Episode Notes:
Soft-tissue injuries consist of damage sustained to muscles, ligaments and tendons, such as sprains, strains, and tears. These injuries are extremely prevalent, accounting 35-50% of all workplace injuries and are the most common type of sport injury. Depending on severity, acute soft-tissue injuries can impair an individual’s quality of life and performance for up to months at a time, and chronic injuries much longer.
In this episode, you’re going to discover three unconventional rules that will allow you to return to full health shockingly fast. Topics covered include inflammation, the role of amino acids and collagen, and importance of actively rehab. I’ll also share the protocol I used to recover remarkably fast after impulsively running an ultramarathon with no training.
Topics
[2:38] Inflammation is your best friend
[4:35] The problem with RICE and NSAIDs
[6:40] Collagen peptides and tissue regeneration
[8:36] Role of amino acids in recovery
[10:38] Immobilizing a joint is detrimental to recovery
[13:02] Aftermath of running an ultramarathon with no training
[15:23] Recovery from possible grade II sprains in both ankles in less than 2 weeks
[20:14] Your three rules to turbocharge soft-tissue injury recovery
Thank you all for joining me on this journey to lifelong health, happiness, and higher performance. And remember, always be grateful, love yourself, and serve others.
Teaser
In this episode… the formation of Type I Collagen cross-links are primarily driven by a specific enzyme that requires lysine. Arginine, meanwhile, is synthesized in muscle and connective tissue development, but injury rapidly depletes reserves and most people lack the quantities of arginine necessary for collagen synthesis. So in the case of an injury, it has been proposed that arginine should actually be considered an essential amino acid…
Episode Intro
Learn II Perform: Practical lessons so that you can immediately learn to optimize your health, happiness, and performance.
Gratitude
Today’s gratitude expression goes to a great friend, Morgan Ziegler. While she has always challenged my thinking and pushed me to learn more, work harder, and become a better person, she is also the reason I ran an ultramarathon with no training. After a modest 7-mile run, she recommended I run a half-marathon. She planted the seed, and within a few hours, I had signed up for the Calgary Marathon Ultra 50K [1]. As it turns out, that was an incredible experience, a great test of my resilience, and it provided me with an opportunity to test out my soft-tissue injury rehab philosophy firsthand. So today’s thank you is to Morgan for that, and all the other lessons I’ve learned from her.
Topic Introduction
Alright, on to injuries. Soft-tissue injuries consist of damage sustained to muscles, ligaments and tendons, such as sprains, strains, and tears. These injuries are extremely prevalent, accounting for 35-50% of all workplace injuries, resulting in hundreds of thousands of Americans missing work every year [2, 3]. In sports, these injuries make up close to 90% of all injuries [4, 5]. Minor, grade one injuries typically require 1-2 weeks to recover; moderate, grade two injuries typically require 3-4 weeks, if not longer; and severe, grade three injuries may take many months [6].
After being proposed in 1978 by Dr. Gabe Mirkin, the RICE protocol – rest, ice, compression, and elevate has been the gold standard [7]. In fact, the most reputable sources including WebMD, Harvard Health and Michigan Medicine at the University of Michigan all recommend RICE and anti-inflammatory drugs, such as Ibuprofen and Naproxen, found in Advil and Aleve, respectively [8-10]. However, Dr. Mirkin has actually come out and claimed that RICE may actually be impairing your ability to recover, putting the mainstream practice of injury recovery into question.
So What’s The Bottom Line
Conventional rehab protocols are delaying your recovery, preventing you from optimizing your health, happiness, and performance. However, by following three rules, you can turbo charge your recovery and return high intensity and high performance activities:
1. Don’t fight inflammation
2. Supplement with collagen peptides and essential amino acids
3. Move more and eat less often
1. Don’t fight inflammation
Inflammation is the body’s natural response to injury and infection by increasing blood flow to the site of the injury [11]. As explained in depth in a fantastic 2013 research paper, inflammation enables the optimal amount of inflammatory cells, nutrients, and minerals to be distributed to the damaged location [12]. The natural response to a soft tissue injury has been described with three distinct phases: the acute inflammatory phase, the regenerative or repair phase, and tissue remodeling [13]. In this section, we are focused on the inflammatory phase, which begins immediately and typically lasts 48-72 hours.
