Tendinitis, sprains, fractures, dislocations but also muscle tears are common, in athletes as well as in amateur sportsmen and women. After a sports injury, there are many points to consider in order to recover as well as possible. The affected area must regain its functions (range of motion, strength, control) without pain or inflammation. Muscles that have been resting must regain their tone and the cardiovascular system must regain its endurance. To do this, appropriate and supervised physical exercise is necessary, but good nutrition is also essential. Psychological support can be useful as a complement.
What’s going on in our body?
Muscles can regenerate themselves thanks to their reserve of muscle stem cells. Three phases have been identified following an injury:
- The initial inflammatory process, where immune cells arrive at the site, cleanse the injury and secrete cytokines and growth factors for healing.
- The regeneration phase where stem cells are activated and proliferate.
- The maturation phase where these new muscle cells (myoblasts) mature and remodel the tissue.
During the last 2 phases, collagen is synthesised, to help strengthen tissue tension (healing) and the new muscle tissue is revascularized and connected to the nervous network. Most small muscle injuries (elongations, contractures) thus heal spontaneously, but this can take from 3 to 52 weeks.
It is important to let it heal well, so as not to risk subsequent injuries. After applying “rest, ice, compression, elevation” to minimize internal bleeding (haematoma) directly after the injury, complete rest is recommended for 5-7 days. Then, if the symptoms of the injury (bruising, tenderness on palpation, loss of range of motion and pain) have improved, remobilization is advised. Gentle and gradual mobilisation (agility of the affected muscle, stabilisation of the trunk) will strengthen the regeneration of the tissue and regain muscle strength, provided that it is not rewound due to overloading.
Attention, more severe muscle ruptures must be treated quickly, as fibrous tissue can form and lead to muscle rigidity and chronic pain. Sometimes an operation is necessary.1-3
A tendon is the extension of the muscle that attaches to a bone, allowing movement of the joint. It is composed mainly of collagen (I and a little III). Whether it is a tear due to a strong and acute impact, tendonitis (inflammation) from overuse or age-related degeneration, a tendon injury is often disabling and painful. Healing generally follows the three phases mentioned for the muscle. Surgery is sometimes necessary (often to reattach the tendon to the bone). The inflammatory phase lasts about a week after the operation, the proliferative phase of the cells a few weeks and the extracellular matrix remodelling phase several months (or even years).4-6 Some studies suggest that type III collagen is first synthesised after injury. It remains there for several months, and then allows type I collagen to gradually regain the upper hand, allowing the tendon to regain its basic composition.7
Here too, while some rest time is beneficial, a too long immobilisation is harmful. Physiotherapy exercises increase cell proliferation and collagen production, strengthening the tendon. Rehabilitation should be progressive. Initially, passive mobilisation allows good improvements, without risk of overloading and therefore re-injury. In the case of tendinitis, an anti-inflammatory diet is also recommended. There are also certain treatments, such as laser, shock wave, growth factor or other treatments for major injuries.4–6,8
Ligaments connect two bones together around a joint. In the case of a sprain, it is the ligament(s) that is distended, through incorrect movement or overuse. In this case, progressive remobilisation of the joint after a period of rest is necessary, as well as strengthening of the area around the joint and proprioception and balance exercises to prevent recurrences.
If the ligament ruptures, an operation may be recommended to ensure the stability of the joint. A dislocation is a rupture of the ligaments with an additional dislocation of the joint. We find again the three phases of healing mentioned above : inflammation, regeneration and remodelling. Immobilisation can be useful for a short time at first, but not too long, as it can have harmful effects. On the contrary, controlled movements are beneficial for healing: passive mobilisation increases the organisation of the extracellular matrix and the concentration of collagen, avoiding fibrosis. However, be careful not to lean too much on an unstable joint and not to mobilise too early or too hard.9-12
In a fracture, the bone is cracked or broken, and some of the surrounding tissue may also be affected. It may be necessary to operate if the two ends of the bone are no longer in line or are too far apart. The bone has its own regeneration process, unlike previous examples where fibrous tissue fills in the injury. There are four stages of bone healing (the number of days is indicative):
- Days 1 to 5: a haematoma forms directly after the injury, accompanied by an inflammation which attracts immune cells to clean the necrotic tissue and secrete growth factors.
- Days 5 to 11: the tissue begins to re-form: bone stem cells differentiate, and collagen is secreted, creating a fibrous cartilage network.
- Days 11 to 28: this network is then ossified and vascularised, forming a calcified bone, hard but still immature.
