It is common knowledge that at some stage throughout your training career you will inevitably become victim to injury. Multiple factors will determine how severe that injury will be, however, it is important to note that injury is quite a broad subject matter therefore it is almost impossible to predict what will happen.
As you can probably tell by now we are painting a picture for you with the above statistics. The message from me is: Unfortunately injuries happen, but, it is how you adapt your training during this time is what is most important.
The First Thing You Need Is An Accurate Diagnosis
Before you are able to start training again the fundamental principle that you need to follow is initially understanding what injury you have in the first place. Without a doubt, it sounds self-explanatory, but in all honesty, knowing this is going to guide you immensely along your training journey both now and in the future.
The diagnostic stage of an injury is a relatively simple process for those who are trained to do so. At Camden Sports Clinic, we assess movement patterns on a daily basis and examine the integrity of the damage structures which ultimately enables us to decide what the overall issue is for that given client. At this stage of the diagnostic process, the client is left in one of two physical states; they are either immobilized or not.
When someone is immobilized it means that they need to have some sort of protective mechanism surrounding the injured structure for the initial stages of their injury. For example, if someone breaks a bone in their foot, they are usually placed in a protective boot for a period of weeks until the bone is healed enough for the patient to walk around freely. On the other end of the spectrum, if someone has had a surgical repair for an ACL injury they are normally placed in a knee brace for an extended period of time. These are common practices. From a training perspective, it just means that you need to take this into consideration when it comes to developing a training plan.
If your injury isn’t severe enough to be immobilized it does not mean that you are off the hook. It just means that you have a greater scope of opportunity when it comes to creating a personalised training plan. You should note though that just because you don’t have a boot on your foot doesn’t mean that your ankle joint is strong, stable and willing to withstand a large amount of force out through it.
For example, have you ever sprained your ankle and tried to perform a high volume of squats two or three days afterwards? If you answered ‘Yes’ then you will know exactly the pain that I am talking about and you will appreciate the importance of working around your injury.
Once You Have A Diagnosis, You Can Learn More About The Movement Risk Factors Associated With The Injury
Certain injuries bring certain movement restrictions, that is a fact. And to show you what I mean by that we will continue to use the ankle sprain example from above, more specifically, let’s say that the client has a Grade 2 Anterior Talofibular Ligament (ATFL) Sprain.
The ATFL is a lateral ankle ligament that is responsible for keeping the joint stable. Injury mainly occurs when a person lands on their ankle with the toes pointed (plantar-flexion) and the foot turned in (inversion). This movement puts a strain on the ATFL ligament as it takes the full force of the person's body motion and most often leads to tearing of the structure. In terms of recovery timelines, a grade 2 strain of this ligament is an injury that typically lasts for anywhere between 3-6 weeks depending on the athlete, sport played, genetics and response to certain treatments.
What we have just outlined above is the overall mechanism of how the injury occurred in the first place & how long typically the injury takes to heal.
This is really important to understand because once you know this information you can critically analyse the risk factors associated with certain exercises in your training plan.
Let’s try a self-assessment drill to see if you can understand the movement of certain exercises.
Do you think it is safe for the client to squat?
Do you think it is safe for the client to box jump?
Do you think it is safe for the client to deadlift?
Do you think it is safe for the client to lunge?
I know that right now there will probably be a lot of mixed answers about the above exercises. Some of you will say that yes it is safe for them to do so. Others will say that they should stay away from all lower limb injuries. There will be a smaller group who will try and consider the timing of their recovery and say it depends on whether they have just had the injury or if it were 5 weeks ago. Welcome to the world of critical thinking! It is what makes the health and fitness industry so diverse because we all have opinions and without those opinions we would not make any progress as an industry.
Have A Think About What Exercises Interact With Your Injury
Let’s go back on the above question and break down how we think each exercise would interact with an ankle joint; especially a Grade 2 ATFL Sprain.
Do you think it is safe for the client to squat? Answer = YES
Do you think it is safe for the client to box jump? Answer = NO
Do you think it is safe for the client to deadlift? Answer = YES
Do you think it is safe for the client to lunge? Answer = YES
The most straightforward way to explain the above answers is to describe the healing process of a ligament injury. It is divided up into broad stages which are not mutually exclusive and overlap considerably. There are several different ways to ‘divide up’ the entire process, but the allocation of 4 phases is common and will be adopted here – these being BLEEDING, INFLAMMATION, PROLIFERATION and REMODELLING.
