Have you ever incurred an injury and been told to take time off to ‘rest’ that particular structure? While I don’t discredit rest from being an integral part of the healing process, I will say this - it’s not enough.
I’ve been around many tennis settings where a player twists an ankle (an acute issue) or has some lingering shoulder pain (a chronic issue) and in both cases, he or she is advised to ‘get some rest’. Or worse yet, ‘just ice it’.
Here’s my proposed alternative: movement.
Not just any type of movement, but movement of the injured area. Movement into positions that might induce some pain. And do this as frequently as you can, especially early on in the healing process.
It’s obvious that it won’t be possible to place the same amount of load into the injured area right off the bat. What we need to do instead, is adapt the loading in a manner that promotes both tissue healing AND remodeling.
I will argue that not only does this accelerate the entire process - and allow a player to get back on the court sooner - it sets the stage for better physical preparedness in the future.
Keep in mind that I’m not a physical therapist. I’m coming at this topic with my strength coach hat on. And most of what I’ve learned in this post - which I’ll share below - come from the views of experienced therapists.
I’ll share these insights, sprinkle in my own experiences and shed some light on the research that supports this approach.
Motion is Lotion
I know this is a catchy rhyme - and a bit corny as well - but there’s truth to it. Before I dive deeper, here’s what my mentor - legendary track coach Dan Pfaff - has to say about this topic:
“There’s a myth or dogma - if you will - that when a chronic or acute injury occurs, that rest is the answer. If you rest long enough, the injury will heal itself and return to play will take care of itself. That’s not been my experience or research. There’s a remodeling process that goes on which is influenced by stimuli that you’re placing on these factors”.
All tissues are made up of cells and cells respond best to stimuli. I say best because if we’re talking about tissue remodeling, cell proliferation will occur whether we send a signal to a tissue or not. But there’s a massive cost associated with the latter outcome.
If we just rest, the remodeling process will occur but new tissue will be ‘laid down’ in a random and unorganized manner (studies have linked this process to scar tissue and tissue degeneration).
What we want to do instead, is use a stimulus - force in this case - to send very specific signals to the target tissues. This process is termed mechanotransduction:
“Mechanotransduction converts mechanical signals (loading) from the environment into biochemical signals. As a mechanical signal is transmitted to the microenvironment, it causes the physical perturbation of cells and deformation of the extracellular matrix.” (Wang et al 2020).
Mechanotransduction is important because it allows us to be very specific about the type of force we want the target tissue to experience. This provides a greater opportunity for a tissue to respond in a favorable manner.
If, for example, you’ve sprained your ankle, the tenocytes (tissues that make up a tendon) will be affected. We can then decide, given the severity of the sprain, how we want to apply force. We know that tendon responds well to various exercise modalities and loading parameters. Isometrics, traditional strength training and plyometrics, to name a few. So not only can we use these means to accelerate the healing process, we might also be able to make the structures surrounding the ankle more resilient (mitigating a re-injury in the future).
Move Right Away
The ‘movement’ process needs to get started as soon as possible. If you’re able to do it the next day, do so. Note - inflammation isn’t bad, it’s part of the healing process so don’t fear it.
There are various ways that this movement process can begin. On one end of the spectrum, we might have isometrics. This contraction type has been seen to provide an analgesic effect - with research indicating a relief in patellar tendon pain, for instance, of up to 45min (Rio et al 2017)!
This is preferred over things like rest and ice because of additional reasons beyond just pain relief, including:
Removing the fear of exercises or training (which brings about a host of positive psychological benefits to the athlete)
Seeing the injury in a different light - passive analgesia (rest and/or ice) imply tissue damage whereas active analgesia (movement) implies health, recovery, capacity and so on.
In general, isometrics can be a great start because we can also apply force to the specific tissue, at a given angle, for a certain period of time and we can modulate the amount of load throughout.
From my viewpoint, however, it’s not enough to simply use isometrics. We also need to consider what the final outcome is. In the case of a tennis player who’s incurred an acute ankle injury, they need to be able to handle forces during the unpredictable environment of on-court play.
Because playing tennis can include sliding, jumping, landing, explosively changing direction, along with a number of other movement demands. All of which happen under various velocities and force requirements.
Graded Exposure
We want to gradually expose the injured area to dynamic movements that - more and more - resemble what the player will see on the tennis court.
An example:
I’m actually bringing this entire topic up because a player I coach recently sprained his ankle (and was told to rest it). I took a different approach - explaining to him what the tissue healing + remodeling process entails.
After the sprain, we removed tennis for one week as he was fearful of making things worse. But instead of complete rest, we implemented various isometric movements, along with some low level mobility exercises, to get the joints moving, muscles activating and cells responding.
After the first week, we were back on the tennis court. I would have liked to get to this point sooner, but there were other logistical constraints that didn’t allow this to happen (midterms being one of them).
In any case, here’s what we did:
Adapted warm-up
Light tier (very low level) plyometrics (see video below)
Light stationary hitting
(Very) light tier plyometrics. We’re using leaps and bounds to gradually expose the tissues surrounding the ankle to stress. Hops (which are unilateral) would likely have been too much load, too soon.
The entire practice was 1 hour in length and was relatively easy overall. But it immediately built confidence in his ability to do a little more. Which allowed us to get back to an adapted version of our regular training regime.
In the two weeks since that encounter, he was able to practice 4 times, increasing the intensity of his movements (and the duration of these sessions), on each occasion. He also re-integrated his strength training program (adapted to accommodate the ankle + to further accelerate the remodeling process).
Yesterday, we went through another practice where we increased the movement demands. We did a variety of predictable movement drills. These entail patterns that allow for pre-planned movements. In other words, drills where you know ahead of time, where the ball is heading.
Apart from some fatigue and minor soreness (which are to be expected), things seem to be improving. We’re not out of the woods by any stretch, but it seems like we’re on the right track.
This IS NOT The Only Way
This is one way that you could do it, many others exist. But the principles should remain the same - rest is important, but it needs to be coupled with the appropriate stimuli/stress. This stress needs to progress in both exposure, intensity and duration - until we’re at a point where a full practice can be executed.
Of course the severity of the injury will dictate how long this process will take. In our case, it was a mild ankle sprain. I’ve worked with other players where the process was longer (partial tear of the supraspinatus). It was non-surgical but painful enough where we didn’t get back to full practices for close to 2 months.
But we didn’t stop training. Whatever we could continue doing in the gym we did (which was almost everything) and on top of that, we played tennis most days - using foam balls to start and progressing to real balls over an 8-week period.
Whether you like it or not, remodeling will take place. You can ‘just rest’ if you want, but according to science, not only will the process take longer, if the pain subsides (which is a big if), the transition back to play will be anything but smooth.