Using exercise to heal injuries

The majority of us know that exercise is crucial in maintaining a health state however did you realize that exercise in general is critical in promoting the healing of soft tissue injuries. The old school of thought was that once we injure ourselves we should immobilize the injured area while reducing the swelling and inflammation. However, studies have shown that that early mobilization after injury increases capillary invasiveness and granulation tissue but limits muscle fiber spread into scar tissue 1. Immobilization, on the other hand, increases penetration of muscle fibers into scar tissue in addition to reducing the tensile strength of the injured muscle.

The Body’s Natural Repair Process

Fibronectin (Fn) is a protein found in the blood which stimulates white blood cells called macrophage to eat up cellular waste in our bodies. Whereas, fibronectin complex with connective tissue matrixes promote cell adhesion and cell to cell interaction 2. Fibronectin plays an important role in tissue repair and wound healing. After injury, the body starts making more fibronectin which spreads throughout the damaged muscle and increases its structural integrity. As the damaged muscle continues to heal, fibronectin diminishes.

The Effects of Immobilization

M. Lehto et al. (1985) studied the effects of physical activity, during various stages of wound healing, on scar formation, regeneration of muscle and production of granulation tissue. Using a rat model of injured calf muscle, they found that early immobilization after injury rapidly increased Type I collagen but poor structural organization of the tissue with contraction of the scar occurred with prolonged immobility. A short immobilization period (2 days) followed by mobilization resulted in a lack of Type I and III collagen fibers (at 7 days) and a visible fibrin clot containing fibronectin; a sign of re-injury. Faster resorption of scar tissue and better structural organization of Types I and III collagen occurred with the 5 days immobilization/mobilization interval.

Hopefully you are convinced that movement particularly in the form of a rehabilitation program is a key part to making a successful return to running. Although many specific aspects of rehabilitation protocols remain highly controversial, current evidence supports the concept that intensive rehabilitation can help to prevent early arthrofibrosis and to restore strength and function earlier. The most intensive programs have been recommended particularly for patients who are predisposed to stiffness, such as those who have had an Achilles tendon injury.

Rehabilitation

I am going to provide you an outline of the key points in to take into consideration in developing a rehabilitation program for a runner who suffers from Achilles tendinopathy which has afflicted up to 29% of all runners. The initial stage of rehabilitation will focus on keeping the ankle in a neutral position and a synthetic graft can be molded to keep the ankle in neutral during low resistance exercises. Patients are encouraged to continue to weight bear on the injured Achilles tendon as tolerated eventually progressing to full weight bearing while keeping the inflammation and swelling down.

 If the Achilles tendon has been surgically repaired the patient can start with gentle mobilization exercises of the ankle, isometric contraction of the gastrosoleus complex, and gentle concentric contraction of the calf muscles immediately post-surgery. It wasn’t too long ago that doctors requested that patients who are recovering from post surgical Achilles tendon repair remain bedridden for 3-4 weeks!

Reconditioning

Is used to address the athlete’s need to continue fitness and strength training for the first four months post-op. Reconditioning and performance training are basically the same, with the understanding that the training protocol will need to be adjusted according to the athlete’s tolerance and healing response.

After Achilles tendon surgery, managing an athlete’s physical qualities is more than just following an Achilles tendon protocol. It is developing a plan to train the entire body from post-op to return-to-comp-from strength development to cardiovascular conditioning to movement quality training. It is an individualized plan that focuses less on the on the ankle and more on the athlete’s overall physiological profile. Of course, the surgery creates limitations that require special strategies that make appropriate strength trains. Successfully managing an athlete encourages using familiar movements to motivate them. To do this requires exercising around the ankle, rather than focusing on traditional rehabilitation techniques that target isolated muscles of the lower extremity. For example, an upper-body cycle ergometer is often implemented during rehabilitation to condition an athlete’s cardiovascular system, but this is not exercising around the ankle. It is exercising without the ankle. Using functional and sport-specific movement patterns offers a level of familiarity and predictability. For the athlete, this translates into a higher-quality effort and helps to restore confidence. For example, deep-water training within two to three weeks post-op can effectively address core strength endurance and cardiovascular conditioning. Many of the movements may be new, but they encourage athletic coordination in a non-loading environment. This program’s hidden agenda is hundreds of repetitions to improve ankle ROM and reduce post-op swelling. By four weeks post-op, the athlete may be working as hard in the water as an uninjured athlete. Using winged water walkers (W3s) for forward- and backward-resisted pool running is excellent for hip strength and anaerobic conditioning. The goal is for the athlete’s cardiovascular system to be well conditioned by three to four months post-op, so he or she will require less of this training in later stages of the comeback. Now the athlete can focus more time on sports specificity, weight training, and various movement-specific qualities. Spinning bike, elliptical cross-trainers, and treadmill programs are also developed for every phase of the comeback. The emphasis here is cardiovascular and strength endurance training. Due to lower joint stress, this training can be done very well during the first few months.

 Total body training that encourages upper and core strength should be implemented as well during the reconditioning phase. Much of this work should be performed in the standing position to emphasize the athletes’ inherent athletic ability, allowing stabilization and control during athletic conditioning.

Putting the Puzzle Together

Each rehabilitation program is uniquely different, treatment must be individualized, comprehensive, and goal directed. Formal treatment programs are mainly for pain relief rather than focusing on restoring function and promoting a speedy returning to functional activity. Now that you are healthy get running!

References

1. M. Lehto. V. C. Duance, D. Restall, Collagen And Fibronectin In A Healing Skeletal Muscle Injury An Immunohistological Study Of The Effects Of Physical Activity On The Repair Of Injured Gastrocnemius Muscle In The Rat, The Journal Of Bone And Joint Surgery, Vol. 67 B. No. 5., 820-828, 1985

2. P. N. Thompson, E. Cho, F. A. Blumenstock, D. M. Shah and T. M. Saba, Rebound elevation of fibronectin after tissue injury and ischemia: role of fibronectin synthesis, American Journal of Physiology.Gastrointestinal and Liver Physiology, Vol 263, Issue 4 437-G445, 1992