How to Return to Training After an Injury - Coach Tip Tuesday

Whether you are a cyclist, a runner, a triathlete, a swimmer, or any other type of endurance athlete, an injury is every athlete’s nemesis and worst nightmare.  Not only is the injury itself often a nuisance (at best) and a massive disruption to one’s life, but injuries often force athletes to have to step away from workouts, which are usually one of the more significant things that helps them manage the ups and downs of their daily lives.  The reduction or elimination of workouts can have a profound mental impact on athletes, which then snowballs the adverse effects of the injury itself.

Because of the many adverse impacts of injuries, too many athletes mismanage injuries and their subsequent return to training and to sport.  This then snowballs into extended injury timeframes, impaired performance, and a delayed return to full training capacity and performance.  All of these things can not only lead to missed goals, but to adverse psychological impacts.  In short, it’s a mess.

I get it.  Injuries are frustrating.  None of us want to experience them.  As a result, when we do experience them, we often engage in one or more of the following behaviors: Denial, rushing, and emotional decision-making.  Unfortunately (and perhaps paradoxically or counterintuitively), these behaviors can cause the exact opposite of what we want, which is to move through the injury as quickly as possible.

The fastest way to return to training after sustaining an injury is to engage in the behaviors that will keep you as healthy as possible throughout your injury recovery process. The patience required to appropriately navigate and manage this process is very real.  Quite frankly, a lot of athletes do not have the patience for it, which ends up costing them in the end.  That being said, an understanding of what the nature of your injury is alongside a pragmatic, thoughtful, patient approach to managing it is the recipe to returning successfully to training.

Types of Injuries Sustained by Endurance Athletes

In the years that I’ve been an endurance athlete and coach, I’ve observed that there are generally six main “categories” that injuries can be classified into.  These are not necessarily widely accepted classifications known or used by many experts in the endurance sports space.  Rather, they are the classifications I have personally observed and have come to think about injuries in.  By doing so, I’ve been able to hone my approach and recommendations when I am working with an athlete who is dealing with an injury and have been able to help literally hundreds of athletes successfully return to sport without an injury recurrence and with strength.  The classifications that I break injuries down into are:

1. Niggle
2. Fully-Developed (Overuse)
3. Acute
4. Chronic
5. Catastrophic
6. Surgery

Niggle

A niggle is something that doesn’t feel “normal” or “right”.  Generally speaking, I would say that niggles do not cross the line to true pain.  Rather, they are more annoyances or heightened sensations above your baseline normal; uncomfortable and/or annoying are probably the best words to use to describe the sensation of a niggle.  An example of a niggle would be increased sensation in a joint (such as a knee) or a particular muscle or muscle group (such as the hamstrings).  Niggles can be thought of as “whispers” from your body; your body is telling you that something is not quite right.  

Niggles are not full-blown injuries…yet.  That being said, they do have the potential to turn into full-blown injuries if they are ignored.  As such, niggles are something to pay attention to and to monitor.  Feeling a niggle does not necessarily mean that you need to change anything in your training; the main thing you need to change is your awareness of it and how it is feeling.  Some good questions to ask yourself when you are experiencing a niggle are:

• Is this the site of a past injury and/or niggle?
• Is the sensation you are feeling new to you?  Have you ever felt this before?
• Is there something in particular that makes it feel worse?
• Is there something in particular that makes it feel better?
• Does it feel better or worse with activity?
• Is what you are feeling causing you to move or sleep differently throughout your daily life?
• Is what you are feeling painful?  (If so, it probably isn’t a niggle anymore.)

Again, it’s important to note that feeling a niggle does not necessarily mean that things need to change in your training.  That being said, there are some best practices to implement when it comes to managing niggles.  Many times, an athlete’s first reaction to a niggle may be to take time off from training to get it under control or make it go away, but this may or may not be an effective strategy when it comes to identifying and addressing the underlying issue…depending on what the underlying issue is.  That being said, some niggles (especially ones that involve a bone) may require decreasing or ceasing any offending activities to allow time for inflammation to decrease and for things to settle down a bit.  If the niggle you are experiencing is causing you to engage with poor or altered form and/or mechanics, it’s worth considering decreasing workout intensity, volume, or both.

