by Scott Johnston
Caveat: What follows is not a substitute for professional advice. These ideas have been accumulated over dozens of years of dealing with our own injuries and those of our athletes. Over those years we’ve developed some very general suggestions on the subject that we’d like to share. Every athlete and every injury is different and so making blanket recommendations is risky. We put forth these suggestions knowing that they help in *most* cases, but maybe not yours. Remember that there is no substitute of in-person, hand-on evaluation by a sports rehab professional.
If you are a runner, skier or climber, and especially if you’re doing all three your chances of getting injured, perhaps seriously, sometime in your career are probably better then 50%. How you deal with that injury will determine how quickly, if ever, that you are able to return to the activities that are such a big part of who you are. We see and hear from quite a few mountain athletes looking for guidance in recovering from injury.
In this article we’re going to look at two categories of injury since they require slightly different approaches.
1) Overuse: This type of injury is caused by repetitive stress that often goes either unnoticed or ignored until it can’t be ignored any longer. It’s the niggling pain and tightness in your calf that you have to warm up through (that’s actually when the endorphins kick in masking the pain) that “suddenly” becomes Achilles Tendonitis.
2) Trauma: This can’t be ignored. You fall climbing, you hit the ground running, blow an ACL skiing. There are many, many ways to become injured. With trauma, there is no faking it. You’re hurt. You may need surgery. There’s no getting around the fact that this is going to slow or stop you for a significant time.
Soft tissue injuries are the most common of this category. Stress fractures are much tougher to deal with and will take professional help to diagnose.
The best way to deal with overuse injuries is what I call the kitchen sink approach. As soon as the problem makes itself known jump on it and throw the kitchen sink at it.
1) Pain. You know the difference between good pain (which is more like discomfort) and injury pain (something doesn’t feel right in that shoulder or knee) right? You should figure this out or you are going to have a very short athletic career. When you feel a pain. Slow or stop until it either resolves or at least diminishes. Don’t hesitate to walk, call for a ride or even hitch hike home. By all means don’t ignore it just so you can finish the workout/climb.
a. Climbers are also at significant risk for these especially shoulder and finger injuries. Climbing near your limit and doing the same sort of hard move many times over is a typical mechanism of injury.
b. Runners are more at risk of lower leg, knee or hip issues. High mileage will put you into the high risk category
2) Prevention: It is much easier to prevent overuse injuries than it is to cure them once they become apparent. Above all you need to be proactive with your body maintenance. Recovery has to become a part of your training routine. Recovery is not just plopping down on the couch with a beer after a run. It is actively attending to the overused muscles and fascia. Massage is great but a luxury that most can’t afford on a near daily basis. Instead rolling, either with a foam roller or a ball should become your go-to method for injury prevention.
3) Kitchen Sink. Once injured though, the kitchen sink should include the following. You don’t care which one, or which combo is effective so do them all.
a. Rest. Your body is remarkable adept at healing itself if given the opportunity
b. Ice/heat alternation
c. NSAIDs with Vitamin I (Ibuprofen) being the most common
d. Rolling and self-massage
e. If no change in a few days of the above: Seek professional help
4) Do not return to normal training abruptly, after a few days of the above treatments, as if nothing was wrong. There’s a good chance that doing so will get you into a cycle of re-injury and partial healing. A very gradual return to full loading is required. How long and gradual? We can’t tell you that here but it is probably longer and more gradual than you think is reasonable. Plan on one day of light load (gradually increasing from day to day). for every day of training you have missed.
We’re very aware of the difficulty of implementing these strategies. The cruel reality is that your torn Achilles does not care that you have a race coming up. That tweak in your shoulder that prevents you from doing a strong Gaston is unmoved by the fact that the weather window for your project is closing. Lamenting will get you nowhere. Life is not fair.
These are in your face injuries. You’ve probably been to a doctor regarding them and may even have been under the surgeon’s knife and have a few screws and metal plates to show for it. Having the best surgeon in the world put you back together again is only the start. It’s an important start and one that is pretty much completely out of your hands. Unfortunately, many people think that the job starts and stops with the surgeon. But the hard work of rehab, which is completely within your control, is only just beginning when the doc sends you home.
How you approach your rehab will play the main determining role as to when and how much function you regain. Some tips:
1) Do the assigned rehab every day, even twice a day. Don’t do it only on your weekly Physical Therapist visits for the 6 weeks your insurance pays for PT. That’s THE surest way to get a poor outcome.
2) Listen to the PT and doc very carefully and follow their instructions about reintroducing activities. Getting re-injured is costly, and not just financially
3) Your strength, mobility and functionality will be compromised, perhaps seriously and perhaps for the rest of your life. You can work through huge setbacks but don’t expect to be “like new” after you’ve broken bones in, or close to, a joint, or ruptured or torn ligaments.