During this phase, a variety of complicated processes take place. First, blood directed to the injury forms platelet-rich clots that release growth factors that stimulate healing. These processes include the attraction and proliferation of immune cells, development of new blood vessels to increase blood flow, and the development of cells responsible for collagen and cartilage development [13]. Additionally, these growth factors are necessary to initiate the removal of cellular debris and begin matrix turnover, which is essentially the replacement of damaged tissue with newly generated tissue.
Of course, the mechanisms of healing are actually far more complex than this, but here is a metaphor to make it easier to understand. Consider a natural disaster, such as Hurricane Katrina in 2005. Immediate damage was sustained, devastating an entire area. In response, the Red Cross employed more than 245,000 disaster relief workers to assist in immediate support for people, removal of debris, and cleaning of the area, eventually rebuilding the community [14]. The Red Cross’ disaster team is what inflammation is in the body.
Now, to supply the necessary healing molecules, a significant increase in fluids delivered to the injured area is required, resulting in swelling, and ultimately, pain due to the compression and activation of afferent neurons [15]. When we combat inflammation, while we may subjectively feel as though we are helping our body recover and feel better, we are actually inhibiting certain cellular processes necessary for tissue repair [16].
So why are we constantly told to follow the RICE protocol – rest, ice, compression, and elevation? And why are we also prescribed non-steroidal anti-inflammatory drugs, or NSAIDS? Well, with the exception of rest, all of these mechanisms function in the same manner – to reduce inflammation and therefore reduce pain [17-19]. Ice works by inducing vasoconstriction, the body’s natural response to cold exposure, in which the blood vessels below the skin are restricted [20]. Therefore, by applying ice to an injury, you are affectively forcing the blood vessels to constrict, preventing the influx of blood, inflammatory cells, nutrients, and minerals. Compression works to provide physical residence to the build-up of fluid at the injured location, preventing excessive inflammation, meanwhile elevation uses gravity to decrease pressure in the blood and drain inflammatory fluids [19].
Now let’s talk about NSAIDs. A terrific 2011 paper warns against the use of NSAIDs, concluding that when used, “the histological, biochemical, and biomechanical properties of ligament healing are inhibited” [13]. A simplified explanation is that NSAIDs function by specifically blocking enzymes that catalyze necessary reactions for ligament healing to occur. Another concern is that the pain-relieving effect may trick the user into thinking they are healthier than they actually are, leading to a premature return to activity. The key point is that there are numerous studies indicating that the use of NSAIDs inhibits ligament healing and results in weakened mechanical strength [13, 21, 22].
So, to reiterate, RICE and NSAIDs are treatments for the symptoms of an injury, the pain and swelling, but not for the root cause of the injury. Yes, they will reduce swelling, therefore reducing pain and enabling faster and more tolerable return to some level of activity. However, in terms of a full recovery, they are preventing the body from healing – they are delaying the actual mechanisms of recovery.
Back to our Red Cross example. Hurricane Katrina just hit. Rather than immediately sending as many Red Cross workers as possible to the damaged area to begin the healing and recovery process, the government tries to restrict the emergency response as much as possible, blocking travel in and out of New Orleans. Think about how much longer it would take for people to get the necessary help and assistance they need. This is what trying to reduce inflammation does to your recovery.
2. Supplement with collagen peptides and essential amino acids
Okay, now let’s transition into the second phase of recovery, tissue regeneration [13]. In this section, we are going to talk a lot about collagen peptides and amino acids. Let’s start with collagen.
Collagen is a family of proteins that makes up connective tissue, and is found abundantly in the body’s muscle, skin, tendons, ligaments, cartilage, bones, and much more. Peptides are short chain amino acids, which are known as the building blocks of proteins, and therefore, collagen. Taken in higher doses, there are numerous studies demonstrating the incredible healing potential of collagen – a few of which I will include in the show notes on the website [23-26].
