Rest, ice, and Celebrex. If you've got a sprain, a strain, a tendonitis, a tendonosis, a fracture, or any other sports injury, you're likely going to leave the doc's office with the same prescription. Rest, ice, and Celebrex.
Unfortunately you're unlikely to hear about the healing benefits of curry powder, garlic, pineapple, cocoa, tea, and blueberries. Nor will you be advised to increase vitamin A, vitamin C, copper, or zinc intake.
You probably won't walk away with a prescription for fish oils. And you certainly won't be given a stack of glutamine, HMB, and arginine.
Maybe it's because your doc thinks this is too much to remember. Or maybe your doc isn't up on the latest nutritional research. Regardless of the reason, it's a shame as nutrition plays an important role in injury repair. From boosting immune function, to improved collagen deposition, to a more rapid return to function, the right nutritional intake can make a big difference.
There's more to treating injury that ice!
Nutrition and Injury Repair
Although we may perceive injury as chaotic — with the pain, swelling, and dysfunction — when we look at things biologically we see that injury does lead to an organized, consistent pattern of repair. Researchers and clinicians typically break this pattern down into 3 defined stages.
Stage 1 — Inflammation
This stage lasts up to 4-5 days post soft tissue injury (2-3 weeks in bone injury) and is in place to clear out injured tissue debris.
Stage 2 — Proliferation
This stage comes after inflammation and lasts about 2-3 weeks (10-12 weeks in bone injury) and is in place to form temporary replacement tissues. These tissues are usually weaker than the originally injured tissues yet still provide some structure and function to the site of injury.
Stage 3 - Remodeling
This stage comes after proliferation and can last up to 1-2 years (even longer in bone injury) and is in place to form new tissues nearly as strong as the original tissues.
By understanding this process of injury and injury repair, scientists can look at each step in the repair process, targeting different nutritional angles in the support of injury recovery. These targets typically fall into the following three categories:
1. Nutritional strategies that promote, yet manage, acute inflammation.
2. Nutritional strategies for supporting immune function.
3. Nutritional strategies that support long term tissue healing and regeneration.
As inflammation is the most acute and problematic phase, one major goal of any injury repair protocol should be to support (but manage) the inflammatory process. While most folks think inflammation is a bad thing, it's important to know that the inflammatory process is critical and that any strategy designed to eliminate inflammation or blood flow to the injured area should be avoided. However, pro-inflammatory agents should also be avoided as excessive inflammation could increase total tissue damage, slowing down the repair process.
Further, a secondary goal of managing inflammation is to reduce pain, as pain can cause biomechanical compensations/changes that can lead to secondary injury as well as restrict movement necessary for the development of strong, functionally adapted replacement tissues. However, again, strategies that eliminate pain often target inflammation. And in this case, the elimination of inflammation (and pain) may also reduce healing.
With these goals in mind, it's time to think about how specific macronutrient and micronutrient interventions can help manage inflammation, boost immune function, and help lay down stronger replacement tissues more quickly. We'll talk about each of these in this article.
Dietary Fats and Inflammation Management
A diet high in trans-fats, omega 6 rich vegetable oils, and saturated fat will be pro-inflammatory while a diet high in monounsaturated fats and omega 3 fats will be anti-inflammatory. Of course, most of us already know that it's the ratio of omega 6 to omega 3 in the diet that helps us maintain a balanced inflammatory profile, but this refresher lesson is often necessary during periods of injury recovery.
Another required refresher is the fact that beyond 3s and 6s, the overall fat balance is important here. With a good balance of saturated, monounsaturated, and polyunsaturated fats (about 1/3 of total caloric intake each), the body's inflammatory profile will most likely fall right into line — especially during periods of injury repair.
To this end, the following simple strategies should go a long way during injury repair and even during injury prevention:
To balance your fats:
Increase intake of olive oil, mixed nuts, avocados, flax oil, ground flax, and other seeds, etc., making sure to get some of each fat source every day. By eating these foods, you'll likely balance out the saturated fats naturally present in your protein sources, leading to a healthy profile without breaking out the calculator.