4) Start a strength training program. Once you are cleared by the doc and PT for weight bearing exercise consider prioritizing strength training. Start with a general strength program because you’ve probably been laid up for weeks. This general strength base will be your insurance policy against future injuries. With serious joint injuries you will need to keep this strength focus for the rest of your life or you will lose function.
5) This is going to be tough mentally. Set yourself up for success. Plan appropriate goals to help motivate you during this lengthy recovery period. Start smaller than you might have otherwise so that you set attainable encouraging, intermediate goals.
6) Don’t give up.
Advice for Specific Injuries
We are not sports-rehab professionals and the range of injuries is too broad to attempt a comprehensive list. But, we’ve seen many recurring injuries that do seem to lend themselves to self-treatment. Following is a list of some of the more common ones we have dealt with and the remedies that seem to help and are certainly worth trying in your kitchen sink approach.
• Knee pain: Most common with runners and often under the patella (knee cap), especially when going down stairs. One cause of this pain can be tight hip (gluteal and tensor fascia latae) and quadriceps muscles all of which can pull on the Iliotibial band (IT band) and the knee cap. Relief can be had by extensive rolling of the lateral hip muscles and the lateral quadriceps. This condition usually responds very fast to treatment but needs constant maintenance. For the scientifically minded, here is a good overview of the current medical thinking on Patellar Tendonitis.
• Foot Pain: The most common is plantar fasciitis which is a nasty injury felt just on the front edge of the heel pad on the sole of your foot. It will make you hobble and limp when first getting out of bed in the morning but will loosened up and feel better. The best cure is resting it, train on this only with great awareness and caution. Neuromas in the foot can cause extreme pain and typically need surgical treatment although there are some non-surgical treatments that seem to give some people relief.
• Calf Pain: Often a tear in one of the ankle extensors like the gastrocnemius or soleus. Rest, heat (to keep it loose) and rolling or massage. Do not stretch a torn muscle till pain free. You will just keep reinjuring that already weakened spot.
• Achilles Tendonitis: This is another really nasty one that can take months and even years to resolve. The Achilles tendon (the cord felt just above the heel) should be firm and hard and about 2cm in diameter. Serious Achilles tendonitis can result in doubling of the thickness (compare to the healthy tendon) and a soft pulpy feel. It will also be very tender when palpated. Nothing to do for this but rest, heat and NSAIDs. Do not train on this condition or you may have it for years.
• Shoulder: When the big prime mover muscles around the shoulders overpower the smaller stabilizer muscles, the head of the humerus can move out of place. Having this happen repeatedly under high loads as can happen when repeatedly will often tear one or more of the smaller shoulder stabilizers (the group of which is referred to as the ‘rotator cuff’). This can happen with repeatedly trying a hard climbing move wherein the small stabilizers become fatigued allowing more laxity in the joint. Stop when you feel any small shooting pain. You’ve done some damage and should not risk more. Shoulder surgery often has iffy outcomes and can spell the end of hard climbing. A simple maintenance program like this can help prevent this condition by isolating and activating the shoulder stabilizers.
• Fingers: These can be a big issue for rock climbers. The tendons and ligaments in the finger joints are also quite small yet climbers often expose them to forces above body weight. While it is possible to condition these vital connective tissues to high loads it takes many many months of consistent, progressive over-loading to avoiding the dreaded “pop” of a ruptured pulley tendon. Tendons and ligaments take about twice as long as muscles gain strength so it’s a big temptation to ramp up the joint loads as rapidly as your finger muscles gains gain strength and you can hold on to smaller holds and put more force through the joints. Finger maintenance should involve extending the fingers (bending them backwards to stretch the tendons. Stop climbing hard at the first sign of pain in the finger joints as injuries to these joints tend to be sudden and will take a very long time to heal (months to years).
Recovering from Surgery
Formulate and adhere to a therapy plan with your doc and or PT. As soon as you are cleared to do so get on a strength training plan that focuses on the injured limb bringing its strength and mobility closer to that of its healthy partner. Failing to do all you can as early as you are able, may result in persistent imbalances. Your body will deal with structural and functional imbalances by developing compensatory movement patterns as workarounds for a lack of strength or mobility. This is especially true after hip/knee/ankle surgeries since these joints are heavily loaded everyday locomotion. These new neural pathways solve the short term problem of getting you moving again but they often result in problems down the road because these workarounds are moving and loading your joints in ways they are not meant for.
Depending on the joint and the type and severity of injury you may be dealing with a great deal of imbalance some of which will never be eliminated. But the closer you get to balance the better. Having strong leg muscles can really help keep that knee with ligament damage from getting re-injured.
None of this is going to be easy whether it is the maintenance and pre-hab or the long post injury rehab process. However, going into this with eyes open will be the best strategy.