Setbacks are an inevitable part of the long-term training process. Progress is driven by applying more training stimulus over time to induce adaptation — and this stimulus always carries an inherent risk of injury. Although there are effective strategies we can use to mitigate the risk of injury, preventing injuries entirely is impossible. Furthermore, preventing the experience of pain is not only impossible, but undesirable, given the importance of pain as a protective mechanism for survival.
Pain and adversity are therefore a part of life, a normal human experience. Learning how to respond to and overcome these situations is what matters most. Setting the expectation that such setbacks are part of the process and cultivating acceptance of the situation allows us to respond skilfully and, with time, return to our normal life and desired activities. This article aims to discuss some of the nuances of returning to “baseline” fitness levels following an injury and the mindset required to execute an effective rehabilitation plan.
For the purposes of this article, we’ll focus on acute injury that results in a sudden onset of symptoms that can be attributed to an identifiable mechanism of injury, ultimately producing a decrease in performance.
The first step in managing an acute injury is to attempt to stay calm — which is often much easier said than done. Experiencing an unexpected sensation during training often leads to ‘worst case scenario’ thinking known as catastrophizing, which perpetuates fear and anxiety. Catastrophizing, defined as ‘the tendency to focus on pain and negatively evaluate one’s ability to deal with pain’, has been shown to increase pain intensity, decrease activity levels, and is associated with the development of persistent pain. It is important to understand that the experience of pain is complex, always resulting from multiple factors (never just one single “problem”). It also has a variable (often poor) correlation with tissue damage. So even in the setting of an acute injury, there are always multiple inputs driving the experience of pain.
Furthermore, an acute pain experience can also occur in the absence of objective tissue damage, and discerning a single structural cause with imaging like X-rays or MRIs can be quite difficult. This is because we find lots of pain-free individuals with evidence of rotator cuff tears, intervertebral disc degeneration, labral tears, cartilage changes, and many other ‘abnormal’ findings on imaging. So, when individuals experience pain it can be tempting to immediately blame the “objective” abnormalities on imaging, but it can be hard (if not impossible) to know whether those findings were present all along without symptoms, and the new pain has developed for another reason entirely.
When we recognize that several factors contribute to pain, we can appreciate how things like psychological stress, poor sleep, and fatigue can contribute to an exacerbation of pain symptoms. This recognition can help decrease the perception of “danger” associated with pain and should provide us reassurance.
Laying the blame on a specific tissue can create fear about the ability to train safely. Deconditioning (loss of fitness, detraining) occurs when this fear leads to the avoidance of loading. Similarly, ignoring these sensations completely and continuing to load aggressively can also lead to exacerbation of symptoms, which often delays the return to normal training. The goal is to find the appropriate dose of training stimulus to maintain as much fitness as possible while creating a positive environment for healing.
Why Is This Information Important?
Fear of re-injury, doing further harm, “wasting time”, and not being able to return to previous levels of performance are thoughts that are likely to arise after an injury. With an understanding that symptoms are not typically indicative of further or ongoing damage, we can cultivate an acceptance of tolerable levels of symptoms during the rehab process. It is important to note that the level of “tolerable” symptoms will be subjective and specific to each individual. In other words, an increase in symptoms doesn’t necessarily mean you are doing more harm or experiencing a new setback.
Outside life stress, fear, catastrophizing, fatigue, and ineffective coping strategies are several factors that have a huge impact on the experience of symptoms day-to-day. Setting the expectation that the issue will get better with time promotes acceptance over the injury. Also, having a plan in place promotes a sense that the symptoms and process are within the individual’s control (rather than feeling helpless or dependent on others to “fix”). This internal sense of control is known as self-efficacy and is a major contributing factor for the resolution of symptoms. The sooner we can cultivate acceptance over the injury, the sooner we can get to work on the solution in an active manner.
Most non-contact musculoskeletal injuries are related to poor management of training load. Training load is defined as the cumulative amount of stress (physiological, psychological, or mechanical) placed on an individual from a single training session, or from multiple training sessions over a period of time. Training load can be further subdivided into external load (e.g., absolute weight on the barbell, sets, and reps) and internal load (the individual’s perceptual and physiological response to an external load; ‘how difficult was that session/set?’).
Tracking session RPE (Rating of Perceived Exertion) is likely a good idea and is very easy to implement. At the end of each training session, simply ask yourself, “How difficult was that session?” with 1 representing complete rest, and 10 representing the hardest session of your life. The rating is supposed to be subjective — this subjectivity is where the benefit lies, since it captures the all the “intangible” factors contributing to an individual’s total internal load at any given time. The idea is that if we are having multiple sessions in a row where the workload leaves us feeling like we’re on the brink of death, it may be wise to change course.
As an injured area starts feeling better, the temptation to jump back into normal training becomes almost irresistible. However, at this point the concepts of load management are as critical as ever because there is likely a period of deconditioning that occurs following an injury due to a decrease in performance levels. Returning to normal training without doing the necessary work to build back up to that level of training is associated with increased risk of injury due to a relative ‘spike’ in workload and can potentially be detrimental. Conversely, if we avoid loading completely (i.e., rest) for an extended period of time following an injury, then we risk unnecessary deconditioning, developing fear of movement, and becoming less resilient.
Embrace The Process
Although the timeline for recovery will vary depending on the injury, the process will require setting appropriate expectations. Based on the work of Thompson and Sunol, there are four different types of expectations:
- Predicted expectations: what the individual believes will occur.
- Ideal expectations: what the individual wants to occur.
- Normative expectations: what the individual believes should occur.
- Unformed expectations: the lack of a preconceived idea regarding a situation or intervention.
Predicted expectations are the most important to consider based on their association with outcomes related to the management of musculoskeletal pain conditions. In other words, your predicted expectations (such as believing an injury will get better, versus believing the area is permanently damaged) can influence outcomes of pain, function, and likelihood of returning to work following an injury.
In the context of sustaining an injury during training, the ideal expectation is to achieve full recovery as soon as possible. However, going into a training session expecting to perform at the same level as before the injury with no symptoms can quickly lead to frustration and discouragement. Controlling predicted expectations and operating from the premise of training to get back to baseline, rather than training for a performance-based goal (strength, hypertrophy, endurance, etc.) can help with embracing the process and acceptance of symptoms.
All of this is to say, our approach to adversity makes a substantial difference in outcomes. Recovering from an injury requires patience and an understanding that progress — both in rehab and in regular training — is made through an accumulation of small “wins” over time.
The process will not be easy, there will be setbacks, and there will be days where you feel defeated. Don’t let that discourage you. As long as you keep showing up and putting in the necessary work, you will get back to baseline and far beyond.