Guidelines for Exercising After an Injury
Note: The information in the following article is meant to provide the reader with general guidelines regarding therapeutic exercise for injury rehabilitation. These guidelines do not apply to all injuries, and all injuries will require some unique aspect of care. Therefore, if you are currently suffering from an injury and are wondering about returning to activity, we highly suggest speaking with your doctor and/or physiotherapist prior to initiating self-treatment.
Many people have come to understand that exercise holds many benefits for general health, both physical and mental. Gone are the days of encouraging as much rest as possible following an injury or surgery. For example, many hip replacement patients begin standing and walking in the first day or two after their surgery, whereas in the past this would have been replaced with rest.
However, it is equally important to understand when rest is necessary as well. Every injury is different, and therefore, every injury will require a different course of action. You don’t want to push yourself too soon and cause a setback or increase the severity of the injury, but at the same time you don’t want to prolong the recovery process more than you have to, so it can be pretty tricky to determine on your own.
In this article, we will provide some general information on how to know if you are healed enough to exercise, what types of exercise may be appropriate, and when to avoid exercise after an injury. Please keep in mind we are assuming the injury is minor enough that you did not require a visit to the ER or urgent visit to the doctor for diagnosis or treatment (if you did, please follow your current medical advice if from a health care professional).
How do I know if it is too early to exercise?
The healing process will require time and patience regardless of the injury. While we cannot accelerate the natural biological pathways that facilitate healing (for the most part), we can provide an optimal setting for healing to occur, ensuring we do not prolong the process.
So how do you know if your injury is still in the early stages of healing? The earliest stage of healing is known as the inflammatory stage, and this stage usually lasts about a week, but can be a bit longer depending on the severity of the injury. The inflammatory phase is typically characterized mainly by pain and swelling, but you may also notice significant stiffness or laxity depending on the anatomical structure that has been injured.
To be clear, swelling and inflammation are not the same thing, but they are often associated directly with each other, which is why we can often determine if there is inflammation by checking for the presence of swelling. So while we do not want to extend the inflammatory phase more than we need to, it is still an imperative process in healing, especially in the very acute phase, as it’s crucial for clearing debris and damaged tissue from the region.
During this inflammatory phase, rest usually takes priority over exercise, but there are still some things you can do to help yourself out. In cases like a sprained ankle or wrist, or an injured knee, elbow, fingers, and/or toes, you can usually being gentle range of motion exercises assuming a fracture has already been ruled out and the pain doesn’t increase with these movements.
For example, if you rolled your ankle and notice that the swelling is going down (or at least not increasing) after a couple days of applying rest and applying ice, then it may be suitable to begin moving your ankle around a little bit without any added resistance. To make sure you are not pushing it too far, be cautious and use pain as an indicator. Don’t move the joint beyond the point where pain begins to increase, and start slow so that you can monitor how your body responds in the following couple days.
Aside from these types of gentle range of motion exercises, we wouldn’t really recommend any other type of exercise that involves the injured area. Again, in this very early stage, it’s a good idea to allow the body some time to go through it’s inflammation process and heal up a little bit before stressing the tissue.
When can I start exercising after an injury?
Again, this question is best answered by someone who can directly assess your individual injury, but for the sake of knowledge, here is some general information.
Once you begin to reach the end of the inflammation stage, the injured area then goes into the proliferative healing stage. This means that the inflammation process has cleared the area of old damaged tissue and debris, and as such, the site is now ready for new tissue to be laid down.
As an analogy, think of a new high-rise building being built. If it becomes damaged in an earthquake and cannot support any type of load without sustaining further damage, this could be analogous with the inflammation stage. Once the damaged parts of the building have been removed and new material is added to help repair it, this is analogous to entering the proliferative phase. Keep in mind that during the proliferative phase, the building is still under repair, so it cannot support 100% of the load that it will be capable of yet. In the case of the body, the new tissue that is being laid down in the proliferative phase is not yet strong enough to withstand the forces that it is normally subjected to.
What exercises should I start with after an injury?
The further along we go, the more specific the treatment will be for different injuries. For example, strengthening, stretching, and aerobic training all have different indications and contraindications, so once again, this is best determined by someone directly assessing your injury, but here is the general info.
Once we are out of the inflammatory phase and into the proliferative healing phase, the tissue can now be stressed a little more, but knowing that it is not yet strong enough to take the forces it that it used to, we need to be extra cautious and diligent in monitoring the body’s response.
