Rehabilitation Exercises — Stephanie Attwater

Rebuilding strength after an injury can be incredibly frustrating. Go too fast and you’re likely to re-injure yourself. Too slow and you may not see the gains you’d like to and give up altogether. So how can you help yourself recover with the optimal amount of stimulus to drive tissue growth without overdoing it? Let me drop some science for you…

Tissue repair happens when your body is in the parasympathetic state - meaning, if you're stressed out about work, or life, or your injury, guess what? Your body is not healing. Your stress response means you're in 'fight or flight' mode. What your body cares about in this mode is either getting you away from or ready to fight whatever threat happens to be causing the response. Healing can happen later, once you've survived. But if you happen to just stay in your stress response, well... That's when it becomes detrimental to your health. So first off, please see this post here on how best to switch off your sympathetic mode and switch on your 'rest and digest' parasympathetic mode so tissue repair and healing can optimally occur.

It's important to note that exercise of any form is considered a stressor. It’s important to understand this so you can better life hack the recovery process. If you’re going to add the stress of exercise to your tissue to stimulate growth, try to limit other stressors in your life so your body can focus on the one stress at a time so you don’t accidentally overwhelm the system. Also, try to spend as much time as possible in a parasympathetic ‘recovery’ state post exercise to optimize tissue repair.

So, that said, tissue repair works like this - there’s the initial inflammation stage, which is an important time to maintain pain-free range of motion (assuming you’re not in a cast, of course; if you are, wait until consolidation has occurred before starting to wiggle fingers or toes, which is typically 2 weeks) but you don’t want to actively strengthen the damaged tissue yet. It’s a bit like when you have a cut on your knuckle. Anytime you bend the finger, you reopen the cut and it takes longer to heal. So wait until the signs of inflammation (pain, redness, swelling, heat) have subsided before you begin trying to rebuild strength. The nice part is, you have a handy, built-in warning system to let you know if you’re further damaging anything - pain. Pain is the signal that tissue damage is likely to occur, if not currently occurring. This is why it’s important to stay within the ‘pain-free’ limits during recovery. If you overdo it, your body will let you know. Don’t push it, otherwise, you delay healing, like reopening the cut on your knuckle. So think of your pain signal as your helpful friend. Just stay away from that and you’re good. The inflammation stage lasts anywhere from a few days to a few weeks, depending on how bad the injury is.

Typically between 2-8 weeks is when folks are at most risk of re-injury. This is when the repair phase has mostly occurred and you no longer have an active wound, but the tissue is still fragile as remodeling happens, which is the stage where the new tissue fibers strengthen. This is a wonderful time to start making slow strength gains, but still within the pain-free range. The reasons for slowly increasing activity during this phase are two-fold - 1) the increase in activity helps the re-coordination of your muscles, joints, fascia, and nervous system that has likely been immobile for a while which 2) feeds back to your brain that healing has occurred and the body is no longer injured. So the more you move in that pain-free range, the more your body and brain will begin to believe that it’s healed. But that’s only true as long as you don’t push it. Because if you do then your brain and body basically get into an argument over which one is the liar and you have a flair up of symptoms. This means your tissue will be less likely to trust that it’s actually healed, so when you start re-introducing activity after the flare up, it will be much more hesitant to trust that it is healed, more reactive to over stretch stimuli and more likely to go into protective spasm sooner. This can set you up for a chronic injury that just never seems to get better despite tissue healing, or what we call a ‘hyper-sensitization reaction’. This is a miscoordination of the nervous system where it becomes more sensitive to previously neutral stimuli. Basically, your body begins to see everything as a threat because it can no longer trust the signals it’s receiving. And that will lead to a much longer and in-depth rehabilitation to retrain that.

So what are some good guidelines for the re-introduction of pain-free activity? Honestly, it depends on the injury, which is why I usually send patients to one of the physiotherapists I work with to develop an individualized program. But! That’s not why you’re here and reading this post. So here are some handy websites who have already done the work for me:

Remember, go slow. You are not trying to get to fatigue of the muscle. Going to muscle fatigue causes delayed onset muscle soreness, which is your goal if you’re trying to build size. This is about rehabilitation. Okay, hang on, let me explain a bit more for you.

Think about a muscle like strands of uncooked spaghetti that are each wrapped in saran wrap. Then take bundles of ten of those strands and wrap that bundle in saran wrap. Then take a bunch of those bundles, wrap the whole thing in saran wrap and stick it in water and you have a basic muscle. The individual spaghetti strands are what we call muscle filaments. A bundle of filaments is called a muscle fiber. A bunch of fibers together makes up a muscle. These guys do a pretty good job of explaining the relationship of fascia (the saran wrap) and muscles (the bundles of spaghetti and saran wrap together). They also have really great injury recovery exercises if you want to play around on their site.

