Breaking The Injury Cycle

by: Michael Lord

Introduction
One of the most frustrating parts of the endurance performance journey is repeated patterns of soft injury that lead to disruption or destruction of the race build and readiness. You are highly motivated, committed to improving, but just cannot get yourself out of the challenge of injuries. Whether it is a recurrence of a single injury or a series of niggles that seem to have no rhyme or pattern, the frustration is the same. Are you more prone to injury than others? Are endurance sports more suited to others than yourself?  Likely not, and there is a way out.

Please enjoy this wonderful article from purplepatch resident sports med expert, Mike Lord DC. Mike works with many of the purplepatch professionals here in San Francisco, as well as a broad spectrum of athletes at all levels. In the article, Mike breaks apart the "why?" behind recurring injuries and sets out an initial approach to break the cycle of injury.

Enjoy and please share if you find helpful.

- Matt Dixon

 

Why Rest As A Strategy For Injury Prevention Is The Wrong Approach
My guess is that you've heard, or perhaps even thought to yourself, one of the following lines:

  • “I’m chronically injured and I don’t think my body is designed for this.”
  • “I’m going to take a long break after this race and let my body recover.”
  • “I think my body is wearing out because all this training is bad for it.”
  • “Running is bad for my knees and hips so I think I should stop.”
  • “I must be injury prone because I always seem to end up injured.”

If any of this is familiar to you, you are not alone.

The holy grail of sports medicine and performance is injury prevention, yet it's hard to know if such a thing is even possible. There are countless variables, all of which interact with each other, that lead to injuries. To think we can control and purposefully manipulate these variables with any degree of certainty is an unlikely endeavor. Rather than taking the commonly utilized reductionist and narrow view to preventing injuries, such as specific exercises or stretches, the optimal path to reducing injury risk is to employ a more holistic view and focus on building global resilience. A resilient athlete is, under all circumstances, less likely to get injured than a non-resilient athlete.

The mistake of many rehab practitioners (i.e., PT, Chiro) is allowing athletes to become rehab junkies. Yet this is not due to a lack of expertise or skill in treating a specific injury. The mistake is made when too much focus is placed on the symptom or specific injury, advising the athlete away from load and training for extended periods of time. This results in detraining and can be the beginning of a long cycle of symptom chasing. Soon the athlete develops a dependence on therapy and sees training as the bad guy. Unfortunately, the expertise of many practitioners almost blinds them to the bigger picture. Too much time and energy is spent promoting or relying on a specific treatment technique, exercise, or stretch; continually placing band-aids on each new problem. We need to shift this mindset and promote a journey towards independence and resilience.

Consider my work with purplepatch, a group of professional and serious age-group triathletes. We have seen this cycle repetitively when onboarding new athletes - both amateurs and professionals. We noticed that a major contributing factor to the chronic cycle of injury was not the training itself but the breaks athletes were taking away from training due to injury. The time away from training was robbing them of the thing which builds resilience — prolonged consistent training. To break this cycle, the first step is often to get them away from the treatment room and into the strength room. Combine this with changing habits (listed below), shifting the mindset away from what their limitations are, and getting them to move towards what they can do, and now we are having a different conversation.


Why Do Some Athletes Get Stuck in a Chronic Cycle of Injury?
Chronically injured athletes tend to fall into one of two buckets:

1) They accumulate recurring injuries to the same body part; or

2) They frequently collect new injuries.  

In both cases, risk factors tend to be a combination of internal (e.g., aerobic capacity, biomechanics, strength, age, hormonal imbalances) and external (e.g., training program, sleep, nutrition). It should not be overlooked that external risk factors can lead to and magnify internal issues.

The Cycle of Injury
It is undeniable that injuries eventually occur in all athletes. They can be due to an unavoidable circumstance, such as an accident, or may come on gradually during the course of training. Whatever the initial trigger, the injury cycle ultimately ends up the same 

 

This vicious cycle repeats, and before long the athlete hasn’t been training consistently for an extended period, this can be months or even years. There always seems to be an injury that takes them back to square one. The longer the athlete spends in this cycle the less resilient they are to training, leaving them vulnerable to sustaining another injury.

Let’s use an analogy to crystalize the point. Imagine two bodies of water. One is a large reservoir many miles across, the other is a pond the size of a child’s swimming pool. If a boulder is thrown into the large reservoir the ripple will disrupt the water in one small section but ultimately the large volume of water will absorb and dissipate the ripples and not disrupt the whole reservoir. If the same size boulder is thrown into the smaller pond the effect will be vastly different, the ripples will disrupt the entire surface of the pond and it will take time for the water to settle.

A more resilient athlete can withstand different stressors such as a hard training day, a tight hip, stress from work, lack of sleep, etc. These are all examples of the boulder from our analogy. The resilient athlete has developed the resources to absorb these stressors without it causing a significant impact on the whole system. The non-resilient athlete cannot absorb the stressor without breaking down.

Building Resilience
The conventional approach to dealing with the chronic cycle of injury is to take time off and “let your body heal,” but this is often the opposite of what you actually want to do. 

