by Dallas Hartwig, PT, MS
As a physical therapist and strength and conditioning coach, I’ve spent a good portion of my professional career talking to people about recovery, either in the clinic following an injury or in the gym following a high-intensity workout. Since I believe that brief, high-intensity exercise is the most productive in terms of maximizing fitness and minimizing risk of overuse injury and excessive oxidative stress on the body, I prescribe exercise programs that look a lot like CrossFit, with a heavy emphasis on strength movements and gymnastics.
Unfortunately, there’s a lot of information out there about how to exercise, but far less information about the application of proper rest and recovery techniques. I see more sub-acute and chronic injuries resulting from inadequate recovery from exercise (especially with high-intensity programs), than resulting from an acute or traumatic incident. The primary fault lies with inadequate or improper recovery from exercise, not the type or intensity of exercise. (To put it another way, it’s not that you’re hurting yourself doing pull-ups – more often than not, it’s because you’re not properly recovering from those pull-ups.)
I believe that a high intensity exercise program is both effective and sustainable life-long, when combined with good nutrition and recovery practices. So I find myself educating my PT patients about nutrition, sleep, active recovery techniques, and stress management practices as often as I do about the physiology of connective tissue healing, lumbar stabilization, or biomechanics. It was this experience that, in part, led Melissa and me to develop a comprehensive and integrative practice (Whole9) to help our clients continue to aggressively chase health and performance without being hindered by nagging pain and injuries.
At some point in our lives, we’re likely to find ourselves over-trained, under-recovered, under-fed, under-slept, over-caffeinated, and (eventually) actually injured. Ideally, the early stages are the time to pay attention to what your body is trying to tell you, and take immediate action to ensure those nagging aches and pains don’t become a seriously limiting chronic injury. So here are the Whole9’s recommendations for what to do when you’re All Banged Up.
1. Take extra rest days. I’m not talking about swapping your rest day from Wednesday to Tuesday – I’m telling you to skip a bunch of workouts. I’m a proponent of taking an entire week off once or twice a year from hard training – and can think of no better time to do so than when you’re banged up. And once you go back to intense training, you also need to give that injured body part another week or three of rest. Yes, really – rest it longer than you think you should. Trust me, you’d rather take three weeks off from all pulling exercises than be plagued with chronic injuries (and sucky performance) for the next six months. Finally, don’t even think about doing two workouts a day or a long met-con to “make up for” your extra rest days. The whole point is extra rest.
2. Get felt up (or feel yourself up). Seek out a good massage therapist. Cyclic compression of muscles after intense exercise reduce swelling and muscle damage. Massage can improve muscle function, resulting in less swelling and fewer signs of inflammation after exercise. Too busy to book an hour long massage? If you’re beat up, no you’re not… skip today’s workout and hit the massage table. Too broke to see your massage therapist every week? Luckily, there are cheaper and still-effective alternatives. Spend enough intimate time with your foam roller to make your significant other jealous. Buy a Stick and use it. Work with a tennis ball or lacrosse ball for some self-myofascial release.
3. Keep moving. Low intensity exercise can protect and enhance the immune system, even when you’re banged up or sick. It also helps with injury prevention and recovery. Moving your body increases blood flow and the number of cells that eat up “debris” in the injury. It also increases oxygen levels to speed up healing, and increases circulation to remove the debris out of injured areas. Finally, exercise prevents stiffness and decreases the formation of scar adhesions. Stay active with movements different from those you normally perform during workouts, but remember to keep things light and easy. Think dynamic warm-up drills, kripalu yoga, an easy swim or a brisk walk. And people… stretch.
4. Use thermal modalities (heat and ice) appropriately. If you have an acute injury (less than 5 days old), ice is your best friend. I prefer crushed ice (in a plastic bag inside a pillowcase) instead of those commercial gel packs – they warm up too fast. Apply the ice to the injured area for 20-30 minutes, at least 3 times daily. Or you could apply ice directly to the injured area with ice massage (as pictured above) for 8-10 minutes. Most importantly, don’t put heat on an acute injury. The inflammatory process is biochemical, and heat literally speeds up that process. Heat vasodilates and promotes the accumulation of interstitial fluid (edema), and the last thing you want with a fresh injury is to add to the swelling. If you really love your Tiger Balm or Icy Hot, that’s okay – but these products have no real thermal effect. (You might get the sensation, but it doesn’t actually heat or cool your tissue.)
