How Strict Rest can actually make your running injury last longer

How Strict Rest can actually make your running injury last longer

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Today on the Doc On The Run Podcast we’re talking about how over-resting can actually slow down your recovery from a running injury.

How Strict Rest Can Actually Make Your Running Injury Last LongerIs over-resting slowing your recovery? It might be.

Sitting still is a killer for athletes. Not only does it bum you out, but a long period of immobilization can actually increase your chances of having another injury later.

A few days ago I got a call from an athlete who had been unfortunate enough to have a serious injury that required surgery. So when he called me, he already had surgery and was well on the way to recovery.

What happened to having common with most of the people who listen to this podcast is that his doctor had told him he needed to rest in order to recover. Strict rest. As in sit-on-the-couch and do nothing sort of rest.

After six weeks of rest he felt like the rest was killing him. And he had just been told by his doctor that he needed another month or so of rest before he could start regaining strength and becoming active again.

Understandably, he became frustrated.

So he called me.

He very clearly explained that he was dying sitting around doing nothing. And he could not see how he could sit around for another month or so without any activity.

The first thing he asked is whether or not I might be able to help him.

Given that he would have to pay out-of-pocket for the consultation that certainly is a reasonable question.
But I get that question a lot. When other doctors used to ask me what I do, I would simply answer, “I help injured runners run.”

But to be a little more clear, my answer to this particular injured athlete was, “I specialize in helping athletes develop customized plans which will permit healing yet maintain fitness.”

If you are runner and you’ve ever been injured, and you actually went to see a doctor, you probably got some sort of lecture about the necessity of rest. You may have even felt scolded for your dedication to fitness. “You need to slow down.”

“You need to calm down.”

“You have to sit still.”

Has a doctor ever said any of these things to you?

I’ve had doctors tell me these sort of things. And frankly they all sound like the sorts of things I tell my nine-year-old son when he’s had too much sugar. Often they are uttered with the same annoyed paternalistic tone.

The first thing I will tell you is that your doctor is actually thinking about your best interests when she tells you to stop all exercise. She actually believes rest is best.

And just to be clear, I do believe strict rest is important after a severe injury or immediately after surgery. But only for a very brief period of time.

When I do foot surgery on a runner or a triathlete, I tell them they need to prepare themselves for two days of suffering. Rent lots of movies, by a couple of books but be prepared to sit still with the foot elevated for the first 48 hours after surgery.

But most athletes are so healthy and heal so quickly they only need a matter of days of true strict rest. Athletes don’t need weeks or months of strict rest. In fact, what I would argue is that the standard approach of strict immobilization and bed rest is completely counterproductive to the long-term goals of every runner who becomes severely injured or has to have foot surgery.

Most patients I see who develop overtraining injuries are lifelong athletes. They may not have all competed in the Olympics, but what they all have in common is they have been moving and active their entire lives. I believe that a physiologic result of a life of physical activity is that endurance athletes are physiologically different from sedentary patients.

I believe runners heal differently than normal patients. And I believe normal treatments should be administered to normal patients….not runners.

1. Runners get stressed when they rest.

Have you ever taken any long period of time off from running? Have you ever stopped running for a week or a month? How did you feel? Did you get angry? Did you get grumpy? Did you get depressed?

Have any of your athletic friends been injured? Have any of your running buddies ever had to stop running? What about them? Did they actually become clinically depressed after they suffered an injury and stopped all activity? If so, it’s really not surprising.

A study published in the International Journal of Sports Medicine reported increased levels of stress hormones when athletes stop working out.

1. Sedentary people don’t get these increases in stress hormones, just from inactivity. You, as a runner react differently when you sit still. Even your brain chemistry gets thrown off.

Another study published in the Annals of Behavioral Medicine reported exercise training was correlated not only with significant reductions in depressed mood and fatigue, but more importantly, reduced levels of the stress hormone cortisol when compared to those randomized to a control group.

So when you are bummed out sitting around doing nothing as you recover, you may have higher levels of cortisol.

