Injury Series Part 2 - Interventions and Modifications to Train Past an Injury

January 17, 2022

By Jennie Hansen, DPT

In the previous edition of this “dealing with injuries/pain” blog series, I discussed some guidelines for when an athlete might be able to train through some sort of injury or pain, vs when a hard stop might be indicated.  But, even if an athlete is able to continue working through pain, that doesn’t mean that nothing should be done otherwise in order to try to address it, especially when pain levels fall into that “yellow zone” 3-5/10 range.  Plus, even low levels of pain aren’t fun, so even though we might not want to stop training entirely, of course we still want to make it better, and get past any injuries in order to progress in the longer term!  When niggles strike and maintaining fitness is important, some considerations can be made in order to decrease provocative stresses on the body, while still working towards goals.

Change Training Load (and Prioritize!)

Training load is the combination of the frequency, intensity, and duration of training sessions.  It might not be necessary, in the absence of the red flag factors, to decrease any individual sport training to zero, but altering (either redistributing or decreasing) training load in order to decrease the stresses and strain on the body is frequently indicated.  But, how is this best accomplished?  Fewer sessions a week?  Slower paces?  Shorter sessions?  The answer is, of course, the definitively helpful, “it depends”.  If an injury tends to rear up after a certain run (or bike, but we’ll use running for the sake of this discussion) duration, as is often the case with injuries triggered by fatigue-related form changes (shoulder impingements while swimming are often prone to this), it might be a matter of decreasing duration to below the threshold, while maintaining frequency and intensity.  If pain is triggered when running at faster speeds (calf and Achilles injuries are frequently indicated here), slower runs might be the key.  Conversely, faster paces sometimes feel better in runners with knee pain, so maintaining intensity might make sense for some.  Other injuries might be fine the day after an individual run, but worse if consecutive days are tried, in which case, less frequent but still quality sessions could be indicated.  Collagen, the building block of tendons, shows a net degradation for 24-36 hours after activity followed by a net synthesis from 36-72 hours.  So, this means that tendons may take up to 3 days to recover from heavier loading, and decreased frequency may be indicated when working through tendinopathies in particular (Silbernagel). 

In reality, though, it’s rare that one particular aspect of load stands out as the clear-cut winner, and the interaction of the factors needs to be considered.  Pain levels during and after activity, and the athlete’s perceived difficulty of the activity with regards to the painful area should be taken into consideration.  If no one aspect of load (frequency, intensity, duration) seems to be a trigger, and the athlete needs to decrease overall load, race goals could be considered.  Swapping out intense sessions for easier ones in order to maintain volumes might make sense for an Ironman-focused athlete, while a 5k-focused athlete would benefit more from scaling back run durations while maintaining intensity.  Then, of course, there’s the fact that triathlon is three sports in one, so load redistribution can be done not just within single disciplines, but between all three.  For example, a calf strain might prevent harder running, but the athlete could still be able to reach top end efforts on the bike instead.  Or, an athlete might not be able to run long durations when returning from a stress fracture, but could supplement with longer swim workouts to maintain cardiovascular endurance.  Altogether, figuring out how to best alter load requires careful consideration, and a bit of finesse in there.  And finally, a note of caution-while “making up for lost time” after a period of decreased load might be tempting, don’t do this!  Large increases in acute (shorter term) training load relative to chronic (past several weeks-months) training load are linked with increased injury risk.

Alter Stresses on the Body

Along with training load, stresses on the body (both intrinsic and extrinsic) can be evaluated.  These can include factors such as running surface, terrain, bike setup, or biomechanics.  In some cases, the factor to alter or eliminate could be a direct trigger of the pain in question-for example, an athlete might feel Achilles pain only when running uphill, or anterior knee pain only when riding with low cadences on the bike.  In other cases, coming up with something to change might take a bit of logical brainstorming.  Sticking to a smooth running surface might make sense for chronic ankle soreness, while the decreased impact of trail running could help a sore shin.  Avoiding cambered roads frequently can assist with IT band issues or ankle tendinopathies.  Bike fit is another area to consider.  Athletes with anterior knee pain might consider raising their seat heights, while those with lower back pain could benefit from a less aggressive position.           

Altering stresses also might involve working on mechanics.  As mentioned in the previous blog post, deliberately changing mechanics in order to correct faulty movement patterns potentially contributing to pain differs from compensations, as compensations are faulty movement patterns that arise due to pain and adversely load other structures.  For example, an athlete with shoulder pain due to a rotator cuff impingement could benefit from working to correct a crossover upon entry while swimming.  Running-wise, a common intervention involves increasing cadence (stride rate) by 5-10%, which promotes a better landing pattern, decreases impact forces and loading rates, and in turn can lessen pain for a variety of conditions, especially knee pain.  The “5/20” rule is frequently cited-that is, a 5% increase in cadence decreases stress on the knees by 20%.  So, whether it’s by avoiding an external trigger related to training environment, tweaking bike fit, or working on biomechanics, finding logical ways to change training-related stresses on the body can make a difference.