- Last phase that can last many months or even years: the bone is remodelled. A balance is created between the osteoclasts resorbing the bone and the osteoblasts forming the new bone, to recreate the normal structure of a bone: a dense layer around and a more porous interior. Bone is made up of 70% minerals and 30% of a flexible matrix, mainly made up of elastic collagen fibres and glycosaminoglycans. Approximately 10% of the wound may not fully heal.11,13–15
Skin and scar
Some injuries, especially if caused by shock, can damage connective tissue and skin. Surgery also leaves a scar. The healing of the skin follows the three phases of healing mentioned for the muscles/tendons/ligaments :
- Bleeding stops, inflammation and cleansing by immune cells
- Tissue regeneration, cell proliferation (fibroblasts), revascularisation and innervation
- Remodelling of the tissue and restoration of the functional integrity of the skin.
As with tendons, the healing of surgical wounds benefits from the increase in type III collagen during phase 2), which gradually allows the formation of type I collagen during phase 3), normally in the majority in the skin.16-19
Factors such as smoking, skin stretching, sunlight, stress, glucocorticoid drugs or poor nutrition can negatively affect healing. On the contrary, maintaining good hydration, using a silicone or hyaluronic acid gel to moisturize the tissue, disinfecting well and using sunscreen can help to take good care of the scar once the wound is closed.20
Exercises to rehabilitate and prevent a second injury
Gradually increasing strength, flexibility, proprioception, neuromuscular functions and endurance helps to regain confidence in the affected area and avoid stiffening. When the range of motion, strength and control have returned and there is no more pain or inflammation, the decision can be made to return to sport, initially by adapting certain exercises.
Once the injury has fully recovered, it is important to be careful not to re-injure yourself. Good rehabilitation is essential for this, but other factors can help prevention: maintaining muscle strength, flexibility and a good proprioceptive balance. Regular monitoring also allows early detection of a small anomaly, and particular attention must be paid so as not to overload the healed area.21,22
Appropriate nutrition to support specific healing needs
Nutritional status is essential for proper wound healing. An adequate amount of carbohydrates provides the energy needed for healing, but the decrease in energy expended when at rest must be taken into account to avoid weight gain. Fatty acids, particularly omega-3, play an anti-inflammatory role, are involved in healing and maintain cell integrity, so their consumption is recommended. Proteins and amino acids help maintain muscle mass and the proper functioning of tissues. Nevertheless, the quality of the proteins must be a point of attention and the consumption of leucine and HMB is recommended to increase the synthesis of muscular proteins, as a good musculature allows the joints to be well stabilised.23,24 HMB is particularly effective in limiting muscle wasting, useful especially for people who are bedridden or have poor mobility.25
There are also specific nutrients that allow a better recovery :
The intake of certain elements that make up our tissues can help promote the repair of an injury. Collagen is the protein par excellence that is used for all healing processes. When taken orally, collagen peptides will disperse throughout the body and concentrate in the affected area, accelerating the healing process: they will stimulate the cells of the affected tissue and can be integrated into the formation of new collagen proteins.26,27 Collagen and glycosaminoglycans (chondroitin and glucosamine) are the basic components of the joint (cartilage, tendons, ligaments) and their consuption strengthens the structure of the joint and improves its mobility. Similarly, hyaluronic acid allows the hydration of the tissues, promoting their normal functioning.
In addition, antioxidants such as rosehip, edelweiss, MSM… help limit the damage of oxidative stress and inflammation on the tissues. Vitamins and minerals are also essential for the proper functioning of our tissues, especially in the repair phase, as they stimulate various physiological processes.
A psychological support often welcomed
Good coordination between the different practitioners involved in the rehabilitation protocol is essential. Communication between the physiotherapist, sports doctor, orthopaedic surgeon and/or sports trainer, and the patient ensures the proper management of the injury. By having a better understanding of what is happening, the patient can be involved in his or her recovery in the best possible way.21,22,28 Indeed, the psychological impact of an injury and/or an operation should not be taken lightly.
It has mainly been studied in athletes, because for them, sport can represent their entire daily life, their ambition, their social position, the meaning of their life, etc. Their emotional and behavioural responses can therefore be big. Some go through the five stages of mourning, even though they may compete again in the future.29 Psychological support, by therapists and relatives, is then essential, as it has been shown that a negative emotional response after injury can significantly delay the return to sport, whereas a positive adherence to rehabilitation can accelerate it. Psychological stress can limit the healing process, while a positive emotional response can increase confidence in the injured body part.30-32
But athletes are not the only ones who can benefit from psychological support: for all of us, pain, changes of habits in our environment, the emotional impact of not being free to move around, lack of confidence in this part of our body, etc. can be difficult to live with.
Coaching by a therapist, guided visualisation and relaxation, positive thinking, setting achievable short-term goals, writing down emotions or videos showing the progress and frustrations of people who have gone through the same rehabilitation can be effective psychological supports and can help accelerate musculoskeletal recovery.33,34 This helps to increase motivation and manage expectations, rising the sense of satisfaction with one’s progress during rehabilitation.35 Returning to pre-injury sports habits as soon as it is advisable also increases positive psychological responses, creating a virtuous circle. Going step by step helps to regain confidence in the affected area.36
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