2. If it is true that higher levels of cortisol and other stress hormones slow healing, then in theory, when you get stressed out when you’re sitting around doing nothing, not exercising, you may take longer to heal.

2. Movement facilitates recovery.

One of the many benefits of physical activity is the tissues become better perfused. What I mean by that is that you have increased blood flow when you move any portion of your body.

When you have surgery, or for that matter even just a severe running injury, the tissue damage creates a pool of metabolic junk. You can think of it as pulverized tissue debris, which is essentially garbage in your injured foot. That garbage has to be removed.

By increasing blood flow through an extremity you can essentially flush out that garbage. If you’re sitting still then you have to rely on your white blood cells to work their way down there and gobble up the garbage one cell at a time.

3. Micro-motion can help fractures and bone heal faster.

As foot surgeons, when we do surgery on a patient and apply an external fixator or frame to stabilize a reconstructed foot and ankle, we all follow very simple routine. What I’m talking about here are those frames that you may have seen where they are a big circular metal rings and a U-shaped foot plate surrounding the foot and ankle and the leg. Steel pins go all through the frame connecting the bones by running the metal rods and pins straight through the leg at all different angles. The external frames hold the foot and ankle in a very stable position. They are so stable the patient can even walk on it while it heals.

When we reposition the bones we need them to heal in a different position. We have to hold the healing bones still. But within a few weeks you get enough healing at all of those fracture and bone fusion sites that the bones gain enough stability that they can tolerate a small amount of motion. Interestingly, if we loosen the frame a little bit so the wires can move a tiny bit, it creates micro motion across the healing sites and it actually accelerates the healing process.

External ring fixation technique

If you don’t loosen the frame and you keep everything locked up, it takes longer to heal. The bottom line is that motion can help healing bones heal faster.

A study published in the medical journal Injury reported tibial fractures healed about 4 weeks faster when micro-motion was allowed compared to those healing with no motion.3

Just think about that for as second. How much fitness would you lose with an entire extra month of sitting on the couch? How much weaker, and grumpier would you be? If you have a fracture you need to think about (and ask your doctor about) how micro-motion can help your fracture heal faster.

Micro-motion doesn’t just help bones heal either. Motion also helps tendons, ligaments and torn joint capsules…which are all made up largely of collagen.

4. Motion can help collagen remodel and become stronger.

In a similar way micro-motion can help collagen fibers remodel and become stronger. Whenever you tear a ligament, a plantar plate, the Achilles tendon, the plantar fascia or a joint capsule you actually rip apart the collagen fibers.
Some research has shown a similar process of stressing structures made of collagen, which actually comprises an enormous proportion of structures which get injured from over training injuries in running, can help the collagen heal faster.

Immobilization is the enemy of healing athletes. A study published in The Journal of Bone and Joint Surgery reported that when ligaments are injury and immobilized, immobilization leads to a greater percentage of disorganized collagen fibrils, decreased structural properties of the healing collagen, decreased mechanical properties of the ligament substance, and even slower recovery of the resorbed insertion sites where the ligaments actually attach to the bones.5

Of course to you, the injured runner, that means those structures which have “healed” while you are stuck in that cast are just plain weaker than when allowed to heal with a little motion.

You don’t want to apply too much motion. You don’t want to apply so much force you rip the healing collagen apart. But you do want to apply gentle little repetitive applications of force sufficient to stimulate remodeling of the collagen. There is also a theory that the repetitive slight stretching of those tissues increases blood flow in the area.

We’re talking about micro-motion. Very small motions, very small forces with very small stresses. But if applied correctly, micro-motion should help accelerate the healing process following a running injury, particularly if the injury happens to involve a bone, tendon, ligament or joint capsule.

If that’s true, it seems like it would be a good idea to have a recovery plan that involves a period of applied micro-motion at the appropriate healing interval. You want to start the micro-motion right when it will help you the most.