When athletes view themselves as fragile and prone to injury they tend to shy away from load and training stress. By doing this they actually create a more fragile system. This stems from the misconception that athletes need to let their bodies rest and heal up because training is breaking them down. They think they are protecting themselves from an overuse injury by limiting their exposure to training. However, by doing less they are setting themselves up to be less resilient. This is not because the system itself is inherently weak - it is because, without training, the system begins to lose the strength and resilience it once had, becoming weaker. In other words, prolonged rest doesn’t create resilience, it works against it.

More Not Less
Paradoxically, developing a consistent platform of training more, not less, will protect you from injury.

The chronic rehabbers are typically stuck in this cycle because they are managed away from load and training. While this might be an appropriate strategy to manage the short-term acute injury, you must ultimately work to increase the load intelligently to develop a consistent platform of training stress. This is how athletes begin to develop resilience. This consistent platform of training is called high chronic workloads. Interestingly, a high chronic workload is protective against injury, as long as you reach a high chronic workload safely.

Ultimately, athletes need to shift their mindset and understand that training hard is not the culprit for chronic injuries. Referencing our earlier analogy, our goal is to develop the appropriate resources—the large reservoir—to withstand stress. This is accomplished through consistent training. When you are able to build up and maintain a high chronic workload, you can better tolerate a stressor to the system.

Spikes In Workload Lead to Injury
Now, this isn’t giving you license to throw caution to the wind and bury yourself with huge training loads. It’s how you develop the high chronic workload that breaks the cycle of injury. 

The important thing to realize is that part of the injury cycle is an inappropriate increase in workload, called spikes. While the goal is to obtain a high chronic workload, such a workload is achieved through consistency over a long period of time and avoids dramatic spikes as well as long breaks away from training.

You want to develop a long and consistent training platform to gradually build upon. The goal is to follow a program that has appropriate progressions in workload and includes periods of lower stress. The periods of lower stress will magnify the benefits of the hard training days allowing your body to absorb the load. This is the training cycle you must embrace. “Load is the vehicle which drives athletes to, or from, injury,” says Tim Gabbett, an expert on injury prevention in athletes. Stress is relative and it is relative to your baseline; too much and you will overload the system, just right and you build resilience.

Practical Application of Habit Changes
The chasm between acute injury rehab and training becomes larger and larger as injured athletes are managed away from training loads. Here are some simple recommendations to increase your success when trying to break the cycle of chronic injury: 

  • Don’t wait for your body to feel 100% - While you may need to take the time to recover from the most recent injury, don’t wait for your body to feel perfect. By waiting you are robbing your body of load (which creates resilience). You may be surprised how much better you’ll feel by finding a training load that is challenging yet safe.
  • Don’t be beholden to the plan written on paper - Making micro adjustments to the training plan when needed is crucial to avoiding the need for a longer break away from training. Develop an internal physical awareness and be honest with how your body is responding to the training loads.
  • Communicate with your coach - It’s not a failure if the plan needs to be adjusted.
  • Go hard on hard days and easy on easy days -  This is a foundation to any training plan but its importance cannot be overstated. A common mistake is not following this simple habit and is often the road to injury.
  • Get out of the treatment room and into the strength room - This teaches athletes that they are physically robust and capable while improving their strength and resilience. Strength training is a pillar in all good training programs. Often this is as much mental as it is physical when breaking the chronic cycle of injury.
  • Commit to supportive practices - Consistency with activation, restoration work (i.e., foam rolling), and strength training is key. These routines are designed to support the most important muscle groups and movements for optimal performance. They may seem simple but when done consistently they are powerful.

Long Term Development
To break the cycle of injury an athlete’s mindset needs to shift towards the long-term development of chronic training loads. This will undoubtedly mean different things to different people. Some people may be in a short-term situation while others may be on a much longer journey. Unfortunately, if an athlete has been in a cycle of chronic injury, it means they will likely need to take a long-term approach to building high chronic training loads.  

To get to the point where an athlete is resilient and adaptable their habits have to evolve. To truly break the injury cycle athletes cannot just focus on rehabbing from one injury in isolation. That is like siloing off one limb or joint of the body and treating it like it exists in a vacuum and has no interaction with the whole system. This is not how the body functions. We need to expand the lens and look at the role training plays in recovering from an injury. Focusing on what an athlete CAN do, not focusing on what they CAN’T do. This process should take on two parallel journeys: rehabbing the specific injury while concurrently mapping back to performance training.

The athlete needs to understand and quantify the training volumes and intensities that they are trying to get back to, understand where they currently are, and identify what limitations the injury of the moment poses. Then a program can be designed that safely ramps back towards their ultimate goals in a way which creates system resilience. This should take place while the athlete is recovering from their current injury. These two things should not be viewed as separate isolated journeys, but concurrent.

And herein lies the difference. If we only focus only on the injured tissue, the rest of the body isn’t getting any training stress. The result is detraining. This creates a more fragile system and ultimately leaves a rehabbing athlete vulnerable to another injury.  

We can’t ever promise to predict, let alone prevent, all injuries. What we can do, however, is look at what aspects mitigate the risks and develop a more resilient and adaptable system. Consistent training, not consistently taking time away from training, is the path to reducing injuries.

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