Chronic injuries (anything that persists for longer than 2-3 weeks) respond best to heat, which improves blood flow to the healing tissue. So once you’re into the 5-plus day range, you can use contrasting hot and cold, alternating every 2-5 minutes for a total of 20-30 minutes, especially post-workout.
5. Remove inflammatory dietary factors. This should be a no-brainer around here. If you’ve been slipping back into old (poor) eating habits, now’s the time to clean up that mess. Get rid of grains, legumes, and dairy altogether. Need I even mention cutting out booze? And though it’s controversial, I’d also recommend eating less saturated animal fat (especially egg yolks and fat from feedlot-raised, grain-fed animals) as it can increase pro-inflammatory compounds in your body.
6. Boost your vegetable intake. Alkaline foods, especially richly coloured vegetables, help to offset the negative effects of acidic metabolic waste. Vitamin C and polyphenols, like those in broccoli and dark leafy greens, are essential for the repair of connective tissue and to reduce inflammation. Vitamins E (found in sprouts, avocado and dark, leafy greens) and A (found in green and yellow vegetables) are also important nutrients for connective tissue and cell repair. In summary, eat more veggies, especially green leafies… but not more fruit. (I’m wary of fruit’s impact on insulin levels, which, when elevated, increase inflammatory markers in the body). Go easy on carbohydrate-dense root vegetables for the same reason.
7. Calm down (your inflammation). The ratio of omega fats in your diet help dictate the “inflammation status” of your body. If your diet consists of mostly omega-6 fats, your inflammation response will be unbalanced and damaging to your cells. To that end, per Robb Wolf’s recommendations, bump up your fish oil supplementation to 0.8-1.0 gram of DHA + EPA per 10 pounds of body weight. The additional omega-3 fatty acids can help tip the balance in your body away from an inflammatory state. Also, avoid concentrated sources of omega-6 fatty acids, such as “industrial” vegetable oils like peanut, safflower, soybean, and corn oils. You could also consider a GLA (gamma-lineolic acid) supplement. (GLA, while in the Omega-6 family, is not converted to the pro-inflammatory arachidonic acid (AA), but rather to dihomo-γ-linolenic acid (DGLA). DGLA competes with AA and prevents the negative inflammatory effects that AA would otherwise cause in the body.)
And it may sound weird, but… don’t forget to brush your teeth and, just as importantly, floss daily. Periodontal disease can contribute to systemic inflammation in the body just like grains, legumes and dairy.
8. Get more and better sleep. This article explains how sleep contributes to a whole host of health and fitness factors, including injury prevention and recovery. During this time period, avoid caffeine, which can disrupt the quality of your sleep even if it doesn’t actually keep you awake.
9. Ditch the Advil. While I don’t purport to be smarter than your doctor, here is one area where I disagree with his recommendation to scarf the Vitamin I (ibuprofen) and other NSAIDs (non-steriodal anti-inflammatories). Sure, NSAIDs suppress the inflammatory process and help with pain control. But research has shown that they actually slow down the overall healing process, and cause the “healed” tissue to be less strong. So allow your body’s healing process run its natural course, and don’t band-aid it with Advil.
Following these tips will help keep you injury-free – and get you out of my PT office that much faster, should you find yourself all banged up. Post questions, leave your feedback or (at least) take the first step and cop to your serious “Vitamin I” habit in comments.
(Photo Credit: Shiatsu Loft Berlin / cc)
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Happy New Year, all you Broken People! (That category includes me, BTW, so I’m taking a few days off from training, eating some really good food, and getting a massage this weekend.)
We’re on vacation until January 4th, but will respond to comments/questions once we’re back online.
Last year’s motto (Jeff Martone’s quote): “If you’re gonna be dumb, you’d better be tough.” This year’s motto: being less dumb will allow me to be more tough. Even a monkey can learn.
Dallas
Great article. Thank you for taking the time to address this. We have experienced a few injuries in our gym and chose to bring in a couple of PT’s to address what I could not. We have also forwarded your article to most of our clients too.
Thank you
Once again, good solid info from the W9. Thanks Dallas! I ran across this post by K-Starr a month or so back. Figured it was appropriate to put a link. It’s titled Get off the Ibuprofens Peoples! http://sanfranciscocrossfit.blogspot.com/2009/06/get-off-ibuprofen-peoples.html
Looking forward to the new year & all the challenges it holds!