Unload Stressed Area

Although equipment alterations and aides might not be the first resort or a long-term solution, they can assist on a short-term or temporary basis, particularly when the main goal might be getting an athlete to (and through) and impending competition.  Replacing running shoes (particularly when old or worn) is a common one, but this can also include tools and toys such as orthotics, heel lifts, various forms of taping, or braces and straps.  While shoe inserts such as orthotics, wedges, and heel lifts and pads have not been shown to be clearly beneficial when it comes to preventing injury, they can be useful in treating foot and ankle pain, such as plantar fasciitis, by temporarily unloading the structures.  Heel lifts decrease strain on the entire posterior leg (calf/Achilles) complex, so they are frequently used to help overcome acute calf and Achilles pain.  Over-the-counter models typically perform just as well as their more expensive custom-made counterparts.  Certain types of knee braces can assist with tracking of the kneecap, and keep patellofemoral (pain in the front of the knee) pain at bay.  Straps that are worn around knees or elbows for tendon-related injuries such as patellar tendonitis, IT band syndrome, and tennis elbow can help to decrease strain on tendon attachments and relieve pain with activity.  While the purported mechanisms of various types of taping (KT tape, Rocktape, etc) vary and may be via the placebo effect at best, many athletes do find relief.  Most of these “extras” are available over the counter at relatively low costs and involve relatively little risk, so may be worth a try in a pinch.

Optimize Mobility and Stability

When it comes to triathlon, the body needs to be mobile enough to move through the ranges of motion required for each individual sport, and stable enough to efficiently generate force to move the body forward.  An assessment by a qualified physical therapist or other professional familiar with the specific demands of triathlon can help an athlete determine underlying individual deficits in mobility or stability that could be contributing to current issues.  If that’s tough to come by, many athletes benefit from working on some commonly tight or weak areas.  Mobility-wise, hip flexors (especially in athletes who sit for work), calves, and big toe extension are frequent limiters.  Stability-wise, the majority of athletes benefit from working on the lateral hips, hip extensors, deep trunk muscles, and small intrinsic foot muscles.  Single leg activities are often great for these purposes.  But, be careful-make sure that any mobility or stability work doesn’t further exacerbate a cranky area.  Those pain guidelines from the previous article also apply to strength and stability work!  Maxing out squats with a glute strain won’t heal it-stick to loads it can handle while still improving.  Stretching a more acutely painful muscle/tendon complex does more harm than good, as it can disrupt healing fibers and compress already irritated tendons-so hold off on that calf stretching with a painful Achilles.  Soft tissue work not directly over the painful area-think using a percussion gun or foam rolling the calves-is a more useful way to help out mobility without sacrificing injury healing.  Let’s face it-when time (and energy) constraints start to take over, that mobility and stability work is often gets dropped.  I’m plenty guilty of this one myself!  But, those niggly times are a fair reminder to get back on track with that.

Think About Life Loads

Finally, remember that training is just a small sliver of what an athlete does throughout the course of the day!  Often overlooked is what goes on for the other, say, 17-23 hours of the day.  How much sitting, standing, and walking does the athlete do?  In what kind of footwear?  How’s the work setup?  Is the athlete frequently bending and lifting, squatting on the floor playing with kids, or taking the dog for a hike?  What about sleeping position?  Is the athlete stuck sitting in a car on a long commute?  And what about all of those other details that are so important to overall recovery-how much sleep does the athlete get, what’s the life stress level like, and so on?  While pain might manifest during training, movements, positions, postures, stresses and recovery habits can play just as big of a role in controlling pain as anything training-related.  Some factors, such as workstation ergonomics and recovery habits, can be improved, while other work and family activities may be non-modifiable.  But, they still need to be considered, and factored into the overall picture with regards to loads placed on the body.

So, there you have it!  While many athletes fear being given the traditional “take 2-4 weeks off of running and get back to it like nothing happened”, the reality is that rarely is that when a body part lets itself be known, the answer is rarely that straightforward.  When something hurts-change something.  Easier said than done, but ideally, with some alterations and considerations, small injuries don’t become the large ones that end up resulting in significant time and fitness loss.  Consistency is always the key to success in endurance sports, so always remember that working to nip problems in the bud early beats trying to barrel through!

Reference:    

Silbernagel KG, Crossley KM. A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation. J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86. doi: 10.2519/jospt.2015.5885. Epub 2015 Sep 21. PMID: 26390272.

About the author ...

Jennie Hansen is a Coach with QT2 Systems Coach as well as a Physical Therapist and Certified Strength & Conditioning Specialist.  Jennie is also a Professional Triathlete, racing for QT2 Systems.