Why You Should Be Stressing Your Injuries
The Case for Load in Healing
Traditionally, sports injuries have been treated with RICE: rest; ice; compression; and elevation. This type of passive approach is good for calming down acute symptoms. But, it turns out that the next step to treating many injuries should be anything but passive. Although the myth that rest is the best approach remains entrenched in our society, evidence to support the opposite—a more active approach—has been mounting for some time.
We understand that to make our muscles stronger we need to load them through training; for example, lifting weights or running. When we do so, we are applying a stressor to generate an adaptive response from the body. Injuries are no different. Although slightly more complex than training for fitness, we could generalize and say that to promote a healing response you must stress the injured tissues.
Consider just a few examples of the evidence:
A study on plantar fasciitis conducted by Michael Rathleff, PhD, out of Aalborg University Hospital in Denmark, showed that loading the plantar fascia, via single leg heel raises with a towel inserted under the toes, significantly out preformed typical care (stretching and shoe inserts) at a three month follow up.
- Pekka Kannus, MD, PhD, discussed the negative effects of rest without load in the Scandinavian Journal of Sports medicine & Science in Sports (link) noting that substantial reductions in tendon loading have been shown to negatively affect tendon strength. Tendons do not heal with rest alone. Although the pain may settle, it often returns because rest alone does nothing to improve the underlying problem in the tendon. In fact, loading the tendon happens to be the gold standard in treatment of tendon pain today. In most cases tendonopathy will not improve without some form of load stimulus. (Article links: 1, 2)
- Most clinical practice guidelines for treating low back pain recommend patients remain active. In fact, bed rest has been shown to have negative side effects: the soft tissues (muscles, tendons, ligaments, and discs) get stiff, weaken, lose their flexibility, and lose nutrients vital to tissue health. Additionally, those who remain inactive increase their likelihood of depression as well as prolong healing time. (Article links: 1, 2)
- The concept of “stress to heal” may not just work for the body but also the brain! Consider a recent study published in the Journal of the American Medical Association, which evaluated different approaches to concussion care in a pediatric population. Researchers found that physical activity within the first week (following a concussion) reduced the risk of persistent symptoms versus complete rest. (NOTE: research on concussion care is evolving rapidly. Concussions are serious and should be evaluated by a medical professional.)
As I mentioned in opening, rest may be a short-term strategy to control acute symptoms, but stress is the ultimate pathway to healing. That said, there is some nuance: we have to establish how much stress will create a positive healing response, while not being too much to further aggravate the injury. There are three important parts to this discussion:
Why You Load
1. To find the sweet spot for healing
2. To change the experience of pain
How You Load
3. via functional training
The “Sweet Spot” of Tissue Loading
When we are finding the sweet spot of loading we are trying to load enough to produce a healing response. Too little and we don’t make any change. Too much and we irritate the injury and further delay healing.
Appropriately loading the injured tissues can lead to two positive adaptations:
- It aids in accelerating the healing of injured tissue
- It provides additional support to the structures around it
Either way, loading the injured tissue increases your capacity and tolerance to stress. This is the same as slowly being able to increase weight in a strength training program or increasing distance in a running program. It takes repeated bouts of stress followed by adaptation to create this change.
Hopefully now you understand the “concept” of the sweet-spot for tissue loading. What that exact sweet-spot is, however, is different for each unique injury. Injury-specific articles (on my blog) will help you find that spot.
Pain and Graded Exposure
In addition to strengthening the tissue and surrounding structures, loading an injury also changes the perception of pain. When you first get injured the pain response is like an alarm going off telling you something is wrong. Subsequently, the alarm system stays on ”high alert,” so when you begin to load the injury the alarm may go off —pain. However, when we are in the “sweet spot” for loading, your body will gradually stop sounding the alarm. This happens for two reasons:
- The tissues and surrounding structures are getting stronger
- When you load an injury with the proper intensity, your body and brain start to learn that it everything is OK and thus the pain starts to decrease
As a result of these two processes, the body will lower its defense system and learn it is no longer under threat of injury. This leads to a reduction in pain which will allow for an increase in loading and increased adaptation. So as pain reduces, load can increase, and we can begin our return to activity.
The concept of functional training is very simple. The exercises should be as close to your goal activity as possible. Early on in the process you may not be able to do this. You may need to get creative in the way you load the tissue to be able to stimulate a healing response without aggravating the injury. However, you don’t need to stay in the mundane abyss of rehab (e.g. clam shells and bridges) forever. At some point you need to get off the floor, progress the load, and stress your system in a way that more closely resembles your sport. The faster you do this the sooner you will get back to your activity of choice.
Key take aways
Rest can be beneficial to manage acute injuries and for symptom control. However, load is integral to actual healing.
- Finding the sweet spot: enough stress to create an adaptive response but not enough to irritate the injury.
- Adopt a nuanced view of pain. Conventional wisdom says use pain as your guide: in other words, “stop if it hurts.” Yet, oftentimes, a little pain is OK - it can be useful in finding the sweet spot for loading. Additionally loading can help the body reset its alarm (pain) system.
- While you may have to be creative with how you load early on, the ultimate goal is to progress to exercises which closely resemble the demands of your sport as soon as possible.