Aerobic Training After an Injury
In terms of aerobic training, assuming you don’t have any cardiovascular, pulmonary, or systemic conditions that are contraindications to aerobic exercise, this can be implemented at almost any point if it does not involve the injured body part. For example, if you sprained your wrist, exercising on a stationary bike should be fine as long as you can avoid putting weight through your wrist. Same thing with running – it should be fine, but be careful of the jarring forces from stepping. If your wrist hurts after a short gentle jog, maybe wait a couple more days before getting back to it.
Strengthening After an Injury
In terms of strengthening, this is a bit trickier because not only are we adding resistance, but we’re also adding movement a lot of the time. Therefore, when you are first introducing strengthening to your recovery process, it is often suggested to start with isometric exercises. “Isometric” is simply a fancy word for “not moving”, so as you may be able to guess, these are muscle strengthening exercises that do not involve the motion of a joint.
For example, if you are sitting on the floor with the soles of your feet against the wall and you push against the wall like you would a gas peddle, this would be considered an isometric exercise for your calf muscles, which are very important in walking and running. In this case, there is no movement of the ankle joint, but you are still contracting and strengthening the muscle around it. As a general guideline, many physiotherapists suggest starting by holding this type of contraction for 5 seconds and doing it 6-10 times.
Stretching After an Injury
Stretching is also tricky to figure out on your own. For example, if you injured a ligament, which is a passive elastic-type structure that connects help add stability to a joint (e.g. the ACL in the knee joint), then you will want to avoid stretching this ligament while the tear repairs. However, you also want to avoid losing flexibility as much as possible, so it’s a bit of a balancing act. Once again, stretching should wait until after the inflammatory phase, but if you feel strong enough, you can try incorporating very gentle stretching into your recovery process.
Contraindications for stretching include, but are not limited to, acute tears and sprains, fractures that are still healing, if it will compromise joint stability, if there is a flare-up of a systemic condition like rheumatoid arthritis, hematoma, osteoporosis, etc. There are many more contra-indications, and they aren’t all set in stone, which is one of the reasons it’s really important to be personally assessed by a health professional.
That said, assuming you are cleared to begin stretching, the general guidelines are for young individuals are to hold a stretch for 20-30 seconds, taking a rest for approximately the same amount of time, and then repeat for a total of 4 times. Research has shown little evidence for benefits after holding a stretch for this duration more than 4 times in a session. For older individuals, it appears more effective to stretch for closer to a minute, and repeating this 2-4 times. Many reports suggest a minimum of 2x per week, but in reality, if you want the best results, you may want to consider stretching every single day, or as much as you can if that is not possible.
When can I resume normal activity after an injury?
The answer to this question is purely “it depends”. Everyone’s injury will be different, and the body’s response to that injury will also vary from person to person. Therefore, there is no set recovery timeline for an injury until that injury is investigated in more detail.
In the context of the information we presented above, exercise can become more advanced once the body has surpassed the proliferative phase and has entered the remodeling phase. This timeline is a little more variable than the inflammatory phase, but generally speaking, the body will enter the remodeling phase about 3 weeks after the injury, assuming everything has gone well up to that point.
In the remodelling phase, we really want to emphasize the SAID principle, which stands for Specific Adaptations to Imposed Demands. This sounds complicated, but the theory behind this principle is simple. The body will adapt to the demands placed on it. If we want the healing tissue to be as strong as possible, we need to subject it to stresses that are functional in nature, that is, stresses that will replicate those of daily living or the activities one often engages in (e.g. a sport if they are an athlete).
As you can imagine, this can only be done once the tissue is healed enough for a progression in the loads placed on it. This may still be quite gentle at first. For example, a volleyball player with a knee or ankle injury may perform exercises in a manner that replicated movements of that sport. They may start with gentle half-squats against a wall, as opposed to pure knee extensions on an exercise machine.
Similarly, an avid hiker recovering from a sprained ankle may spend more time rehabilitating on a treadmill as opposed to a stationary bike. In any case, it’s definitely helpful to have assistance with designing an exercise program for your injury recovery. It is our opinion that physiotherapists are best suited to this task, but simply visiting a general physician or your family doctor is a great starting point (you may need a referral anyway depending on where you live).
We acknowledge this information may not have addressed the specific requirements for your individual injury, but we hope it was helpful in allowing you to understand where some health professionals may be coming from when discussing this type of stuff with you, and it is also useful knowledge for future injuries.
If there are a couple take-away messages from this information, they are the following:
We hope this helps. All the best with your injury recovery and return to activity!