So what is collagen’s role in soft tissue injury recovery? Well, after an injury has occurred, various types of collagen, proteins, and amino acids are deposited at the site of the injury [13]. This is what’s called a collagen matrix, a structure of collagen fibers, that forms the soft tissue. In recovery from an injury, this collagen matrix is repeatedly overturned through degradation and synthesis. Basically, the older and damaged tissues are broken down and recycled, and then new tissue is generated to replace it in the matrix. To complete this process, Type I Collagen and Type III Collagen are most commonly used for the synthesis. Naturally, most tissue is composed of Type I collagen, providing strength and stability. However, after an injury, Type III collagen is typically synthesized at a considerably greater rate than Type I. In the final phase of tissue remodeling, it is observed, however, that Type I collagen becomes the primary source for synthesis yet again, helping to return to maximize strength and stability [12].
While collagen is produced by the body in response to an injury, it is required in high quantities for tissue regeneration. For many people, collagen levels in the body may be insufficient, therefore limiting tissue recovery and regeneration. This is where supplementation with collagen peptides come in, because oral collagen consumption has been shown to be effectively absorbed [27]. And as mentioned earlier, there are numerous studies linking collagen supplementation to improved healing [23-26]. But collagen itself isn’t sufficient to optimize healing, because the formation of collagen fibers requires other factors to enable the process, including a few key amino acids.
Collagen fibers that form most soft tissue have a triple helical domain formed from three amino acid chains, each with around 1,000 amino acid residues [12]. In particular, these chains feature large quantities of glycine and proline. Proline appears to be particularly important, as wounds have been observed to have 30-50% more proline than typical plasma levels, indicating an important role in injury healing [28]. But supplementing with proline alone isn’t enough, because proline’s function is dependent on an enzymatic reaction that requires oxygen, iron, and vitamin C.
This leads to further evidence of the value of Vitamin C in injury recovery, as well as maintaining an overall nutrient profile and healthy diet. Vitamin C has been shown to increase the natural production of collagen, meanwhile another mineral, Zinc, is associated with optimal immune system functionality, both key pieces to injury recovery [29, 30]. Without exploring the entire nutrient profile, let’s just note that it’s important to have a well-balanced diet to best ensure that you have all the vitamins and minerals necessary to facilitate to many different cellular processes. This should always be a priority, but especially so when injured.
Now, in addition to proline, there are other important amino acids that I want to highlight in this episode, lysine and arginine. It has been shown that the formation of Type I Collagen cross-links are primarily driven by a specific enzyme that requires lysine. Arginine, meanwhile, is synthesized in muscle and connective tissue development, but injury rapidly depletes reserves and most people lack the quantities of arginine necessary for collagen synthesis [28]. So in the case of an injury, it has been proposed that arginine should actually be considered an essential amino acid and therefore should be supplemented. In fact, arginine supplementation has been shown to improve recovery in many animal studies, and in two additional human studies, it was observed that arginine supplementation increased collagen deposition [28, 31, 32].
That’s as deep as we are going today, but may be a topic for further exploration in the future. At the end of this episode, I will recap what are the important supplements that you should take to maximize your recovery.
3. Move more and eat less often
Generally, after sustaining an injury, it is recommended to completely immobilize the injured area, focusing on rest. Often with many injuries, splints, casts, and braces are provided to prevent any movement of the injured tissue. Extensive research tells us that this may be hindering the ability to recover from an injury [13]. Let’s dive in.
Regarding ligament injuries, research shows that immobilizing a joint breaks down existing collagen faster, but decreases collagen rebuilding [13]. Additionally, it has also been found that collagen fibers are more frequently disorganized, potentially compromising their strength and integrity [33, 34]. A theory is that complete immobilization forces the tissues to switch from an anabolic state to a catabolic state [13]. Just to clarify, an anabolic state promotes tissue growth and repair, hence anabolic steroids, whereas catabolic breaks down tissue.
A 1995 study on dogs with injured ligaments found that, as injured dogs exercised more, they had an increase in total collagen fibers and the fibers had thicker diameters [35]. When ligament tissued were not loaded through exercise, the breakdown of the collagen matrix occurred at a faster rate than the rebuilding. This has led to the conclusion that controlled return to activity, specifically by applying strategic loading to injured tissues, promotes drastic improvements in overall recovery, tissue size, strength, and proper formation [36].