Self-massage (to include foam rolling and/or using a massage gun) for 2-3 minutes at a time on a particular muscle group no more than 2-3 times per day can be effective.  Consistent daily stretching can also be useful.  Additionally, using a Transcutaneous Electrical Nerve Stimulation unit (more commonly referred to as a TENS unit) can be effective.  Finally, making sure to take the time to do a proper dynamic warm-up before workouts and an appropriate cool-down after workouts can also help manage niggles.

Fully-Developed (Overuse) Injuries

A fully-developed injury is something that has transitioned from a niggle into an “actual” injury.  Generally speaking, these are overuse injuries, which are also known as repetitive strain injuries.  This type of injury occurs when tissue in the body (bones, muscles, ligaments, or tendons) is damaged due to repetitive demand over a period of time.  The load imposed on this area of the body exceeds its capacity, leading to microtraumas in the body’s tissues occurring from repeatedly using the same parts of the body over time.  In other words, this type of injury does not happen in one workout or overnight; it is the result of many workouts and many stresses on the body over time.  

It is not uncommon for athletes to mismanage niggles, which then causes things to snowball into a fully-developed injury.  If niggles are whispers, then fully-developed injuries are “shouts”.  (And this is why it’s important to pay attention to and manage niggles; you don’t want those whispers to turn into shouts.)  A fully-developed injury has crossed the threshold from discomfort to actual pain.  Because you are in pain, you are likely already compensating for the injury (meaning that - consciously or unconsciously - your movement patterns are altered because of the damage that has occurred).  Compensations due to fully-developed injuries put you at risk of sustaining secondary overuse injuries, aka more injuries in addition to the one that you have already sustained.

There are several risk factors for overuse injuries, including (but not limited to):

• Doing too much too soon (volume, intensity, frequency, or any combination of those)some text
  • Based on my experience over the years, this - doing too much too soon - is the number one reason athletes get injured and it’s the most common mistake athletes make in their training (whether they are injured or not).
• Skipping workouts and not altering the subsequent schedule of workouts after skipping workoutssome text
  • Doing workouts out of sequence is like trying to assemble IKEA furniture by skipping ahead to the middle of the directions.  Sometimes it works; a lot of the time, it does not.
• Too much of a single type of activity (such as too much running and not enough complementary strength training or cross training)
• Shifting workouts around in a schedule so that they are arranged differently from their originally planned sequence
• Running in shoes with too many miles on them
• An improper bike fit
• Poor technique, form, and/or mechanics (for any sport)

When experiencing an overuse injury, there are several good questions to ask yourself and reflect on…many of them the same as when you are managing a niggle:

• Is this the site of a past injury and/or niggle?
• Is the sensation you are feeling new to you?  Have you ever felt this before?
• Is there something in particular that makes it feel worse?
• Is there something in particular that makes it feel better?
• Does it feel better or worse with activity?
• Is what you are feeling causing you to move or sleep differently throughout your daily life?

There are several important components that enable an athlete to successfully manage an overuse injury.  The first is to listen to any recommendations made by a doctor or a medical provider, especially when it comes to restrictions or limitations to your training.  Related to that, it’s important for you as the athlete to ask your doctor or medical provider questions.  Just because the doctor doesn’t say something doesn’t mean that there isn’t an appropriate limitation that is in play.  Often, doctors don’t fully understand what is “normal” for an endurance athlete.  Remember: Endurance sports training in and of itself is an extraordinary thing.  You need to be proactive and make sure you are doing your due diligence to fully understand your injury and any appropriate restrictions, even if (and perhaps most especially if) you do not like them.

As much as athletes may hate reducing or ceasing training, a reduction or cessation of the offending athlete that caused the overuse injury is often helpful.  For bone fractures or soft tissue tears, it is necessary.  That being said, cessation of training is not always appropriate and/or it is sometimes necessary to reengage with training in order to help an injury to heal.  For instance, tendon injuries require loading to heal (meaning that total rest will not resolve an injury such as tendonitis).  That being said, cross-training or using alternative modalities (such as cycling or swimming instead of running) can be effectively leveraged to help accomplish this without imposing the amount of volume and/or intensity that caused the overuse in the first place.

