Nutrition for Injury Recovery: Bounce back to training
During September last year, an unfortunate mountain bike accident left me in hospital for three days with a 10cm gash above my right knee (severing my favourite muscle – the VMO), a fractured right thumb and a 5cm cut above my left eye. After an operation to sew up my quadriceps and pin my thumb, I was left with ample time (and an appropriate mindset) to investigate optimum nutrition therapy post injury. While my story may be more than your average calf strain during running, we can apply the same principles to more significant injuries. In this article I would like to discuss mechanisms of injury healing and how that may affect what nutrition we need, optimal nutrition post injury, what to avoid and issues with determining energy intake during recovery.
We can break up injury healing into three steps: inflammation, proliferation and maturation/remodelling. While it is uncomfortable and usually results in swelling, the inflammatory process is crucial for your body to remove damaged cells and begin tissue repair. The timeframe for inflammation depends on the severity of the injury and is longer for broken bone (14-21 days), but it is for soft tissue (approximately three days). In the proliferation phase, collagen is formed and granulation occurs (laying down of new connective tissue and tiny blood vessels). This may take three weeks or more. Finally, the maturation/remodelling stage, which may last two years, allows new collagen to be synthesised and results in the formation of scar tissue.
Why is it important to know this Pete?
We often see inflammation, in particular, as a burden. It stops you training, it reduces range of motion and quite frankly – it hurts. But we need to understand that inflammation is a normal biological response and one that more recent research suggests should not to be trifled with. A review article by physiotherapist Dr Bahram Jam questions the use of ice and non-steroidal anti-inflammatory drugs (NSAIDS) e.g. ibuprofen. Drawing results from recent research studies that suggest topical cooling (ice) and NSAID use on a recent injury may have the potential to delay healing of muscle tissue and increase reoccurrence of injury (Jam, 2014a, 2014b). Please note I am merely using this as evidence for the importance of inflammation phase. Please take your physiotherapist or doctor’s advice on the best course of action for you when recovering from injury.
Can we reduce inflammation through diet and is this helpful?
The answer to these questions is yes, and more likely when long-term or chronic inflammation is present (post the acute inflammatory stage). There are a number of foods that may play a role in reducing inflammation. These popular anti-inflammatory foods include Omega-3 polyunsaturated fatty acids (PUFAs), monounsaturated fats (MUFAs), fruits and vegetables (particularly carotenoid-containing bright orange and dark green cruciferous vegetables), fibre, turmeric and garlic (Franz, 2014; Galland, 2010; Tilg, 2015). Whereas pro-inflammatory foods include saturated fatty acids (SFAs), low fibre/refined carbohydrates and diets with a high Omega-6 to Omega-3 ratio (Galland, 2010).
How do we get these foods in our diet?
One of the most highly praised diets, the Mediterranean diet, is also anti-inflammatory. The Mediterranean diet focuses on a high vegetable and fruit content with legumes, whole grains, fish, nuts, olive oil and small amounts of full-fat dairy, meat and red wine. Further anti-inflammatory additions you could make to this diet include black tea and flaxseed (linseed) (Galland, 2010). The consumption of anti-inflammatory foods may also play a role in maintaining functionality of the immune system
(Tilg, 2015). Maintaining a healthy immune system is an important consideration for those who may be out of action due to an infection. Those who have ever contracted a staph infection from an old razor know what I’m talking about. However, more research is required in this area.
“The consumption of anti-inflammatory foods may also play a role in maintaining functionality of
the immune system.” – Tilg, 2005
I know, you are all thinking it: what about supplements?
Nutrition research is ongoing regarding isolating specific nutrients, and most of that research would suggest you are better off going to the source for your vitamins and minerals. That is – eating whole foods, particularly your vegetables like mum always told you to do. There is evidence to suggest supplementing omega-3 PUFAs to improve intake (if high omega-3 fish aren’t available) and to improve the omega-3:omega-6 ratio may promote an anti-inflammatory effect (Galland, 2010). Other supplements have some evidence in injury recovery, though when considering supplementation, you always have to ask yourself – 1) is my diet deficient in this? 2) Does my blood test show I am deficient? 3) If so, can I get it from whole foods? 4) Will this affect any medications I am taking? If you are not sure, please ask your doctor or dietitian.
Similar to when we want to increase muscle, we need to have adequate protein to recover from injury. Adequate protein equals adequate amino acids (the building blocks of protein). No, not peptides – no peptides to see here (though peptide links or rather bonds join amino acids together to form proteins). If we have a muscle injury, we need to ensure adequate protein to promote healing. For most Australian’s this isn’t an issue. Though if you are on a restrictive nutrition plan, are vegan or vegetarian, or a large athlete in hospital then you need to take extra steps to ensure adequate intake. Just to recap, good protein sources include lean meat, fish, dairy, legumes, soy products (including tofu), nuts, eggs, and some whole grains have more protein than others.
