you need to begin performing your rehab exercises, minimise the amount you use the tissue in everyday life to minimise risk of tissue overload, and perform cross training.
Your rehab exercises will differ depending on a number of factors and should really be given by an exercise professional such as an exercise physiologist or a physio, osteo etc who specialises in rehabilitation (bonus points if they've done a strength and conditioning course). At this stage they should be basic exercises for hypertrophy like squats, rows or calf raises with a range of 2-3 sets of 8-12 reps. They should target the injured tissue and those around it to help stabilise the joint.
During this stage it is easy to overuse the tissue and cause more swelling, at which point you should temporarily revert to phase 1 strategies to minimise the swelling and pain. Not all pain is caused by overuse though - only reduce training if the pain is there 24 hours after your workout. It is common to feel some pain during workouts and the general rule of thumb is less than 3/10 is okay to push through, anything more and you should stop. Expect to have some good days and some bad days, just make sure you are adequately strengthening the muscles, otherwise things won't get better.
To help reduce the chance of overuse injuries occurring, it is important to look at biomechanical factors to ensure that tissue isn't being overloaded. An example of this is checking running form while rehabbing a knee or hip injury. Often, knee injuries in running are caused by poor technique, sending force shooting up from the feet into the knee. We can play around with the biomechanical factors such as wearing different shoes or altering running technique to help reduce the load on the knee while it is recovering.
Finally, we need to maintain conditioning to ensure a smooth return to sport. Cross training is exercising in a different domain to what you are training for, in order to achieve similar benefits. For example, running to improve cardio fitness for the sport of rowing. My two "go-tos" for cross training are stationary bikes and swimming. Both of these options are really good at safely taking the load off the body while also being capable of providing a serious challenge to the cardiovascular system whilst being flexible. Hurt your upper body? Cycle or swim using only kicks. Hurt your lower body? Find an arm cycle or swim using only arm strokes. You have to stay fit while rehabbing, not just to return to sport quicker, but for all the usual health benefits of keeping fit too.
Mental health, in particular, is a big concern while injured. Finding exercises you can do, instead of focusing on what you can't do, will help improve your mental state! Remember mental measures like optimism have a direct impact on your rehabilitation.
Rehab exercises at this stage should be throughout the full range of motion, focusing on joint stability and muscle growth. These exercises should be using extrinsic stimuli, which is most useful (and cost-effective!) in the form of resistance bands. Again, look to your health professional for what specific exercises to do, but movements like band walks, band rows and band knee extensions are common ones.
To progress to stage 3, you should pass some injury-specific tests that look at your function. These functional milestones should be observed by a professional to check form, as you may be able to complete the movement but with significant compensations. Examples of functional milestones include: jogging, hopping on one leg, overhead throwing or changing direction.
Phase 3: Sport-specific training
Goal: To make sure you can perform your sporting movement to a competitive level under careful circumstances. Best approach: Performing complex movement patterns, lots of times.
Exercises: Sport-specific movements, complex lifts and power training (plyometrics), 2-5 days per week with rest days.
Usual duration: 2-6 weeks. Looks like: Fully back in the gym. Return to sports training in a limited capacity (e.g. non-contact).
When to progress: Limited definitive answers on this one... In general, injured limb should have >95% strength of non-injured limb and more functional tests related to the sport are passed.
In this phase, you can return to your sport (yay!) in a limited capacity (boo!). This is where most people can get themselves to, but the rehab journey is not over yet. Just because your limb can support you again, does not mean you are ready to go back into high-intensity usage just yet. This phase is about building up your capacity back to sporting levels. That means that just because you can squat a weight up and down again does not mean you're ready to be jumping into a pack of players. You need to relearn motor patterns, introduce power movements and step up your strength training.
As previously mentioned, motor patterns fade quickly from your brain's neural pathways. You need to perform a movement a plethora of times to ingrain that movement smoothly. To do this, sport-specific patterns such as kicking, changing direction, jumping or swinging should be performed under controlled circumstances to "grease the groove" of that movement. These drills should start pre-planned with minimal reactions required and plenty of time to allow you to learn to solve the movement problem. This means that when the situation comes up in-game, you will have a pre-planned movement to bring out, minimising risk of injury.
