What to do when you get injured?
Understand the amazing process of tissue healing and make all the right decisions after injury
Injuries happen.
Often in these annoying everyday life situations – last 5 minutes of a football game, misplaced step on stairs after a long day or last run of the season on the skiing holidays.
Then, the absurdity of the situation and denial kicks in - when you realise that as a consequence of these annoying few seconds all your plans for next several weeks will have to be amended. It doesn’t matter what sports mean to you - you may be a pro, or it may help you keep you balanced - but due to injury you will likely have to amend your usual sports routine.
Physios too have very similar way of processing such information – we’re all humans after all! I still remember when I dislocated my shoulder on the London tube, and although I felt something bad happened, I was not willing to admit it – even to myself… I was at that time on a very good training routine, deadlifting a lot, and as far as I was concerned, I was going to smash some weights the same evening. I was not able to diagnose myself, so I went to see a colleague who confirmed the dislocation and gave me a good talking to – which is in fact a big part of our jobs as physios. I had to accept & commit (but not without some tearful drama first!), which allowed me to see the bigger picture and – after 6 moths of intense exercise programme, here I am - with a heathy and stable shoulder!
It is of course always advised to see a physio and get an individual advice based on your circumstances and who you are as a patient – your general levels of physical activity, strength, lifestyle, type of work etc. But there are some universal guidelines that can help you get more confident around the decision making in the time immediately after the injury, and further down the line.
Healing process
What are the main processes happening in the the tissues after injury?
Understanding what is happening to your tissues after they suffer injury means that you will know how to recover the best you can, and how to maximise the natural tissue healing properties.
Remember that you are the one who is the expert on your own body. We – physios, doctors and other healthcare professionals - can advise, support and give you best options based on our knowledge, but it needs to be you who leads the process. And the more you understand about your own body, the better the questions you can ask us and the more effective the whole rehab process will be.
Healing is a process that is driven by the biochemical reactions in your body and it can be generally divided into 4 phases. These phases specify different stages of healing and different priorities for your body, but it is important to understand that they are fluid - there are no clear boundaries between them, or clear timelines – we will be operating using the approximate length here.
Phase 1: Bleeding
Immediately post injury up to few hours
What is happening
There is chaos in your body. Your brain and your tissues know that something wrong has happened, and the aim now is to keep your body safe and preserve the tissues. Some tissues with more blood vessels will bleed more (for example muscles), but also the recovery is generally easier in such tissues, other tissues bleed less (such as tendons). In order to transfer as many nutrients to the injured place the blood vessels become wider, and that’s why the bleeding can sometimes be quite overwhelming – but it does have an important function in your recovery!
What to do
Protect, stabilise and don’t let the injury spread further. Do what you need to do to be safe – stop playing football, get off the slope, take off your heels and get safely home. There not much else you can do here apart from letting your body do its job. But you can get mentally ready for what’s ahead – if you want to recover well, these next few months will be different to what you have planned!
What to avoid
Don’t push through. With pain that you feel your body gives you some information – that something may have happened (importantly – but not that something has definitely happened.
Phase 2: Inflammation
Few hours after injury to 2-3 weeks
Now this is a word that sounds scary – inflammation seems like something very bad, something we need to get rid of ASAP.
But inflammation is a vital part of recovery and trying to get rid of it at all costs is not always the best decision in your recovery process. In fact, there is an increasing number of evidence which highlight the potentially harmful effects of non-steroid anti-inflammatory drugs (for example ibuprofen) in treating common musculoskeletal injuries such as ankle sprains or muscle tears. This obviously doesn’t mean that it is always bad to take these meds, but it’s good to have a think whether the decision is optimal – sometimes it is better to let nature run its course, and such approach is sometimes tried in professional sport.
I personally see the inflammation as a process that is necessarily strong, a bit dramatic, intense and powerful - because it needs to achieve great goals - heal the tissue!
What is happening
In this phase your body knows that something bad happened, and it starts to get ready to heal. A set of biochemicals in your body make certain changes to your tissues, cells and blood vessels. Among other things, your blood flow increases, with blood vessels getting wider and some extra capillaries (small blood vessels) opening up to allow more blood flow to the injury – that is why the area is often red, warm and swollen. The wall of the blood vessels becomes more permeable - they let some cells through, which are responsible for the local swelling. The type of cells that ‘leak’ from the blood vessels is well specified – usually these are cells that are full of protein and generally good nutrients for healing, they also clean the injured area and start building a net (mesh) that will then capture other floating cells and start building scar tissue.
