A Patient’s Step-by-Step Guide to Understanding Rehab and Returning back to Sport/Running
by Keval Panchal – Senior Chartered Physiotherapist
Injuries are a nuisance. You put so much time and effort into training for that run, perfecting our sport, pushing ourselves to compete at that higher level. You have your perfectly laid out training programme, invest money in the best trainers, coaches, and personal trainers. Then suddenly BANG! One day you wake up and that annoying calf cramp or hamstring strain that had been a bit of trouble suddenly goes into overdrive, and you feel about as mobile as your auntie Sue after her knee operation, coming down the stair-lift to celebrate her 75th birthday.
People often end up on a physiotherapy bed with an injury due to over training. In fact ‘training error’ accounts for 60-80% of overall running-related injuries. This article and the next few articles after, will hopefully give you the best up-to-date advice regarding 4 key factors in detail to help you best understand your pain, injury and how to also optimise your recovery. It will also aim to put right so many myths and misconceptions that the media and society has drummed into us.
The questions that are most commonly asked by patients at a physiotherapy clinic tend to go along the lines of:
- How much is too much exercise/ too little exercise?
- Am I doing the best workouts for my body/ to help with my sport/ running?
- How do I get back into sport/ gym to increase my fitness post injury?
- How much can I exercise with an injury/ post injury?
- When is the next best time to exercise after completing the initial exercise session?
- Where do I start when it comes to preparing for a 5km/ 10km/ full or half marathon?
- How do I transition from running once per week to running 4-5 times per week?
What everyone should consider, is what they want to achieve with their end goal in mind. With all these questions, the main issue in focus here is the amount of exercise, training, and recovery.
Whatever the mode of exercise, we tend to stick to ones that we like and become familiar to us, after all we are creatures of habit. Getting into a routine of exercises for several months is fine. Any longer than this is not ideal. Our bodies then tend to adapt to only using certain muscles and creates compensations, overworking some muscles whilst others remain weak and tight. This is the first step to injury.
Another faux pas is that we sometimes go to an exercise class but simply go through the motions of the exercises in the class. We sometimes tend not to realise what muscles we are trying to work, and in doing so you can use other compensating muscles which do the work of the muscles that you were intending to use. This 4-part collection of articles will provide you with an idea of how to engage the right muscles and to maximise the efficiency of your workouts.
This issue can be broken up into 4 key factors:
1) Psychosocial Factors – Stress, mood, Fear, Thoughts, Beliefs, Behaviour towards rehab, and motivation.
2) Training Load – response/ adaptations of tissue/muscle stress, rest and fatigue.
3) Muscle Strength and Endurance
4) Biomechanics of the body and the use of adjuncts, such as orthotics. Does the body part move in the correct intended way?
To simplify things, if you had a car, which had a very old engine, poor tracking on the wheels and a flat tyre; it may just about be able to get you down the road. However, if you were to attempt to take this car from London to Edinburgh, then you may find that the car breaks down halfway whilst on route.
Unlike a car, our body can thankfully adapt and improve when given gradual stress in the form of exercise. Attempts to stress the body too much with little rest can lead to fatigue and often injury. This is known as the Training-Load response. Tim Gabbett, a physiotherapy expert explains that “it’s not the load that breaks an individual down, but rather the load they aren’t prepared for.” Also unlike a car, we have thoughts and feelings associated with our pain and inability to exercise which can greatly affects us.
Part One: Psychosocial Factors
This aspect of rehabilitation is often neglected by both patients and therapists. However, it is so fundamentally key to rehab and can be a good predictor of just how successful your rehab programme can be.
Ardern et al. 2013; found that stress slows down healing by 40-60% and can impair tissue response when attempting both resistance and fitness based exercises. Stress extends the time-frame of your recovery and can impair someone’s ability to recover. People’s thoughts, beliefs, and rehab behaviours influence their perceptions of pain and how they deal with the emotional side of pain. Fear changes the way you move and the way you load tissues (muscles/tendons/ligaments). This then creates a difficult environment in which to allow yourself to rehabilitate. It is therefore vitally important that both patient and physiotherapist/consultant have an open and honest discussion to set a plan and address expectations from the outset. This would help dispel any misinformation provided by either media or society. Ardern et al. 2014; reported greater motivational levels, confidence, and lower levels of fear correlated with a greater likelihood of returning to a pre-injury level.