Train Hard / Live Easy
@Chuck,
Glad you could find some direct utility for this info. In any gym with hard-training clients, eventually, someone is gonna get hurt. But you can head off some of these chronic injuries by getting in the habit of some of these practices NOW. Thanks for sharing this with your clients.
@Speed,
Thanks for posting the link to Kelly’s post. Based on what he’s witten, he’s read the same journal articles I have. I have a bunch of the articles archived if you wanted to totally “geek out” (Robb Wolf’s phrase) on them. (If so, shoot me an email, I’d be glad to share them.) Good luck in the new year!
Thanks for clearing up the heat vs. ice thing–I have always been given conflicting information on that topic. Here’s my follow-up question to that:
Say a person (totally not me at all) has a (slightly improving) chronic back injury that doesn’t necessarily hurt or need ice/heat every day but certain WODs trigger the pain. Ice, heat, seance, ??? This person has always used ice no matter what so I’m interested in the benefits of heat for what seems to be a situation I’ve dubbed as an acute chronic pain.
I am a huge advocate of the stick, it is quite useful for the smaller muscle groups that are hard to hit with the foam roller. Definitely a good investment. Great article, thanks for this!
@Kassi,
Hypothetically, for someone other than you, a low-grade, chronic injury would respond best to heat to stimulate blood flow and metabolic activity (healing!), but if you, I mean, “that person” used ice to calm down the inflammation from that acute flare-up, that should work well. At this point, this “person” would probably benefit from contrasting heat/ice, to maximize the blood flow to that area while not promoting too much inflammation with straight heat. The best option, though, would be to have a qualified PT evaluate your, err, their condition to determine if there is a non-muscular component to the injury. Siddharth seems to know a good PT if you need a recommendation.
@Kevin,
Glad you found the info helpful. If you like the Stick and want something for a little more aggressive self-myofascial release, check out muscletrac.com. I’ve recently purchased one and am interested to see how it compares to my old standby, the Stick.
Thanks Dallas! I’ll be sure to pass the information on to the appropriate person. So glad I have no injuries to apply this to! ;)
Wow, muscletrac looks pretty intense. I would love to know if you find it more effective, please keep me posted.
Thanks Dallas! I needed this….
Please post the relevant research papers on ibuprofen. I’ve looked at several (including the ones referenced by Starrett) and found them less than compelling when compared to the benefits I’ve seen while using ibuprofen intelligently. I’ve also had more than a few very high level strength athletes (PL and SM) tell me that that ibuprofen has benefited them in a significant fasion, anecdotally.
Thanks
Steve
@Steve,
Thanks for your inquiry. There’s an important distinction between anecdotal reports of symptom relief (i.e. less pain) and actual physiological healing, and your athletes can’t tell the difference between the two based on how they feel. Sure, some athletes who use NSAIDs like ibuprofen report less pain or post-exercise soreness, but all that tells me is that the drug’s action of suppressing the inflammatory response to injury or intense exercise is, in fact, working. Counterintuitively, less pain does not indicate expedited healing/recovery. In my opinion, the most “intelligent” way to use NSAIDs is, instead of using them regularly to suppress the symptoms from an injury or post-exercise soreness, to use patience and self-discipline to allow more complete tissue healing and recovery to take place. Remember, athletes get fitter when recovering, not when training. As coaches, it is both our position and our responsibility to “reign in” athletes who train too early, too hard, too often, or when hurt. Like we say in our Whole9 “Manifesto”, the cold, hard truth is that what you think you should do may not be what you actually need to do.
At the risk of boring readers to death, I’ve included a list of some of the articles I’ve read that led me to conclude that NSAIDs like ibuprofen are not part of a solid training & recovery plan. If you’re interested, please read, research, ponder, and draw your own conclusions. Best of luck,
Dallas
NSAID References:
Trappe TA, White F, Lambert CP, Cesar D, Hellerstein M, Evans WJ. Effect of ibuprofen and acetaminophen on postexercise muscle protein synthesis. Am J Physiol Endocrinol Metab. 2002 Mar;282 (3):E551-6.
Pizza FX, Cavender D, Stockard A, Baylies H, Beighle A. Anti-inflammatory doses of ibuprofen: effect on neutrophils and exercise-induced muscle injury. Int J Sports Med. 1999 Feb;20 (2):98-102.
Baldwin, Lanier A. Use of nonsteroidal anti-inflammatory drugs following exercise-induced muscle injury. Sports Med. 2003;33 (3):177-85.