So the goal when exercising is to break a few of the filaments. This is what causes delayed onset muscle soreness and is the signal to your body that the muscle wasn’t strong enough to lift the load. So then the body will replace those broken filaments plus add a few more for good measure so that the next time it comes up against a similar weight, it will be better prepared. You do not want to tear a muscle fiber because fibers replace with scar tissue, and a muscle with a scar is only at best 80% as effective as muscle without one. Plus, scar tissue is sticky and takes longer to heal. Filaments take about 48 hours to replace. A torn fiber takes two weeks. This is why it’s so important to give yourself adequate rest time between workouts - if your muscle wasn’t strong enough to lift the load originally, now you’re working with fewer filaments. If it wasn’t strong enough before, it definitely isn’t now, which means you are that much more likely to tear a fiber, which takes two weeks to heal. This is what sets people up for tendonitis. That scar tissue, during those two weeks, is sticky and fragile and likely to re-tear if you go back to your normal routine, which, as we’ve already established, you weren't strong enough to handle the first time around. So you re-tear those fragile fibers, and that requires more scar tissue, which you will re-tear the next time you work out… see where I’m going with this?

You’re already dealing with fragile tissue. You DO NOT want to go to muscle fatigue while re-strengthening when the injury is still fresh. Wait until it has fully healed before you go to muscle fatigue with your work outs. Now, that said - you don’t want to go to fatigue of THAT specific injured muscle. But you’ve got lots of other muscles you can focus on. They’re all fair game.

So for all of you thinking ‘no pain no gain’ or that you can tough out that sprain - just don’t. Why not be kind to your body instead so it doesn’t develop trust issues?

Food for thought…

Till next time, dear Readers!

Rehabbing an injury is rarely fun. I guess it can be, depending on your outlook and whatnot, but that’s a topic for a different post. Today we’re talking about why it’s important to be patient and rebuild strength in a slow and controlled manner so as to prevent re-injury.

So first, let’s talk about how long this healing process thing actually takes because it’s usually a lot longer than what you might want it to be. If you know what kind of timelines you’re looking at heading into it, you’re won’t be dismayed when you still feel sore when you think you should feel better by now. Because, as you can read about here, being able to predict when you’ll be pain-free can help you to manage your pain now.

But before we get into that, we need to talk about the degree of damage. Maybe you’ve had your doctor refer to your sprained ankle as a 2nd degree sprain? Your torn hamstring as a 1st degree strain or tear? Your achilles tendon rupture as a 3rd degree tear? Here’s the low down:

Some terminology for you: A strain refers to damage to muscle or tendon (a tendon is the thickened end part of the muscle where it attaches to the bone) that results from an over-stretch. Sprains refer to the same kind of damage but to ligaments. This is important to note because muscle is composed of well vascularized contractile tissue. Ligaments have some minor contractile ability but are mostly inelastic structures that are poorly vascularized. This makes a difference both in how long it takes to heal from an injury to a muscle versus a ligament and how likely it is to recover function. Typically, a muscle will heal faster with minimal impact long term, depending on the degree of damage, of course. A ligament, however, takes a much longer time to heal and once ‘stretched’ or lengthened from the injury, really doesn’t recover to its original length. Which makes you much more likely to re-injure a joint without proper rehabilitation to strengthen the muscles around said joint to basically ‘pick up the slack’ for the slackened ligament.

Strains

First degree - a ‘pulled’ muscle is typically what people refer to when dealing with a 1st degree strain. This is the mildest form of the injury with minimal tissue tearing. There will be tenderness in the muscle and full range of motion will be limited by pain at end range. Healing time: 4 days to 2 weeks, depending on degree of damage.
Second degree - a ‘torn’ muscle or tendon is typically a 2nd degree strain. This type of injury has more tissue damage. There will be swelling and bruising. This degree of strain is typically the most painful due to intact nerves irritated by the inflammation. There will be limitations to range of motion. Healing time: 2-6 weeks depending on how much damage.
Third degree - a ‘ruptured’ muscle or tendon is typically a 3rd degree strain. This degree of strain has the most tissue damage and often means the muscle has torn completely, which is why it is also referred to as a ‘full thickness tear’. It may or may not require surgery to fix, depending on the muscle or tendon. It is also often less painful due to the damage to nerves in the area. This is also the one that takes the longest to heal, with 6-8 weeks being the minimum time required, but can take months to recover from.