Here are a few questions you need to be asking yourself, and your physiotherapist should be asking you, to help better understand your ideas around rehab, injury and pain:-
- Why is running/exercise/ sport important to you?
- What impact does it have when you can’t run/ perform in your sport?
- Why do you train the way you do?
- How important is rest and recovery in your training plan?
- What do you believe is happening in your bones/muscles/tendons/joints that’s causing you your pain?
There are 3 key psychosocial aspects which influences the athlete:-
- Autonomy – being in control and taking responsibility for your own actions. If you are taking a more active role with the management of training then it is easier to make positive changes. This involves consistently doing the rehab exercises, and communicating your thoughts, successes, and fears when it comes to rehabilitation.
- Competence and Confidence – thoughts and feelings related to athletes perception of how well they perform their sport. Confidence in your ability to perform and the injured limbs ability to perform. This can again reduce stress levels and allow the athlete to train in a gradual way. The more open you are with your physiotherapist/consultant, then more receptive you will be to receiving feedback to improve your confidence and overall rehab experience.
- Relatedness– perception of connectedness or belonging in a social context that surrounds the sport- runners may tweet/ Instagram/ follow each other on Strava about their running. You may also discuss injuries with your teammates in team-sports. Being around the right people who tell you how to solve your injury can improve your autonomy and competence when dealing with injury prevention and rehab. Conversely, if you’re given the wrong information regarding your injury, this can negatively affect your expectations.
A patient explains what running means to them: “It’s so much more than just physical exercise. It’s my sanity and life balancer”.
An article published in 2018 within the British Journal of Sports Medicine by King et al. outlined 4 key habits that all successful physiotherapists and consultants should have. These included empowerment, engaging the patient, providing feedback and being transparent. A positive treatment experience would be shaped by regular communication and openness between patient and physiotherapist.
To help monitor your own stress and anxiety levels, you could use the Profile of mood States, Borg RPE (Rate of perceived exertion), and Recovery-Stress Questionnaires. These were all developed for athletes to monitor both stress and anxiety during their training regimes. Saw et al. 2017, also more recently developed the Acute Recovery and Stress Scale and it’s shortened version for sports practitioners to quantify recovery and stress.
So far we have discussed how important it is to speak with your physiotherapist or consultant about what you want to specifically achieve from training during injury and post injury. It is also imperative to consider factors like the environment you train in, your training habits, and anything else which could help or hinder your training. In the next article we will be discussing training loads and the effect this will have on your fatigue levels, and the recovery of muscles and other tissues.
Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. British Journal of Sports Medicine; 2013.
Ardern CL, Osterberg A, Tagesson S, Gauffn H, Webster KE, Kvist J. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. British Journal of Sports Medicine. 48:22; 2014.
Borg G. Borg’s Percieved Exertion and Pain Rating Scales. Human Kinetics; 1998.
Bourdon PC, Cardinale M, Murray A, Gastin P, Kellmann M, Varley MC, Gabbett TJ, Coutts AJ, Burgess J, Gregson W, Cable NT. Monitoring Athlete Training Loads:Consensus Statement. Int Journal Of Sports Physiology and Performance; 2017.
Gabbett TJ, Hulin BT, Blanch P, Whiteley R. High Training work-loads alone do not cause sports injuries: how you get there is the real issue. Wis Med Journal. 1996.
Gabbett TJ. Ullah S, Finch CF. Identifying risk factors for contact injury in professional rugby league players-application of a frailty model for recurrent injury Journal of Sci Med Sport. 2012.
Gabbett TJ. The training-injury prevention paradox:should athletes be training smarter and harder? British Journal of Sports Medicine. 2016.
Kellmann M, Kallus KW. The Recovery-Stress Questionnaire for Athletes. Human Kinetics; 2001.
Kellmann M, Kolling S, Hitzschke B: The Acute Measure and Short Scale of Recovery and Stress for Sports; 2016.
Saw AE, Kellmann. M. Main LC, Gastin PB. Athlete self-report measures in research and practice: considerations for the discerning reader and fastidious practitioner. Int J Sports Physiology Performance. 2017:12.