To balance your 6:3 ratio:
Add 3-9g of fish oil each day while reducing omega 6 fats like vegetable oils such as corn oil, sunflower oil, safflower oil, cottonseed oil, and soybean oil, etc. This strategy should take care of your omega 6:3 ratio.
Using Herbs and Phytochemicals to Manage Inflammation
Beyond healthy fat balance, certain foods and herbs can be very beneficial in the management of inflammation. These herbs include:
Current research shows that the active ingredient, curcumin, is responsible for the anti-inflammatory benefits of turmeric. As turmeric is present in curry powder, you could start by adding curry to your diet, although a better strategy would be to add 400-600mg of turmeric extract 3x per day to manage inflammation.
Garlic has been shown to inhibit the activity of certain inflammatory enzymes and impact macrophage function. Again, although eating more garlic is a good start, supplementing with 600-1200mg of aged extract likely works best.
This is another anti-inflammatory plant extract that comes from pineapple. While best known for its digestive properties, it's both an anti-inflammatory and analgesic. Doses of 500-1000mg/day should do the trick.
This tree extract also has anti-inflammatory properties and is usually used in 300mg doses 3x per day.
Cocoa, tea, red wine, and certain fruits and veggies are high in the anti-inflammatory flavanoids. Again, while an increase in consumption of flavanoid foods would likely be of benefit during times of acute injury, blueberry or grape extracts, green tea extracts, citrus extracts (hesperedin, naringin, etc), and bioflavonoid supplements containing quercetin/dihydroquercetin and rutin may lead to more marked anti-inflammatory effects.
With all of these nutrients, caution is warranted as wholesale suppression of the inflammatory response in the body isn't warranted during the acute phases of injury. The idea here is to control inflammation from getting out of control, not stop it from happening.
So, in the end, the key is not to load up on all of these anti-inflammatory supplements at once. Rather, focus on foods rich in natural inflammation modulating agents such as these below, only supplementing if inflammation becomes a major/chronic problem(this would likely be discussed with your physician first).
Calorie Needs During Injury
It should be no surprise that energy needs during sport are increased and this is due to the energy cost of activity. As a result, some athletes, especially females, intentionally (to lose body weight) or unintentionally (due to improper nutrition education) under eat.
This can lead to an increased incidence of stress fractures, ligamentous injury, etc. So, on the one hand, too few calories when healthy can lead to injury. On the other hand, too few calories during recovery from injury can prevent an athlete from getting healthy.
During acute injury, energy needs are increased. In fact, BMR
may increase by 15 - 50% based on the severity of the trauma. For
example, sports injury and minor surgery may increase BMR by
15-20%, while major surgery and burn injury may lead to a 50%
increase in BMR. When trying to determine energy needs during
recovery from injury, it's important to consider this increase in
Of course, comparatively speaking, an athlete will have to eat less during injury recovery than during training and competition. Yet if they return to baseline intake, they may be under eating.
Let's take the example of a young athlete here.
Male - 14y
5'6", 140 lbs
Basal Metabolic Rate
1611 kcal/day (based on the mean of 3 predictive equations)
Energy needs when sedentary
1933 kcal/day (based on activity factor of 1.2)
Energy needs with daily training/competition
2739kcal/day (based on activity factor of 1.7)
Energy needs during injury recovery
2319kcal/day (based on activity factor of 1.2 and a 20% increase in metabolism due to injury)
As you can see, although energy intake should decrease (relative to training and competition) during periods of injury repair, returning to baseline intake will lead to underfeeding.
Macronutrient Needs During Injury
When it comes to the macronutrients, increased dietary protein is recommended for injury repair. These increases are based on increasing the clinical recommendations from the usual 0.8g/kg to 1.5-2.0g/kg.