5. Strict rest puts you at higher risk of another over-training injury.

I realize I may have previously beaten this one to death in earlier podcast episodes. But just to retouch on this, you need to understand several things happen when you become immobilized in a fracture walking boot or you have been condemned to a sentence of several week on crutches.

1. Your bones get weaker because you’re not applying force. Doctors called this “dis-use osteopenia.” You actually lose bone density.

2. Your foot and ankle become stiffer as little strands of collagen or scar tissue starts forming around all of those tendons and joints that aren’t moving.

3. Your muscles become weaker because you’re not using them. Muscle atrophy may not only be temporary, if severe enough, it can become permanent.

4. Your neuromuscular connections start fading away. All of the coordination of movement, the intensified coordinated instructions when your brain tells your foot and ankle to move, it all starts to diminish when you become immobilized. If you’re not using the muscle groups they don’t continue to fire in unison. You become uncoordinated. And it takes a long time to rebuild all those neuromuscular connections once you have shut them off with a cast or fracture boot.

5. Your aerobic fitness vanishes. This problem is pretty obvious. If you sit on the couch for six weeks, your aerobic fitness is going to suffer. So we don’t need to talk about this one.

The very worst part of all this equation is all of these things together add up to increase risk of future injury. So if you are a runner, it seems all the more important to hound your doctor and get her to help you identify ways to stay active. You need to fight for you fitness when you’re injured!

Given all of the obvious benefits of physical activity when you’re recovering from an injury, it just makes sense that it’s worth putting all of the effort, thought and creativity into developing a plan of activity that will support and facilitate your recovery, while permitting healing to take place.

The goal of developing this sort of active-recovery plan is to make sure that you choose the appropriate exercises and appropriate amounts of exercise. All of this of course can be aligned with appropriate nutrition and periods of rejuvenating rest.

So here are five questions you should ask your doctor when you’ve been told strict rest is necessary.

1. When would it be best to add some activity, just to elevate my heart rate, without stressing my injured foot?

2. Wouldn’t adding swimming, cycling or maybe some light upper body workouts at the gym help remove all of the metabolic waste accumulating in my foot?

3. If not today, when do you anticipate there will be enough collagen stabilizing my (fracture, healing tendon, etc.) enough so I can safely start doing some light exercise?

4. What can I do to fight the inevitable stiffness, weakness and loss of coordination that will put me at higher risk of re-injury later?

5. Which exercises or activities are safe for me to do….right now…today? There has to be something I can do. Which ones?

Do the math. It’s just stress. Make sure the stress you apply is worth it.

One common recommendation doctors will give to you after you’ve been in a fracture walking boot or on crutches for six weeks is they will tell you that you can start activity. But they typically write down on the instruction sheet they give you is something like:

“Okay to walk 5 to 10 minutes.”

But you really think about that advice, it’s a terrible plan! If you just start walking, you have a whole lot of force applied to your injured foot in very short period of time. To me this seems like maximum risk with minimum reward.

Here’s the way you should think about recommended return to activity.

You are a runner. Your goal isn’t to walk. Your goal certainly isn’t to walk for five minutes in your living room or your kitchen. Your goal is to get back to activity. Chances are good that real return to activity for you looks more like running 10 miles on a trail. Real activity is not walking 5 minutes in your living room.

So, first of all, walking five or ten minutes in your house is not going feel like activity to you. I think it’s actually more likely to just remind you that you are temporarily crippled.

The flip side of this of course is that the amount of stress you apply to your foot when you walk around in this state of profound weakness, complete dis-coordination, and crutch-induced or fracture walking boot-induced state of clumsiness, is very, very risky! Walking around for a few minutes with unpredictable forces getting loaded through your foot is actually relatively stressful.

Everything is weakest right at the end of your period of immobilization. As soon as your doctor takes off that cast, as soon as you stop using crutches, that is the weakest and riskiest time to start full weight-bearing in the form of uncoordinated hobbling. Even 5 minutes of walking is risky.