Looking at changing out equipment (such as running shoes), getting a bike fit, and going to physical therapy are also all viable options when it comes to managing an overuse injury.

Acute Injuries

An acute injury is one that results from a single event or an accident.  Some examples: rolling an ankle and tearing tendons, tripping and breaking a wrist, or stubbing your toe and fracturing it.  Acute injuries are frustrating because of their abruptness.  It can take a little while for athletes to accept their new (even if temporary) circumstances necessitated by an acute injury.  Acute injuries are also frustrating because they sometimes turn into long-term or permanent issues.

Acute injuries almost always require training cessation or detraining.  It takes two times as long as you detrained to get back to where you were before you started that period of detraining…if you are healthy.  For periods of detraining that result from sustaining an injury, this timeline is extended.  It takes at least three times as long as an athlete is “down” or “off” from training for an athlete to return to their pre-injury fitness level.  For instance, if you can’t train for eight weeks, it is going to take at least 24 weeks (yes, almost half a year) for you to return to the same level of fitness and performance that you were at prior to your injury.  Remember: The patience required to successfully navigate an injury rehabilitation and return to training is very real.

Following the recommendations of a doctor or medical provider is essential when managing an acute injury.  Physical therapy is also often helpful.  But the most important thing to do when navigating an acute injury when it comes to returning to training is this: Return slowly.  Slower than you think you need to.  Most likely so slow that you feel like it’s insulting.  Paradoxically, you’ll get to where you want to go faster if you resume your training routine slowly and gently.  Attempts to try to rush and hurry the process along will also extend out the already long recovery timeline required for an acute injury.

Chronic Injuries

A chronic injury is an ongoing injury or circumstance that needs to be managed and cannot be “forgotten” about.  Examples of a chronic injury include:

• A previous acute or catastrophic injury
• A previously broken bone
• Arthritis
• A replaced joint
• An amputation
• A secondary issue that stemmed from a previous injury (such as an issue from wearing a sling for a long period of time due to a broken arm)

Chronic injuries need to be accounted for so that you don’t re-aggravate or re-cause past issues or injuries.  Just as they are chronically occurring, chronic injuries need to be chronically managed.  Following the recommendations of a doctor is key.  Physical therapy is also usually really helpful for chronic injuries.  That being said, if you have a chronic injury, you cannot do physical therapy for 10 weeks and then just stop, never to do the things you did in physical therapy again.  You need to be doing what you did in physical therapy most (if not all) of the time.  This doesn’t mean that you need to go to physical therapy all of the time, but you should be doing the work that you would be doing if you were going to physical therapy (such as exercises, etc.) on your own.

Stretching, self-massage, and massage therapy are all important to consider implementing on a regular basis to manage chronic injuries.  Additionally, paying attention to the volume, intensity, and sequencing of workouts is really important for athletes who have a chronic injury.  Examples might include not running more than one or two days in a row and/or not stacking all of the same type of workout in a single two-day block in a training week.

Catastrophic Injuries

A catastrophic injury is often an escalated acute injury; it is severe trauma.  Examples include (but are not limited to): a cycling crash, a car accident, a skiing accident, or a traumatic brain injury.

A catastrophic injury always results in training cessation.  While the exact amount of time that the training cessation goes on will vary from person to person based on what the nature of the catastrophic injury is, anyone who sustains a catastrophic injury and who doesn’t stop training is being stubborn and is doing more damage to themselves.  Common examples of this stubborn behavior occur in races.  Even if an athlete crashes in a race and gets injured, they will almost always continue in the race, often causing more severe damage and prolonging their overall injury timeline because they didn’t stop when it was prudent to do so.  This happens because they feel like a failure if they don’t cross the finish line, since the finish line is the one and only measure of success athletes utilize once they have started a race.