Sprains

First degree - this is the mildest form of the injury to the ligament with minimal tissue tearing. There will be tenderness locally and full range of motion may be limited by pain at end range, but there is still good stability in the joint. Healing time: 4 days to 3 weeks, depending on degree of damage.
Second degree - this is your typical mild ‘rolled ankle’ injury. There is more tissue damage and moderate to severe pain and swelling. There will be moderate instability to the joint but the ligaments are still intact. There will be limitations to range of motion. Healing time varies depending on the joint: 2-8 weeks depending on how much damage, full recovery may take months.
Third degree - the ligament or ligaments are completely ruptured. This degree of strain has the most tissue damage and often means there are accompanying muscle strains of varying degrees and often varying degrees of damage to other ligaments as well. It may or may not require surgery to fix, depending on the ligament and degree of instability at the joint, but the joint will be unstable and require significant rehabilitation. This type of sprain can take months to recover function, with remodelling often occurring for a full year post injury.

Now, it’s important to note that ‘recovery of function’ and ‘healing’ are two different things. You may be able to return to activities after a few weeks, but recognize that the remodelling process of ligaments takes months to a full year to complete. This means the tissue will be weaker than before the injury until it fully heals. So you may be at risk for re-injury without proper rehabilitation of the muscles surrounding the joint to provide the lacking stability.

So what is the best progression of exercises following a sprain or strain? The following is from the American College of Sports Medicine:

"TREATING A SPRAIN OR STRAIN

Management of both sprains and strains follows the PRICE principle.

P – Protect from further injury.
R – Restrict activity.
I – Apply ice.
C – Apply Compression.
E – Elevate the injured area.

This PRICE principle limits the amount of swelling at the injury and improves the healing process. Splints, pads and crutches will protect a joint or muscle from further injury when appropriately used (usually for more severe sprains or strains). Activity restriction, usually for 48-72 hours, will allow the healing process to begin. During the activity restriction, gentle movement of the muscle or joint should be started. Ice should be applied for 15-20 minutes every 60-90 minutes. Compression, such as an elastic bandage, should be kept on between icings. You may want to remove the bandage while sleeping, but keeping it compressed even during the night is best. Elevating the limb will also keep the swelling to a minimum.

If you suspect more than a mild injury, cannot put weight on the limb, or it gives way, you should consult with a health care provider.

REHABILITATION

The next stage of rehabilitation begins following the first 48 to 72 hours. The second stage focuses on gentle movement of the muscle or joint, mild resistive exercise, joint position training and continued icing. During this stage, you may gradually return to more strenuous activities, such as strengthening. Pain should remain low during rehabilitation. If pain increases, it usually means you have attempted to do too much. Throughout your recovery you can still maintain an aerobic training program. Options for training include stationary bicycling, swimming, walking or running in the water. If the injury is more than mild sprain or strain, it is best to consult your health care provider.

EXAMPLE: PROGRESSION OF ANKLE REHABILITATION EXERCISES

RANGE OF MOTION

Towel pull with toes
Draw the alphabet with ankle
Stretching with towel (advanced)

MILD RESISTIVE EXERCISES (REGAINING STRENGTH)

Foot press against a solid object – up, down and side-to-side
Tubing exercises in all motions (pain free)
Toe raises (advanced)
Hops – start forward and back, short hops (advanced)
Weights – Heavy tubing or cuff weights (advanced)

JOINT POSITION (REGAINING BALANCE)

Standing with eyes closed – partial squats and side-to-side shifts
One-legged stand with eyes closed (advanced)

FUNCTIONING RETURN TO SPORT

Performing sport-specific exercise such as figure 8 or shuttle runs."

The key words here are ‘pain-free’. Only do these exercises as long as they don’t cause pain. Stay within the pain-free range of motion and don’t do too much too soon. You may begin to feel better after a couple of weeks, but the tissue is still fragile and more likely to re-tear should you push too hard too fast.

Which brings me to the point that typically people who are at risk for muscle strains and tendonitis are those who don’t allow adequate rest between activity for the muscles to repair themselves. So make sure when doing any exercise program that you are allowing at least 48 hours rest in between workout sessions. See this post for more information on that.

And remember, seeing a good physiotherapist after injuring yourself can help speed recovery. They can also give you personalized exercises for your specific injury. You can check out the recommendations page here for the folks I typically refer to.

I didn’t cover what to do to manage an acute injury. You can find information on that here. All of this assumes that you’ve seen your doctor and done appropriate acute injury care and are beginning the rehabilitation phase of your injury. So if you’re injured and haven’t seen your doctor yet - go.