Should you rest after an injury?
Those of us of a certain age who spent some time in the UK will have come across some variation of ICE, RICE or PRICE for managing injuries: protect, rest, ice, compress and elevate (give or take one or two of those). I don’t know many people outside the sports massage and injury rehab world who were aware of the subsequent changes: MICE (mobilise) and POLICE (protect, optimally load, etc) and it seems even many within the sports injury and rehab world haven’t followed the very latest change to PEACE & LOVE in 2020:
Did you notice the trend? Rest has gradually been removed - and increasingly replaced with an emphasis on loading. But maybe your GP told you to rest and see if the pain went away - so what are you supposed to do?
I am a big believer in understanding our bodies (and everything, really) so that we can confidently make choices that work for us on a daily basis, so let’s start by explaining some of the processes that go on when you are injured:
Inflammation
Very much considered the root of all evil these days, inflammation is actually a very necessary and helpful response to injury or infection - notice how A stands for “avoid anti-inflammatories”? That’s because your body isn’t out to get you - if it has evolved a process of inflammation, it’s because it’s serving a purpose. Of course, when the system gets dysregulated, as it often is in these days of chronic stress and endocrine disruptors and processed foods and lack of sleep, inflammation gets triggered to fix a problem it is not designed to fix, which is why it’s such a buzzword at the moment - but I maintain that it’s not the inflammation itself that is the issue, but the stressor it is trying to respond to (unsuccessfully, because inflammation can’t fix the tension in your workplace caused by your horrible boss).
Inflammation is what happens in the first few days after an injury, and its purpose is to stop bleeding, clear away damaged tissues and bring nutrients to the area to build new tissue. You clearly don’t want to get in the way of that!
So do you need to rest during the inflammation phase? Well, think about what the body is trying to achieve:
we want to stop the bleeding, so we want to avoid reopening the wound, which might mean rest - or rather, P for protection; if you play a contact sport, you might want to hold off on that until your scabs have come off (on their own - no picking!)
we want to promote circulation (that’s the V for vascularisation), so movement is definitely a good idea - but remember the E for elevation; if your injury is in your lower leg, maybe you don’t want to do an activity that requires a tonne of standing, which would make it harder to get that blood and lymph flowing back up through the heart
So really, we’re not talking about rest but sensible, informed exercise modification.
Proliferation
This is where things get interesting. This starts at the same time as inflammation, but comes into its own when that phase has died down, and the body can focus on rebuilding that tissue. This is where my favourite fun fact comes in: did you know we are born without kneecaps? When we are born, our kneecaps are just little lumps of cartilage encased in the tendon of our thigh muscles - but as we grow, and move, that cartilage senses the pressure on it from the muscles moving, and gets the signal that it needs to develop into something stronger. Our body is constantly sensing and adapting to what it feels - so guess what, if you want your newly regenerated tissue to grow back strong and mobile, you’re going to have to tell it that you plan to load it and move it… by loading it and moving it!
How much? Well, the rule of thumb is not to go beyond a 4/10 on the pain scale. I know, I know - it’s so hard to know where your pain is on the pain scale. This might sound ridiculous but I actually often use this joke pain scale in my head when evaluating my own pain:
Honestly the distinction between “Bees?” and “Bees!” has genuinely served me. When I am acting more professional, though, I tell my clients: 4/10 is a pain or discomfort you’re aware of but can work through without gritting your teeth or holding your breath. I usually add that the pain should subside once the exercise stops, and should not be sharp, stabbing, or hot and angry. It should feel like you are targeting a weak area, but not irritating it. Maybe you’ll describe it more as an “awareness” of the injured area than “pain”.
If it feels scary, it might be fine and causing no damage, but I’d advise regressing the exercise and maybe asking your physio for a progression that feels like less of a jump - if your nervous system is detecting threat, the tissues aren’t going to heal the way we’d like them to. Better to take the scenic route and enjoy the ride, rather than arrive early and so stressed you can’t hold a conversation (or return to your sport). See that O for optimism? That’s because your nervous system plays an important role in governing all these healing processes - sure, it sucks to be injured, and I’m the last person to advocate for toxic positivity, but what I’m saying is that if you don’t feel confident in your rehab process - change the process to one you do feel confident in! You’re going to have to really challenge these tissues and you can’t do that if you don’t feel safe.
Remodelling
After about 3 weeks, and up to about a year, the remodelling phase is taking place; as the name suggests, this is where those somewhat temporary tissues get replaced by more permanent ones. As above, this is really where you want to be telling the body that you’d really love for those tissues to be strong and pliable.
As you can imagine, there is a big difference between tissues at week 3 and tissues at week 51 - so you will need to adjust the load accordingly. But load you must! For many injuries, you will be out of pain by this stage, but may still feel restricted, so while you may not be at such a high risk of re-injury, I would strongly advise working with a professional through this phase who can test and retest key measurements and ensure the interventions are having their desired effect (ok, that massage might have made that calf strain feel less tight - but is it strong enough to go for a run or was that tension there to protect tissues that weren’t yet strong enough?).
This is the phase that makes me tell people: if your rehab is good it should feel like the hardest workouts you’ve ever done, not “time off” your training programme. A well-designed and carried-out rehab programme leaves you feeling stronger than before the injury, and excited to return to your sport. If you don’t feel ready, physically or emotionally, you’re not done yet - and that’s fine!
The caveats
While I hope this has made it clear why rest is no longer being recommended following most injuries, the bottom line is always safety: if you feel that your injury, or the pain you are experiencing, make you unsafe to yourself or others, of course that may require rest. I work with dancers, and often the injured dancer would be safe to dance, but because their injury may affect how they lift or hold a partner, I have to advise they sit that number out. It’s why I may advise someone switch from a road cycling session to a stationary bike session: cycling may not pose a risk to that particular injury, but a fall may be more likely or have more problematic repercussions if the cyclist is already injured.
Pain is also a huge factor: your nervous system does not like being in pain and it can distract you (making you unsafe if you are engaged in other tasks) or cause emotional trauma. So even if physically you can and should exercise, the level of pain you are in may mean you are better off resting until the pain subsides (but, as always, remaining as active as possible is a good idea, even if all you can manage is a gentle walk around the block). If this is the case, it’s a great time to tick off the E of PEACE & LOVE: education. Learn about your injury, learn about your pain, look up professionals in your area or online who can help you - so you’re resting but not totally checked out of the process or your body. Hopefully this post has also contributed, and of course know you can always reach out if you have questions or just want to bounce some ideas off me.
Happy healing!