Most of us know exercise and activity are good for us. The World Health Organisation recommends adults participate in at least 150 mins of moderate to vigorous exercise per week.
This is great advice. However, when you begin an exercise routine or increase your exercise time, it is important to do so safely so that you avoid injury.
In my practice, I have treated plenty of people who have launched into an exercise program with great enthusiasm and commitment, and inadvertently stirred up old injuries or created new ones. It can be quite disheartening when this happens. Those most at risk of injury are those who start from a low strength and fitness base and are either new to excising or haven’t done so in a while. This is when muscular niggles and pain are likely to occur. Novice runners starting a program of running have been shown to face a significantly greater risk of injury than more experienced runners. Many people will give up their new routine after a short period of time. This is because they don’t know what to do or how to safely get back into exercise after resting an injury. Often, people attribute exercise acquired pain and injuries to their age.
Why do injuries occur?
The injuries I am referring to in this blog are those that occur in the absence of a single traumatic event such as a fall or trip. The cause of those injuries is fairly clear. It is the unexplained injuries or pain that seemingly appear from nowhere that I will discuss here. These injuries are usually described as overuse injuries.
Injuries (in the absence of a single traumatic event such as a fall or trip) occur when people overload their bodies and do too much exercise too soon. Your muscles, tendons, ligaments and bones are designed to adapt and change with increased loads and the higher demands exercise places on them. However, they require time to do this effectively and efficiently. Excessive loading occurs when your body cannot adapt to the increased load. The tissue overload manifests as pain and injuries termed overuse injuries. These injuries often present as tendinopathy, muscle strain or even a stress fracture.
What are the factors involved here:
Load capacity is the capacity or tolerance of the body (the bones, muscles and tendon) to adapt to different loads including exercise. Optimal loading occurs when enough exercise occurs to improve strength and function without overburdening the tissues which leads to injury. It is a constant balancing act between applying enough load (or doing enough exercise) to improve function – whether that be the ability to stand up from a chair or run a marathon, and the ability of those tissues to respond and adapt to the applied load. This is often dependent on the integrity of the tissue, its age and any pre-existing injuries.
What influences the load capacity and ability to exercise safely?
- Age – Older adults are at greater risk of injuries when exercising which is often demonstrated with older runners. Older adults are also more likely to experience soft tissue injuries rather than bony injuries, such as tendinopathies and muscle strains. As we age, our tendons lose their stiffness and become less tolerant to quick changes in loading and increased bouts of exercise. Additionally, as we age, we lose muscle mass and strength. Muscular strength has been shown to be protective of injuries and so, age and declining strength can increase risk of injury as we lose these protective properties.
- Pre-existing injury can increase the risk of injuries when returning to exercise. Runners have a significantly high risk of injury if they have had a previous injury.
From a clinical perspective, patients will often report a previously injured area (even injuries sustained years earlier), as never being ‘quite’ the same or as strong as the other side. A typical example is a middle-aged woman in her 50s presenting to me with a left calf strain and signs of achillies tendinopathy three weeks after commencement of a hillwalking program. She had a left sprained ankle 10 years previous. Her left calf strength had never returned to its pre-injured level and although she was aware her left calf wasn’t as strong, it didn’t inhibit her normal day to day function. Now, after starting a hill walking program, in an effort to become healthier and fitter, the left calf weakness has most likely precipitated a tendinopathy injury.
- Muscular strength has been shown to be protective of injuries. Stronger muscles and tendons have greater load capacity than weaker muscles and are more resilient to potential injuries.
The training load will also influence your risk of injury. This is something you can control. It refers to the intensity of the exercise, how often you are exercising and the cumulative loading.
How can you avoid injury when starting or returning to exercise?
Here are a few strategies to help you start an exercise program safely and decrease your risk of injury:
1. Start slowly: Increase your activity levels in small increments. As discussed earlier, injuries occur if you overload your body too quickly. Start with something achievable, a routine or program you know you can do. Everyone has a different level of fitness as a baseline, different pre-existing injuries, different lifestyles and different life stressors.
Essentially, there is no formula that best suits everyone. As a starting point, the 10 % rule is a safe guideline and a reasonable place to begin. It will give your body time to adapt to the increasing amounts of physical activity. The 10% rule is a method of slowly and consistently progressing and building on your strength and fitness. It will also help to reduce your chance of injuries. The 10% rule is simple – increase your exercise loading by no more than 10% a week. Loading refers to the amount of time exercising as well as the intensity. Do not increase both each week – it is one or the other.
For example, if you have decided you would like to work towards a daily brisk 5 km walk and you are starting from a low activity base, start with a 2km medium paced walk on a flat route. It will take you approximately 3 months to increase to 5km safely. Following this, you can increase the speed or introduce hills. Remember to increase one at a time and in small incremental amounts. If you have had a bout of recent illness, try starting smaller at 1km or less. Starting is the most important step, then slowly progressing.
This same principle applies to increasing weights at the gym or any exercise regime.
If you should start to experience problems as you increase your physical activity, then pull back and apply the advice in the following points.
2. Introduce rest days and or less active weeks. Every 3rd week have a quieter exercise week, especially if you have been exercising a lot, or do not increase the 10% for that week. This gives your body time to catch up with the increased loads you are placing on it. Planning helps with this. It seems common sense, but when people want to achieve something, they often focus on the end goal without considering the best way to get there. Plan it out, day by day, week to week. Write up a schedule with the dates, week by week, and the exercise goals you would like to achieve. Schedule the lightened load or ‘recovery week’ every 3rd week to allow your muscles, bones, tendons and ligaments to adapt to new and increasing loads.
3. Pay attention to your body: If you start to feel any aches or pains, reduce the amount and intensity of your exercise.
The temptation is to stop exercising altogether to allow the pain to settle. This seems reasonable because the pain will reduce, and the injured area will settle. The problem is when you completely stop exercising, you will also reverse any gains you have already made. When you recommence exercise again, your tissues are even less adaptive to loading and you may perpetuate a cycle of injury – starting and stopping each time the injury and pain returns.
To alleviate this problem, reduce your exercise enough to allow the injured area to settle while still allowing you to continue exercising. This may involve reducing the amount of walking or running you are doing and increasing other sorts of strengthening exercises that will not affect the injured area.
Then, slowly increase the amount of exercise you are doing.
4. Supplement your training with specific resisted strength exercises to improve the health and strength of the muscles and stiffness of the tendons. There is good evidence that suggests that athletes will have a higher tolerance to loading and reduced risk of injury when supplementing their rehabilitation program with resisted strength training. An example would be running. Running involves a lot of calf strength and load capacity. Studies have shown that doing more running will not specifically help increase the strength of your calf muscles. The best way to specifically target and improve the strength of your calf muscles is to implement a simple calf strengthening program, such as heel raises, to improve the load capacity of the calves and Achilles tendon and reduce the risk of Achilles tendinopathy.
The World Health Organization recommends adults participate in at least 2 sessions of strength training each week at a moderate or greater intensity that
involves all major muscle groups to improve health outcomes.
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