An explanation of the physiology offered is that mobility increases blood flow to the injured tissue, thereby increasing the delivery of nutrients and oxygen required for recovery [13]. Meanwhile, the strain provided forces the tissues to adapt to the stress and repair accordingly. Similar to working out to grow bigger and stronger, in which muscle fibers experience microtears during exercise, the strain provided from mobility forces the tissues to grow stronger. Many human studies and systematic reviews have continually concluded that mobilization improves all aspect of recovery – links to some more studies will be in the show notes [35, 37, 38].
The last part of this section is to eat less often – aka to fast. Now I’m going to be completely honest, I haven’t encountered much literature on the benefits of fasting for injury recovery, particularly for soft tissue injuries, so this is a bit more of a theory on my end. But what we know is that fasting enables the body’s natural recovery processes to instigate through autophagy. By going without food for extended periods of time, the body is able to take a break from regular metabolic processes and divert its attention to cellular repair, removing cellular debris, and healing. For a complete review of how fasting works, I highly recommend you check out episode six for some more insights.
My personal experience
Alright, now for the fun story time – my experience testing out these principles after running the Ultra 50K that I mentioned at the start of this episode.
When I finished the 50K, I was hurting big time. I could barely walk, stand, or move… every joint in my lower body hurt with every step. Despite a lifetime of competitive athletics including a collegiate and pro hockey career, my body had never felt so broken. Getting up the next morning, I could barely stand. Putting any weight onto EITHER foot resulted in excruciating pain. Standing hurt, walking really hurt, and stairs were the absolute worst. Walking to the kitchen felt like a marathon in itself.
So I began to pay closer attention to the pain. I realized that apart from a bit of stiffness, my lower back, hips, groins, hamstrings, quads, knees, calves, and feet were relatively fine. For the most part, they didn’t feel much different than I would after a typical workout. But my ankles, they were excruciating. Both were swollen and had almost no mobility. I found myself walking and standing extremely awkwardly to try and minimize the stress on the injured areas.
Through some research and careful attention to my pain, I identified the primary issue to be my Anterior TaloFibular Ligament, the ATFL, with a secondary area of pain being the CalcaneoFibular Ligament, the CFL [39]. And no, not the Canadian Football League. This makes sense, because the ATFL is the main ligament and upon partial or complete tearing, the CFL is often strained while compensating [40]. When considering my symptoms – swelling, high pain, extreme difficulty load bearing, and reduced mobility – what I was experiencing in both ankles was equivalent to a typical Grade II sprain or strain, which is indicative of a partially torn ligament [40-42].
Now, it is impossible for me to verify the extent of injury as it was completely subjective, so don’t take my experience as conclusive evidence. Unfortunately, I couldn’t obtain objective proof of my injuries because in Canada, to get a free MRI, it is often a year-long waiting list, so that was not an option. Meanwhile, private MRIs are expensive and, in my case, completely unnecessary. The best I could have done was go to a doctor for a second opinion, but I was content to perform a self-assessment. And I didn’t want to leave my house.
So, my assessment was that I damaged my ATFL – possibly suffering partial tears in both ankles – and further damaged both CFLs – likely stretching the ligaments akin to a minor strain. So this was the strategy I implemented.
First of all, I didn’t use NSAIDs with the exception of just one Advil in the first morning and Voltaren gel applied twice. These NSAIDs were used initially, but upon researching injury recovery, I immediately ceased use. I also refused to do RICE – absolutely no ice or compression the entire time. The only exception was when I elevated my legs up the wall twice while meditating, but that was it.
For supplementation, I began with about 10g a day of hydrolyzed collagen peptides, 10g of BCAAs, and 24g of whey protein, in addition to a whole-foods, plant-based diet. The collagen peptides I used were from Purely Inspired, featuring Collagen Types I and III, and a diverse amino acid profile, including about 1,500mg of Proline, 800mg of Lysine, and about 1,400mg of Arginine per serving [43, 44]. The BCAAs were by Cellucor, and featured some additional lysine and arginine [45]. The protein meanwhile, by Kaizen Naturals, also had a diverse amino acid profile with about 700mg Arginine, 2,300mg Lysine, and 500mg Proline per serving [46].