I think it’s much better to try to apply stress in ways that are less risky and more productive. I think it’s better for athletes to do a longer period of exercise, particularly if it involves some sort of aerobic exercise that will make them actually feel like they’re exercising instead of highlighting the fact that they’re injured.

As an aside, we know that if your bones are weaker, you can actually strengthen them, just by moving the limb, firing the muscles, even without applying weight. Even if you are on crutches, you can fight the bone loss known to plague athletes who are told they can’t walk while healing.

In fact, it was reported in the medical journal Current Osteoporosis Reports that disuse osteopenia can be prevented just by moving the limb, even if you aren’t walking on it. The study showed muscle contraction independent of weight bearing could preventing disuse osteopenia and help maintain bone mass.6 Better bone mass means lower risk of stress fractures when you get back to running and peak training.

If you take the right approach, you can probably apply an equivalent amount of force with a much better form of exercise. The goal of the exercise should be to restore some range of motion, start building or rebuilding your muscular strength, and decrease your stress levels.

Again, walking for five minutes after you’ve been on crutches for six weeks is going to apply a lot of stress to your foot. But it’s not going to give you much for stress reduction or rebuilding of strength or fitness.

So rather than just hobble around for five minutes in the boot, wouldn’t you rather get some real exercise, but protect the foot and see if you can’t get a much better bang for your buck?

Think about this?

How much swimming equals the amount of stress as walking around your home with the fracture walking boot for 5 minutes?

20 minutes? 30 minutes? 60 minutes???

How much cycling on a recumbent bike equals the stress of walking 5 to 10 minutes?

20 minutes? 30 minutes? 60 minutes???

Wouldn’t you rather swim for an hour or ride an exercise bike for half an hour rather than hobble around your kitchen for 5 minutes?

Which is going to get your blood flowing better?

Which is going to reduce your stress more?

Which is going to reduce circulating cortisol levels better?

Which is going to feel more like progress and real recovery?

The point of course is that if you can choose an activity that applies a limited amount of stress, roughly the equivalent of hobbling around the house for five or ten minutes. If the stress is incorporated into an exercise lasting for 30 to 60 minutes doesn’t it just stand to reason that is going to help you get on the fast track to healing?

You have to keep in mind the postoperative instruction sheets, and in general any pre-written instructions that are handed to you in a doctor’s office are not usually written for athletes. Trust me, when I had a standard practice I did the same thing. I had the standard instructions written out for every standard patient with every standard condition.

And rather than explain it all to them I would just hand them an instruction sheet.

Most of the people who get that standard instruction sheet never intend to run anyway.

Most of the people who get that instruction sheet, who happen to have had the exact same surgery you, they’re never going to ride a bike for 100 miles. They’re never going to go run on a trail. And they don’t need a recovery plan which will facilitate them getting to the place where they could ride 100 miles or go run on a trail.

Make sure you ask for special instructions that will get you back to running faster!

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2. Perna FM1, Antoni MH, Kumar M, Cruess DG, Schneiderman N. Cognitive-behavioral intervention effects on mood and cortisol during exercise training. Ann Behav Med. 1998 Spring; 20(2):92-8.
3. Vicenti G, Pesce V, Tartaglia N, Abate A, Mori CM, Moretti B. Micromotion in the fracture healing of closed distal metaphyseal tibial fractures: A multicentre prospective study. Injury. 2014 Dec;45 Suppl 6:S27-35.
4. Ho-Joong Jung, Matthew B Fisher, Savio L-Y, Woo. Role of biomechanics in the understanding of normal, injured, and healing ligaments and tendons. Sports Med Arthrosc Rehabil Ther Technol. 2009; 1: 9.
5. Woo SL-Y, Gomez MA, Sites TJ, Newton PO, Orlando CA, Akeson WH. The biomechanical and morphological changes in the medial collateral ligament of the rabbit after immobilization and remobilization. J Bone Joint Surg Am. 1987;69:1200–1211.
6. Bloomfield SA. Disuse osteopenia. Curr Osteoporos Rep. 2010 Jun; 8(2):91-7.