Up until this point, the movements will be very controlled and focused on stability. Well, now you need to be able to perform these movements very quickly, so it's time to train for power. Plyometrics are explosive movements such as jumps, that can train the stretch-shortening cycle in your muscles and improve the amount of force you can create in a short time. These should be performed for low reps (~6) at moderate weight (60% of your maximum) at high intensities to ensure you are creating enough power safely.
It is also time to progress your training from basic strength movements to more complex lifts. One example of this is a lunge to single leg deadlift combo, as this trains not just strength but also unilateral strength, balance and control. This will not only improve your function but also your confidence on the injured limb, which as mentioned earlier can have big impacts on overall rehab.
It is still up for debate when this phase should be progressed into a return to play. Clinicians will want to see functional tests passed, such as agility runs and strength levels greater than 95% of the uninjured side, but both player and coach will be wanting to return to sport as soon as possible. In general, common sense suggests the more time you spend strengthening in this phase, the less risk of injury upon return (albeit with diminishing returns - the first few weeks could half your chance of re-injury, the following few weeks reduce that risk by another quarter, and so on...). Regardless, when you return you should be re-introduced to the game gradually.
Phase 4: Prevent re-injury
Goal: To sustainably reduce injury risk in the future. Best approach: ingrain habits and healthy lifestyle choices to make it easy.
Exercises: All of the previous rehab stages but far less volume is required.
Usual duration: Until death or you don't mind being injured
Looks like: Specific activation drills as part of a warm-up. Continue with at home or gym strengthening routine, though focus is on endurance and sport-specific movements.
All sports injuries will, unfortunately, increase the susceptibility of the athlete to re-injure that tissue, regardless if the tissue regains its structure and function. This is why it is so important that we reduce our injury risk by continuing with our rehab exercises long after the initial injury. The final phase of rehab is all about building up the body's tolerance and maintaining this for life.
To do this, you will need to continue with exercises from the previous phases. BEFORE YOU ROLL YOUR EYES AT ME: you don't need to do anywhere near the same volume. Once you have built up your strength, maintaining it requires about 1/3 of the volume! That means if you were doing hip isometrics 3 times a week, you can do them once a week and not lose any strength! This is important when looking to the future, especially if you plan on playing sport for years to come. It's easier to stay on the track than fight your way back on, so do whatever you need to keep these habits.
One way to minimise re-injury risk is to include some of these basic strengthening movements in your warm-up - it's easy to remember, you'll do it often and it doubles as preparing you for your sport. It's also important to train endurance in your particular sport. So, AFL players should train with repeated sprint efforts, and tennis players should be hitting a similar number of shots per minute as when in game.
A common question people ask is: "when can I stop doing these exercises?" or "when will I be fixed?".
The answer is there are no clinical signs that you should ever stop doing these exercises. If you do, the risk for re-injury increases again. So I like to say: "do them until you don't mind being injured again", which usually translates into "do them until you die". Might seem grim to you, but don't view it as "oh I should have never gotten injured", view it as "I should have always been doing these exercises".
To recap the four phases:
Phase 1: Look after yourself and regain that ROM
Phase 2: Start using those muscles to regain muscle size and stability
Phase 3: Reintroduce some explosive sport movements in a controlled environment
Phase 4: Build that endurance and maintain your health!
FINALLY...
Remember it won't be an easy journey. It can sound somewhat straightforward when written down in this article, but most rehab journeys don't go that way. Below is a real useful graph of what real life rehab journeys look like.
Life gets in the way and sometimes it can feel like you're even moving backwards. Stick with the rehab, get through as many of the exercises as you can and you'll eventually see the upwards trend.
I hope this article has been useful for those of you who have suffered an injury recently. Follow these phases, under the guidance of a professional and you'll be back to fighting fit in no time.
Stay strong and stay on track!
Images and information taken from: Clinical Sports Medicine Injuries by Brukner and Khan, Chapter 18, page 278.