Connolly DA, Sayers SP, McHugh MP. Treatment and prevention of delayed onset muscle soreness. J Strength Cond Res. 2003 Feb;17 (1):197-208.
Tokmakidis SP, Kokkinidis EA, Smilios I, Douda H. The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise. J Strength Cond Res. 2003 Feb;17 (1):53-9.
Almekinders, LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med 28: 383-388, 1999.
Barlas, P, Craig JA, Robinson J, Walsh DM, Baxter GD, and Allen JM. Managing delayed-onset muscle soreness: lack of effect of selected oral systemic analgesics. Arch Phys Med Rehabil 81: 966-972, 2000.
U. R. Mikkelsen, H. Langberg, I. C. Helmark, D. Skovgaard, L. L. Andersen, M. Kjær, and A. L. Mackey. Local NSAID infusion inhibits satellite cell proliferation in human skeletal muscle after eccentric exercise. J Appl Physiol, Nov 2009; 107: 1600 – 1611.
Cohen DB, Kawamura S, Ehteshami JR, Rodeo SA. Indomethacin and Celecoxib Impair Rotator Cuff Tendon-to-Bone Healing. Am J Sports Med. 2006 Mar;34(3):362-9. Epub 2005 Oct 6.
Abigail L. Mackey, Michael Kjaer, Sune Dandanell, Kristian H. Mikkelsen, Lars Holm, Simon Døssing, Fawzi Kadi, Satu O. Koskinen, Charlotte H. Jensen, Henrik D. Schrøder, and Henning Langberg. The influence of anti-inflammatory medication on exercise-induced myogenic precursor cell responses in humans. J Appl Physiol 103: 425–431, 2007.
E. M. Weinheimer, B. Jemiolo, C. C. Carroll, M. P. Harber, J. M. Haus, N. A. Burd, J. K. LeMoine, S. W. Trappe, and T. A. Trappe. Resistance exercise and cyclooxygenase (COX) expression in human skeletal muscle: implications for COX-inhibiting drugs and protein synthesis. Am J Physiol Regul Integr Comp Physiol 292: R2241–R2248, 2007.
Dallas-
I will preface this by saying this is a totally unfair thing to post/ask on the internet but I shamelessly will anyway….so I was chugging along in my WOD this past Saturday and 2 hang snatch squats in my right knee popped (literal audible POP) and I went down followed by pain int he lateral part of the knee. It hurt like 8/10 initially then tapered off to about a 3/10. The joint is now swollen with limited flexion and painful extension. I have been resting since with ice. Went to PCP today who recommended conservative treatment plus PT then if it doesn’t get better ortho consult.Their (and my) main concern are a meniscus tear but I don’t have the clicking or locking that goes along with this typically.
So my plan is to follow you advice above….rest rest rest. I do plan on walking to keep the joint mobile. Next week if the pain is better I was going to start some body weight stuff (pull ups, push ups, ring rows) that don’t involve the knee and to just keep walking. My PT eval is not until NEXT Friday (11 days from now).
Question…..would you recommend NO weight lifting until after my PT eval….I was thinking about doing some shoulder press next week (if the knee was doing better). I know this seems minuscule BUT I have been making such great progress and am TOTALLY bummed by this injury.
Again I know this is not a fair question considering you have never seen my knee but any advice would help. Thank you!!!
DIana
I am slowly but surely working through your website.
May I say: thanks for having putting treasure trove out there!
edit: thanks for putting this treasure trove out there!
Great article! I am wondering if you have had any experience dealing with frozen shoulder?
Rebecca,
It would not be an exaggeration to say that I’ve worked with hundreds of frozen shoulder patients in my 10 years as a PT. It’s a tough, complex diagnosis, and, in my opinion, is a situation where the medical community has failed to connect health/lifestyle factors with an “orthopedic” problem. Is there anything I can help with?
Dallas
Why are NSAIDs “bad” (#9) but the anti-inflammatory supplements (#7) are good?
Dave,
That’s a reasonable question. It really goes back to how the substances cause an anti-inflammatory effect. Anti-inflammatory supplements like fish oil improve the chemical makeup of your cell membranes, and predispose your immune system to less (hyper)reactivity, whereas NSAIDs like ibuprofen actually suppress aspects of the inflammatory pathways, basically blocking the function of some important enzymes that have other functions in your body (like controlling the protective mucus production in your gut). And after all, your best choice is eating an anti-inflammatory diet and not needing any supplements, but I don’t know very many people who have it that dialed in. Hope this helps.
Dallas