Due to their nature, a catastrophic injury often results in a permanent change to how an athlete needs to wisely approach training moving forward.  This permanent departure from their previous normal can be very frustrating and demoralizing for an athlete.  Any stubbornness about accepting these new circumstances can delay a successful return to training.  Having experienced a catastrophic injury myself and a permanent alteration to how I am able to train because of it, I can speak from experience when I say that focusing on what you can do (versus ruminating on or lamenting about what you can no longer do) is the secret to successfully managing catastrophic injuries.

The same advice given for how to manage acute injuries holds true for catastrophic injuries: Follow any recommendations made by a doctor and resume training slowly by slowly, and only when it is actually safe for you to do so.

Surgery

While undergoing surgery may not meet the traditional definition of an injury, what happens to the body during surgery is effectively an injury, and should be treated as such.  In most cases, surgeries need to be treated like at least acute injuries, though in some cases they may need to be treated as catastrophic injuries.  

Surgery usually requires training cessation, which in turn means that the athlete will be forced into a period of detraining.  That, in turn, means that the athlete will be forced into a prolonged timeline of returning to sport.  When starting training back up again, it’s important to start easier and slower than you think you “need” to (and almost certainly slower or easier than you want to).

The Best Way to Manage Injuries

When I talk about “managing an injury”, generally speaking, I define it as keeping the injury from getting worse and/or causing an athlete to have to spend more time than necessary in detraining or training cessation.  This being said, there are many ways to manage an injury, and how to best manage an injury (including how long it takes to recover from it and return to training) is going to be very personalized for each athlete, even if their injury is “the same” as another athlete’s injury.

No matter the level of injury, the biggest enemy of injury that I’ve seen in the endurance sports world is denial.  I’ve done this myself.  We will say things like:

• “That happens to other people, not to me.”
• “This isn’t that bad.”
• “If I ignore this, it will go away.”
• “I don’t want to admit that this could stop me from doing something I love, so I’m going to pretend it’s not happening.”
• “I’ve already invested so much in [whatever the thing is that the athlete is doing] so I can’t “quit” now.”

While it’s tempting and - quite honestly - easy to engage in denial, it’s really important to fight this tendency and instead see any injuries you sustain through a pragmatic lens.  Doing so will enable you to chart the best path possible forward for yourself.

All good endurance sports training is planned by balancing an athlete’s limiters and their strengths.  Limiters are the factors in training that restrict an athlete’s performance or their ability to progress in training.  Limiters can be psychological or physiological, but the physiological limiters are the primary limiters that need to be accounted for in order to successfully manage an athlete’s training load versus their capacity so that they do not sustain a physical injury.  A physiological limiter can be related to aerobic endurance, muscular endurance, muscular strength, lung capacity, neuromuscular connections, and more.  Improperly managed limiters can and will cause injuries.

When returning to training or when resuming an activity that has been detrained or ceased, it’s important to remember this: The limiter in play is usually mechanical when you are dealing with an injury.  So even though you may have the cardio-respiratory or muscular ability to do more, you need to have the maturity to do less and to stay within your mechanical limitations.  The ability to do this - to exercise this restraint - is the mark of an experienced and mature athlete.  Inexperienced and immature athletes push through without regard for this, and ultimately pay a hefty price for it in the form of secondary injuries or prolonged recovery timelines.

As an example, an athlete who I coach recently rolled her ankle and had a very, very bad sprain.  The volume and intensity that I am planning in her training right now is very low compared to what it was just before the injury.  She just told me this week on a call that she feels she can do more.  She also said that her ankle is throbbing by the end of the day.  As much as she doesn’t want it to be true, this means she cannot do more than what I am currently planning, as the workout stress isn't the only factor we need to consider when planning her training.  The stress and load on her ankle from her daily life needs to be accounted for as well.  