Finally, I attempted to mobilize as much as possible. I painfully limped down the green strip behind my house everyday with my dog, and tried to move around the house as much as possible. In terms of fasting, I restricted my eating window to four hours from what had previously been an 8-hour feeding windows every day.
So, what happened? Well, for the first three days, I could not put any weight onto EITHER ankle without significant pain. Even just leaning against a wall or table and supporting myself produced a constant pain that was only relieved by sitting down and completely removing the load. Despite no progress in the first 72 hours, this made sense, because as we discussed earlier, the acute inflammatory phase typically lasts 48-72 hours [13].
After the third day, though, I was unsatisfied with no progress, and a little bit impatient. So I decided to increase my collagen peptide intake to 40g daily – quadrupling the previous amount, increasing BCAAs to 20g daily – doubling the previous intake, and reduce my feeding window to one hour a day, therefore fasting 23 hours of every day. I also decided to supplement with an additional 20mg of Zinc and 1,000mg of Vitamin C. Everything else in my recovery regimen stayed the same. No RICE, no NSAIDs, and as much movement as possible.
On the fourth day, I already noticed a considerable improvement in my right ankle, which was able to bear most loads and walk comfortably. My left ankle was just as bad as before, although the pain was a bit different. Instead of being localized at my ATFL and CFL, the pain migrated to my inner ankle and lower shin, likely due to the stress caused from overcompensation and walking and standing in abnormal positions.
By day 5, I only experienced mild discomfort walking and going up and down stairs. I even felt comfortable enough to jog up stairs and take larger steps, two stairs at a time. Imagine that – celebrating two steps at a time! But consider this, within 48 hours, I went from not walking to resuming upper body workouts, moving regularly, and drastically improving my range of motion and comfort with my rehab exercises. To increase ankle mobility, I focused primarily on mobility and strengthening exercises focused on plantarflexion and dorsiflexion following an excellent rehab protocol available online by OrthoInfo by the American Academy of Orthopedic Surgeons [47]. The link will be in the show notes.
On day 6, I took our dog for a two mile walk with only slight discomfort. I tested out jogging, but wasn’t quite ready for increased load-bearing. Day 8, I had my first shift at my new job and was on my feet for four hours straight, but my ankles actually felt relatively good, while wearing dress shoes no less.
Day 9: I woke up with no pain or discomfort at all. Went for a light jog and was completely pain-free! By day 11, I concluded that I was 100% recovered and I did my first High intensity workout, a HIIT workout including squat jumps, lunges, and high knees. Again, pain-free – although I must admit, my cardio was awful!
Day 12 – I did 45 minutes of max intensity hill sprints. Again, ankles were 100%, cardio? Not so much. But what’s important is that the HIIT workout and hill sprints applied intense loading at variable angles and in compromised positions, typically the most demanding exercises in terms of ankle stability, yet I felt 100% healthy.
Take what you want out of my story, but this is my experience:
After running the ultramarathon, I had the symptoms in both ankles that matched grade II sprains. To heal from one grade II ankle sprain is expected to last at least 3-4 weeks, with some sources concluding that 4-6 weeks is required for recovery [48]. Now, consider I had damaged both ankles. The fact that I saw no improvement after 72 hours indicates that the damage done was more severe than simple inflammation from overuse. But just nine days after the ultramarathon, I was running again, and in 11 days, I had returned to full-intensity workouts. Not only did I recover fully, but I did it in less than half the expected time based on my initial symptoms.
Now, I’m not a doctor, but I believe in the science and after experiencing what was a surreal recovery process, I am a believer in this rehab protocol.
So What Can You Do
Follow these rules to turbocharge your recovery from a soft-tissue injury, whether that be an acute injury, chronic inflammation, joint issues, or a nagging injury. But first, a disclaimer – I am not a doctor and this is not medical advice. Before making drastic lifestyle or dietary changes, you are always recommended to speak with a medical professional.
Alright, here are the three rules:
1. Don’t fight inflammation
Don’t follow RICE. No Ice, no compression, no elevation. Unless you really enjoy doing your legs up a wall pose like I do. Also, don’t take any NSAIDs. No Advil, Alleve, or any other anti-inflammatory. Of course, there are exceptions to this rule. If the pain is intolerable, preventing you from sleeping, or you are required to be functional for work or another task, then do what is necessary to reduce inflammation. But the key is to realize that the more you reduce inflammation, the longer your recovery will be. Try to limit RICE and NSAIDs as much as possible.