What to do
Move but don’t push. Find movements that are not painful, or don’t feel too stiff (for example, in ankle sprains it is usually OK to move the foot up and down without putting any weight on it) and move often. Observe whether your body is developing some protective positions (for example, after shoulder injury it likes to travel up and forward) and try to relax it if such protective position occurs. Movement is very important to optimise the healing - and finding this sweet spot between complete rest and straining too much is the most important thing now!
What to avoid
Don’t push through. With pain that you feel your body gives you some information – that something may have happened (importantly – but not that something has definitely happened.
But don’t stop moving either - keep an eye on your energy levels and pain, but find ways in which you can move without too much strain (and too much pain) and keep going!
Phase 3: Proliferation
1-2 days to several months (peaking 2-3 weeks after injury)
What is happening
OK, time to get organised. Your tissue (and in fact your brain) is getting a bit calmer now, as there is a sense of control over what is happening. Your tissues feel a bit safer; the acute pain starts to decrease a bit and the whole area is generally calmer, less swollen and more functional. Your body starts building a special repair tissue in the injury area to start a proper rebuild process. This repair tissue is not specific to the injury area at the beginning (so it doesn’t yet have the strength or properties of the injured tissue), but it is a great point to start showing the healing tissue what will be required from it in the future.
What to do
This is the time to start exposing the injured tissue to the loads and forces that we will require from it in the future – in a safe and stable environment! The new tissue is not yet very strong, but it will change, adapt and grow based almost exclusively on the forces that it is exposed to. So, while still keeping safe and protected, it is time to start some gentle exercises mirroring the future function. For example, in ankle sprain, this is the time to start putting more weight on the foot, so loading the ankle - as much as possible, without too much pain (and fear), and is safe and stable directions.
This is where working together with a physio will really help - to make sure you are adapting the tissue well for future movements, but safely enough not to sabotage the healing process.
What to avoid
This is a tricky phase, as you need to be able to assess how much to push: if you’re not pushing yourself at all, you may lose function; if you push too much, you may re-injure the tissue. In this phase in particular, it is important to ‘push as much as you can, but as little as you have to’. So you need to find your sweet spot, and avoid:
- Total rest, not movement and being too conservative with your injury (not exposing to any new loading at all)
- Pushing too much and forgetting that this is a new and relatively weak tissue
Phase 4: Remodelling
2-3 weeks to over a year
What is happening
The area is relatively stable, the tissue is built, and somewhat organised to function. Your body gets out of emergency mode; your brain, although still a bit protective over the local area, is happy that the crisis is over and ready to return to business as usual. Now the injured tissue needs to get stronger and adapt further – this can take even over a year. This repair tissue starts maturing now, and - just like in the previous phase – it matures to fulfil the requirements of the local stresses. So these stresses need to be provided! In particular, the tensile strength of the mature tissue needs to be built – so the capacity to resist any movements that would strain the tissue.
What to do
This is the time to push and to do some fun exercises! The safety aspect is still key, so make sure you control your risks, but this is the time to foresee all the tricky situations that your injured tissue may experience at any point in the future - and learn it in a safe environment, with a gradual but progressive exposure. For the injured ankle – jumping, side squats, dynamic and functional exercises – whatever your sport and training will require from you in the future.
Remember to focus on providing good healing environment - and while your tissue is learning new and potentially challenging movements, try to be rested, eat well, drink water etc - to maximise its chances for optimal recovery.
What to avoid
Just like in the previous phase – doing too little or doing too much may sabotage your recovery. If you feel that you have healed enough and neglect some more advanced exercises – you may leave your tissue too weak to some specific challenges. This could have some delayed consequences, where your body can deal with the loads in a short run, but may develop some compensations that will later affect you. If you throw too many too difficult elements at once – for example long runs on an uneven terrain – you risk either re-injury, or any secondary injuries. So again – push as much as you can and as little as you have to!