Additionally, what she is feeling is a lack of appropriate cardio-respiratory training stimulus.  She’s not wrong when she says she feels like she can do more; the amount of cardio-respiratory stimulus that I’m currently prescribing in her workouts is low compared to what she needs to be doing to produce adaptation, and it’s low compared with her fitness level before the injury.  However, we are limited not by her cardio-respiratory system, but by her ankle.  If we were to plan for the appropriate cardio-respiratory training stimulus, we would almost certainly cause more and worse damage to her ankle.  So even though this does mean that we will see regressions in her cardio-respiratory fitness, what we are actually seeking right now are progressions in her ankle strength and stability.  As that improves, we will be able to progressively introduce more volume and intensity, ultimately getting her back to loads that are appropriate to produce adaptations across all systems of her body.  This will take time, but if she sticks it out, she will ultimately get to where she wants to go.

Here’s the sequence I most often deploy when making changes to an athlete’s schedule for injury-related or injury prevention reasons:

1. Scale back intensity
2. Scale back volume
3. Scale back frequency
4. Alter sequencing

How much I change each of these things depends - as almost everything in endurance sports training does - on many factors, including:

• Who the athlete is
• What their mental tolerance is for an injury
  • For instance, some athletes may react to a niggle the same way someone else reacts to a muscle tear or bone fracture.  Other athletes might break three bones and think they’re ready to get up and train normally.  Everyone’s tolerance for injury is different.
• What the athlete’s injury history is
• What the athlete's training load has been, and how their current training load compares to what they’ve done in the past

Resist the Urge to Overcompensate While Injured

It’s often tempting for athletes to do something along the lines of: “I can’t run right now, so I’ll do [insert other thing here] instead to “replace” the running I was doing”, especially if they are told that they will have an extended time away from activity.  It’s important to bear in mind that your body needs resources to heal.  Any imposition of stress will divert resources away from where they need to go, which is healing the injury.  As an example, you don’t want to work out your upper body with a vengeance because your injury is in one of your lower extremities.

This is especially true for acute/traumatic injuries.  Stress is stress, and the body is horrendous at distinguishing the source of the stress.  As an example: If you’ve ever worked out through being sick, you’ve likely experienced how your illness lingered longer than you felt it “should”.  The same thing happens with injuries.  Overall training load and intensity should be reduced for acute and traumatic injuries to allow the body to have the full amount of resources available to heal.  If this is not respected, then the timeline to healing will be extended.

When workouts are planned and completed relative to each other always matters, but when managing or coming back from an injury, the sequencing and timing of workouts is more important than it usually is.  The sequence of workouts that is planned for an athlete returning to training is very intentional.  Many times, each workout is a “test” to see how things are going, and it’s only safe to proceed to the next workout that is planned once we know how a given workout actually went.  Thus, if you skip a workout in the sequence of workouts and complete a workout later in that sequence without rescheduling the missed workout and shifting training forward, you will be at higher risk for re-injury or a prolonged injury recovery.

Movement with eccentric loading causes the microtraumas that cause Delayed Onset Muscle Soreness (DOMS).  By extension, movement with higher levels of eccentric loading need to be handled carefully when dealing with an injury.  Examples of activity that have a significant amount of eccentric loading are running and weight lifting.  (For triathletes, this is often why running is the first activity that is cut when managing an injury.)

Cycling is almost exclusively concentric, which makes it a nice option for an activity choice for many, many injuries.  Swimming or any water-based activity off-loads the body, which is useful when seeking to gradually reintroduce load to the body’s tissues after an injury.  Even though there are activities such as cycling and swimming that are lower-risk, intensity levels still need to be considered and managed.  For example, you don’t want to go hard on the bike because you’re pissed you can’t run and you want to “feel” like you got a good workout in.  As I’ve talked about in the past, this desire to feel like you worked hard or got a good workout can sometimes be an athlete’s enemy.  Be open to including cross-training as a general way of existence (not just when you actively have an injury), especially if you are a single-sport athlete (runners, I’m looking at you).  Cross-training can help keep you healthier and at a lower-risk of injury throughout all of your training.

The Bottom Line

Injuries suck.  There’s no two ways about it.  While every injury is unique and will need to be managed as such, there are some best practices when it comes to handling injuries and your return to sport after them.  By understanding what kind of injury you’re dealing with, being honest about what your current circumstances are, and exercising a patient approach when it comes to reintroducing workouts, you can successfully manage an injury and get back to doing what you love most.