2. Supplement with collagen peptides and amino acids
This is easy to do and relatively cheap. Pharmacies, supplement stores, Walmart, Amazon, and many other places will have a good selection. Ideally, look for collagen peptides from quality sources, grass-fed and pasture-raised, and look for ones that have Type I and Type III collagen. For severe injuries, I recommend 40g a day of collagen peptides. For minor injuries or inflammation, 10-20g daily is probably an appropriate amount.
For amino acids, look to get essential amino acids that have a wider profile, not strictly BCAAs which may exclude some of the most desirable amino acids such as proline, arginine and lysine. Also, look for the amino acid profiles in protein powders, which provide another excellent source of essential amino acids.
Additionally, make sure to follow a healthy diet full of vitamins and minerals from whole-food sources. If you have a diet low in Vitamin C, I would highly recommend supplementing it, and would also consider supplementing Zinc. However, with an appropriate diet, these needs should be met.
For the specific supplements I used, they will be posted in the show notes [43-46]. References 43-46 for those interested.
3. Move more and eat less often
Don’t immobilize your injury. Instead, use it as much as possible and tolerable. Test out your range of motion and begin with stretching exercises. Slowly add resistance to build strain. As best as possible, try to maintain everyday use so that the tissue can appropriately rebuild to meet the demands of your daily life.
I also recommend implementing intermittent fasting as best as you can tolerate it. If that means your feeding window is 10 hours, that is fine. If you can go down to four hours, I would recommend it. But with that said, I’m not completely sold on whether or not fasting effectively contributes to injury recovery.
And that’s it. Your body is the best healer on the planet. Let it do what it was designed to do. Your job is to help out by providing the tools and resources it needs, and do your best not to interrupt the natural healing processes.
And of course, feel free to adapt this regimen as required for your lifestyle and as you are comfortable.
To close, I’d like to share a quote from Dr. Mark Hyman about understanding the approach to treating the root cause of injuries and illnesses, rather than attending to the symptoms: “The way modern medicine operates is like trying to diagnose what’s wrong with your car by listening to the noise it makes instead of looking under the hood” [49, 50].
Episode Outro
To discover more, the full transcript of this episode with all citations is available on the website and you can also contact me on social media with any questions or comments. If you found this episode useful or think that it may help someone else, I encourage you to pass it along.
Thank you all for joining me on this journey to lifelong health, happiness, and higher performance. And remember, always be grateful, love yourself, and serve others.
References
[1] The Calgary Marathon / Canada’s Longest Running Marathon. (2019). Calgary Marathon. Retrieved November 3, 2020, from https://calgarymarathon.com/
[45] BCAA Sport. (2020). Cellucor. Retrieved November 4, 2020, from https://cellucor.com/products/bcaa-sport
[46] Kaizen Naturals Grass-Fed Whey Protein Powder, NSF Certified, Decadent Chocolate, 840g. (2020). Amazon.ca. Retrieved November 4, 2020, from https://www.amazon.ca/Kaizen-Naturals-Grass-Fed-Certified-Chocolate/dp/B07MC18VJV [47] Foot and ankle conditioning program. (2012). OrthoInfo. Retrieved November 4, 2020, from https://orthoinfo.aaos.org/en/recovery/foot-and-ankle-conditioning-program/ [48] UVM Health Network – CVMC. (2016, August 31). How to come back stronger and faster after an ankle sprain. Central Vermont Medical Center. https://www.cvmc.org/blog/rehabilitation-therapy/how-come-back-stronger-and-faster-after-ankle-sprain#:~:text=Grade%202%20ankle%20sprains%20involve,ligament%20and%20possible%20bone%20fracture. [49] Quotes. (2020). GoodReads, Inc. Retrieved November 4, 2020, from https://www.goodreads.com/author/quotes/59919.Mark_Hyman [50] Dr. Mark Hyman. (2020). Dr. Mark Hyman. Retrieved November 4, 2020, from https://drhyman.com/