It is likely, as with muscle gain, that spreading protein intake over the day (i.e., over 3-4 meals) will allow better recovery. Research has shown that myofibrillar synthesis rate (or building of new muscle tissue) is promoted by a consistent supply of amino acids (protein) over the day (Areta et al., 2013). Whereas if we consume all of our protein in one meal, a) we can’t use it all for building new muscle (repair) and b) if we are in energy excess, some may be stored as fat. It should be noted that if you aren’t using a muscle (i.e. it is out of action and you can’t move it), its mass will deteriorate regardless of how much protein you throw at it.
So how much is ideal? Well again based on muscle building science, we can suggest that 20-30g protein per meal is sufficient to maximise gains (Moore et al., 2009). However, there will be variation between individuals, and those who are bigger/have more muscle to start with may need more protein. Depending on your particular circumstances, you may require between 0.8-1.5g protein/kg body mass, the higher the number, the more serious the injury. Any of the above protein sources listed above can be combined at your main meals to meet these requirements.
How does alcohol affect muscle rebuilding and recovery?
One food product that is going to counteract your ability to rebuild muscle is alcohol. While it is easy to think consuming alcohol won’t be a bad thing because you aren’t training, alcohol may reduce protein synthesis, making for a longer recovery time. Furthermore, the interaction of alcohol with certain medications (due to a common pathway of metabolism in the liver) is contraindicated. So save the alcohol for when you have fully recovered!
We often assume we need less energy when recovering from injury as we aren’t exercising. If you are in hospital and not moving much, then yes, your energy requirements may be lower than a normal rest day when you are working in your day job and completing household tasks. However, we need not underestimate the energy requirements of healing. In fact, the body may require 5-60% more energy than at rest when trying to heal an injury. This is particularly relevant with complex traumas and burns. So don’t cut your food intake right back below a standard rest day, because it is likely that you will need a slightly higher intake to support recovery. As stated earlier for protein, this may mean you will need some extra food if in hospital. So ask for a bowl of fruit instead of the bunch of flowers!
” Initial inflammation is important, though we can reduce chronic inflammation in the body by adhering to a Mediterranean diet.” – Peter Herzig
I know I hear you – “Pete I don’t want to increase weight when not training.” Weight gain is a common concern, particularly if the injury is debilitating and if you have a history of comfort eating. Your first priority post injury is to ensure consistent meal patterns through the day, including protein, carbohydrate and fats (particularly to allow absorption of fat-soluble vitamins). After the first week post-injury, you could go back to a standard rest day meal plan and begin weighing yourself weekly if you are concerned. However, I would suggest focusing on healthy eating and incorporating the foods described above, in the Mediterranean diet. Think about how good you are going to feel after eating all those vegetables!
So, ask for that bowl of fruit instead of the box of chocolates from concerned friends or family. Consider trading up that box of roses for a punnet of blueberries and raspberries, or any fruit that you are more likely to eat.
Initial inflammation is important, though we can reduce chronic inflammation in the body by adhering to a Mediterranean diet. Protein timing and amount is an important consideration for the rebuilding of muscle (when it can be used). Don’t cut your intake back just because you aren’t training, as your requirements may be more than you think. And finally, really focus on doing the best thing for your body, and you may just find you speed up the recovery process.
Areta, J. L., Burke, L. M., Ross, M. L., Camera, D. M., West, D. W., Broad, E. M., . . . Coffey, V. G. (2013). Timing and distribution of protein ingestion during prolonged recovery from resistance exercise alters myofibrillar protein synthesis. J Physiol, 591(9), 2319-2331. doi: 10.1113/jphysiol.2012.244897
Franz, M. (2014). Nutrition, Inflammation, and Diease. Today’s Dietitian, 16(2), 44-. http://www.todaysdietitian.com/newarchives/020314p44.shtml
Galland, L. (2010). Diet and inflammation. Nutr Clin Pract, 25(6), 634-640. doi: 10.1177/0884533610385703
Jam, B. (2014a). Questioning the use of ICE Given Inflammation is a Perfectly Healthy Response
Following Acute Musculoskeletal Injuries. http://www.aptei.ca/wp-content/uploads/ICE-Paper-2014.pdf
Jam, B. (2014b). Questioning the use of NSAIDs Given Inflammation is a Perfectly Healthy
Response Following Acute Musculoskeletal Injuries. http://www.aptei.ca/wp-content/uploads/NSAID-Paper-2014-3.pdf
Moore, D. R., Robinson, M. J., Fry, J. L., Tang, J. E., Glover, E. I., Wilkinson, S. B., . . . Phillips, S. M. (2009). Ingested protein dose response of muscle and albumin protein synthesis after resistance exercise in young men. Am J Clin Nutr, 89(1), 161-168. doi: 10.3945/ajcn.2008.26401
Tilg, H. (2015). Cruciferous vegetables: prototypic anti-inflammatory food components. Clinical Phytoscience, 1(1), 10. doi: 10.1186/s40816-015-0011-2