Bleeding is a relatively short lived phase and will occur immediately following the injury (in vascular tissues only). The normal time for bleeding to stop will vary with the nature of the injury and the nature of the tissue in question. Simply put, the more vascular tissues (e.g. muscle) will bleed for longer and other tissues (e.g. ligament) will bleed less. It is common for bleeding to last for a few hours, however, other injuries may have longer bleeding periods but at a much slower rate. No exercise is advised during this stage.
Inflammation is an essential component of the tissue repair and is best regarded in this way rather than as an 'inappropriate reaction' to injury. We have all seen the ankle that has ballooned up shortly after an injury has occurred. That is because it overlaps with the bleeding phase and can be brought on almost as soon as the injury happens. Inflammation reaches its peak at 2-3 days and starts to gradually decline over the coming weeks. When it comes to ligaments, the onset and resolution can last for a longer period of time because the tissue is poorly vascularised. It is important to note that repeated minor trauma can initiate the inflammatory events, therefore, repeated bouts of exercise should be considered with caution. Hence why I said ‘NO’ to doing box jumps with this example. Instead, I would use a box jump as a Return To Play (RTP) criteria and if the client can complete a high volume set of this exercise then they are good to go back to normal training.
Proliferation is where the magic happens. This is where we will witness the generation of the repair material, which for the majority of musculoskeletal injuries, involves the production of scar tissue. This stage hits its peak usually between 2-3 weeks post-injury, however, this does not represent the time at which scar production is complete. It just means that the bulk of the scar tissue is formed. Exercise can be used here if adapted.
Remodelling is neither swift nor highly reactive. However, it does result in an organised, quality and functional scar which is capable of behaving in a similar way to the pre-injured tissue. It has been cited to hit its peak 2-3 week post-injury, yet, there have been mixed examples used in the scientific literature surrounding this topic. From our point of view, exercise is definitely advised.
Substitute The Right Exercises For You Into Your Training Plan Or Get One Built By A Specialist
Now that you know a little bit more about the different stages of tissue healing we can start to provide some practical examples of the exercises we were looking at. Remember, the most important thing throughout the early stages of this type of injury is ensuring that the joint, as well as the damaged structures, remain stable at all times.
Let’s start with the squat.
It is a relatively safe exercise to perform for someone who has an ankle sprain. However, I would greatly advise using a box variation for the early stages of your rehab plan. In this way, you can control two key elements, firstly, the level of depth that the client is squatting too. Secondly, you have given them more control during the movement which therefore places less stress on the ankle joint and mentally it gives the client more confidence to execute the movement safely.
Next up we have the box jump.
For obvious reasons, a box jump is out of the equation for the most part of the rehab plan. It is hard to control and quite literally replicates the mechanism of injury. We would advise using a box step up instead. With this exercise, the client can fix their injured ankle on a low elevation and ensure that it does not move during the movement. Keep the more explosive movements to the end.
Deadlifting should be fine unless it is really uncomfortable for the individual.
In all stages of the movement, the client's foot will remain fixed to the floor so there is no risk associated with the movement. The only consideration that one should make is in relation to the amount of load to be used. I would prefer the client to use a higher volume of reps at a lower weight load to ensure that they are comfortable with the force being put through the foot.
Lunge patterns are used almost immediately with an injury of this nature.
To put it simply, it is very similar to the box step up. With little to no elevation, there is minimal risk associated with lunging. However, it should be noted that the exercise needs to remain static to start off with. This means using a split squat variation. Then the client can progress to reverse lunges, forward lunges and finally walking lunges.
As you can see there is a lot of thought that needs to go into planning around an injury, however, there is always something that can be done. If you find yourself in this situation, we would highly recommend working with someone who is specialised in this area. At Camden Sports Clinic, we have recently launched our online coaching platform where we work with clients who have injuries and put training plans in place for them to continue to make progress towards their goals. If you think this is for you, then get in touch with us at @camdensportsclinic or through www.camdensportsclinic.com