I was fortunate this past weekend to lecture at the Boulder Running Clinics with Vern Gambetta, Steve Magness, and Charlie Kern. Speaking with such an accomplished group forces you to raise your knowledge game. You have to be current with your research/background information and not be a minion to common trends just because they are common trends, especially if they logically don’t make sense (I’m looking at you: self-massage rollers). But the think tank conversations that occur with the other lecturers and clinic attendees at the social after the event is where the real learning occurs. It’s an opportunity to get on a soapbox with some very knowledgeable and respected peers to agree, disagree, and/or rant about so many commonly practiced misconceptions that go on in sports performance, recovery, and health care. The reality is, simple and straightforward tend to be the most accurate and efficient. This is especially true in injury rehab, where we’re always looking for the next cool modality that will “accelerate” are recovery. Cold lasers, bone stimulators, compression boots, self-massage rollers, herbal elixirs, cryosaunas, E-stim…..the list of fad and for the most part useless trends is endless! You’re better off being patient, giving the tissue a chance to calm down, then progressively re-loading it with advice from a qualified professional. Below is a list of keys for a successful rehab. It’s not sexy, but if followed appropriately, is usually the most effective at optimizing your recovery.
1) Accurate Diagnosis – There is nothing that can delay your injury rehab timeline more than if your injury is misdiagnosed in the first place. Having the proper assessment lays the foundation for the rehab plan, it is crucial to get it right! Otherwise costs, stress, and frustration will continue to rise as your return to full activity is met with more and more setbacks. Getting the assessment of “your glutes are weak or not firing” is not a diagnosis, neither is an “upslip in my pelvis”. Think about that for a second, if your glutes weren’t firing, you’d be walking with a pretty significant lurch in your step. Get an accurate diagnosis from a qualified individual, not WebMD or your massage therapist, or your buddy in the next cubicle who had something similar! There are some great MDs, Orthos, PTs, and Sports Chiros (start with those that have a CCSP or DACBSP after their name) out there. But, there are also some very bad ones that muddy the waters, so pick wisely. Nothing frustrates me more when I have a patient that comes in and tells me that the problem is “their pelvis over rotates” or they “have a leg length inequality” when they haven’t had the proper assessment that confirms this suspicion (stability testing of the SI ligament or full body X-ray to actually measure the leg length differences). Misdiagnosis leads to misinformation being shared, which in healthcare is a recipe for disaster.
2) Consistency and Compliance – In order to get better at a task, you need adequate time repeating that task in order to develop a proficiency at performing that task well. This is where the SAID (Specific Adaptation to an Imposed Demand) principle comes into play. When the body is placed under a stress/load, it will start to adapt so that it can better handle that specific stimulus in the future. The stress applied must be enough to create a response, but low enough to avoid overtraining or risk injury. This principle can be applied to sports performance, as well as injury rehab. Progressing too quickly before your body has had a chance to adapt to the stimulus your trying to improve (whether it be squatting technique, balance, plank progressions, interval speed, running volume, etc), you risk inhibiting adaptation and promoting injury or causing setbacks in your injury rehab. Setbacks when it comes to injury rehab usually occur when 1) the rehab work isn’t performed or is inconsistently performed (eg. soft tissue rehab and at-home exercise prescriptions) or 2) was progressed too quickly (eg “body weight squatting is easy and I look weak when I’m at the gym, so I’m gonna add some weight to this bar”). So be compliant with the program assigned, whether by a coach or rehab therapist, and be consistent with how you are supposed to perform the prescribed tasks. This includes avoiding the “I feel good so I decided to do more, when I was prescribed less” and the “I don’t feel pain anymore so I really don’t need to get re-assessed by my therapist because I should be able to take it from here” thought processes. We also tend to jump from one therapist to the next. This can not only create confusion if information shared is conflicting, but can also prevent your injury from healing by constantly changing the rehab plan. Find a therapist you trust and feel comfortable with their plan, then follow it!
3) Load Management – As stated above, the SAID principle is key when adapting to a new stimulus. When you get hurt, unloading the injured area initially is crucial. How you unload it and for how long, depends on the type and severity of the injury in question. This is why an accurate diagnosis is key, it sets the foundation for the return to full activity blueprint. If you have a grade 3 stress reaction, but you think it’s just a grade 1, you’re underestimating the length of tissue healing by 6 weeks. So don’t be stubborn, get the injury assessed so you can improve your outcome. Once the tissue is ready to be re-loaded, having a progressive and logically thought-out plan in place is important to avoid setbacks and improve tissue resilience. You have to graduate back to full activity, so be patient and don’t rush the process.
4) Caloric Intake – Relative Energy Deficiency in Sports (RED-S) is a common co-morbid factor that can effect one’s ability to heal and stay healthy. In Div 1 college athletics, around 2-5% of all athletes have this issue. But the number jumps to 67% in long distance runners. This condition boils down to the energy availability is less than the energy output. This means that you are eating too little for what you are outputting in terms of activity level. We automatically associate this to a conscious decision not to eat (disordered eating) in an effort to not gain weight, but it can also mean that we are exercising or working in excess for what our normal eating habits can keep up with. Lack of caloric intake is one of the main injury predictors, especially in females. But it is also a key factor in successful injury rehab. Low caloric intake has been associated with delayed bone healing, inability to heal and build new muscle tissue, decreased immune function, decreased growth hormone, reduced metabolism, and chronic fatigue. The graph below is from the IOC’s 2014 Consensus Statement on RED-S. If you feel like you normally eat enough for your energy output, increase it when you’re hurt. Give your body a better chance at healing by having the necessary energy present to aid the process.
Final Bullet Point Thoughts to Remember:
- Simple doesn’t mean easy
- There’s no silver bullet in performance or rehab, adaptation takes time!
- Modalities (e-stim, ultrasound, normatecs, cold lasers, etc.) are better served to hold your cup of coffee
- Diagnostic Imaging can aid the diagnosis and help with grading the injury, but make sure it’s clinically indicated.
- Eat, eat, and eat some more, especially in endurance sports. If 80% of the time you are eating healthy, don’t feel bad about indulging the other 20%, but EAT, especially when hurt!
- Beware of the used care salesman therapist with the injury diagnosis that isn’t a real injury diagnosis
- Massage therapists, this ones for you and it may sting a little – some of you are great, but more pressure is not better. You can set tissue back, by working it too aggressively for the stage of healing it is in. So know when to back off. It is also not your job to diagnose an injury or prescribe rehab advice! If you want the ability to be the primary practitioner in the rehab process, get a degree that allows you to do so!
- Don’t progress if you’re not ready!
- Find a qualified practitioner to aid your rehab with a progressive plan that has a scientific basis and stick to it!
Ok, jumping off my soapbox!