Since many athletes will already be hitting this 1.5-2.0g/kg
mark, these needs should be covered. So, if a rapid return to
normal function is desired, this is one area that should not be
neglected. Injured athletes should absolutely strive for 1g of
protein per pound of body weight as a minimum.
Dietary fat has already been discussed and to recap, the idea is to balance out dietary fat by getting about 1/3 of total fat intake from each of the three types of fat. Further, the omega 6:3 ratio should come down to anywhere from 3:1 to 1:1.
As far as dietary carbohydrate, while glucose is necessary for athletic injury healing, no specific carbohydrate recommendations have been established for injury periods. However, dietary carbohydrate should likely be included in sufficient amounts to ensure adequate micronutrient intake as well as stable insulin concentrations (which, as an anabolic hormone, may impact wound healing).
Translating these recommendations above into practical strategies, the following habits should help athletes ensure adequate calorie and macronutrient intake for both sport and injury recovery:
Eat every 2-4 hours
Each meal/snack should contain complete protein including lean meats, lean dairy, eggs, or protein supplements.
Vegetables and Fruit
Each meal/snack should contain 1-2 servings veggies and/or fruit (1/2 - 1 1/2 cups or 1-2 pieces) with a greater focus on veggies.
Additional carbohydrates should come from whole grain, minimally processed sources like whole oats, yams, beans, whole grain rice, quinoa, etc. The athlete should eat fewer starches when not training (such as during injury recovery), and more when training (unless fat loss is a goal), but a no carbohydrate or no starch diet is unwarranted.
The athlete should eat each of the following good fats each day - avocadoes, olive oil, mixed nuts, flax seeds, and flax oil. In addition, 3-9g of fish oil should be added to the diet.
Micronutrient Needs During Injury Recovery
When it comes to injury, vitamins A, B, C, and D as well as calcium, copper, iron, magnesium, manganese, and zinc can all play important roles. (Interestingly, vitamin E may slow healing so it's recommended to avoid vitamin E supplements during injury.)
Some of these micronutrients act in permissive roles and others can actually stimulate healing. Until further research confirms these roles, there's controversy as to whether it's simply the prevention of vitamin/mineral deficiency we're after or whether the ingestion of additional vitamins and minerals can be of additional benefit.
So rather than discussing each vitamin and mineral that may impact injury recovery, let's discuss only those that may require additional supplementation. In the end, it appears that the following vitamins and mineral supplements would benefit those with acute injuries:
Vitamin A — 10,000IU/day for 2-4 weeks post-injury
Vitamin C — 1000-2000mg/day for 2-4 weeks post-injury
Copper — 2-4mg/day for 2-4 weeks post-injury
Zinc — 15-30mg/day for 2-4 weeks post-injury
Additional Nutrients That May Impact Injury Recovery
Supplemental amino acids have been shown to exert powerful effects on injury healing. When the body is under stress, arginine and glutamine become conditionally essential amino acids and these as well as the following amino acids have been shown to speed up healing process in the body:
Studies using arginine in rodents and humans have demonstrated the potential of high dose arginine supplementation to increase collagen accumulation, reduce lean body mass loss, reduce nitrogen excretion, and accelerate wound healing. Human doses have been in the range of 15-30g per day with higher doses having the largest effect.
Studies using ornithine in trauma/injury situations have shown that ornithine can shorten healing time, increase healing strength, and increase nitrogen retention. Human doses in these studies have been in the 20-30g/day range (10g 2-3x per day) with larger doses having the greatest effect.
In one study, the combined administration of 14g arginine, 3g HMB, and 14g glutamine in two divided doses (two doses of 7g arginine, 1.5g HMB, 7g glutamine per day) for 14 days significantly increased collagen synthesis in adults.
Research has shown that HMB increases collagen deposition in rodents as well as improves nitrogen balance in critically injured adult patients. Again, in one study, the combined administration of 14g arginine, 3g HMB, and 14g glutamine in two divided doses (two doses of 7g arginine, 1.5g HMB, 7g glutamine per day) for 14 days significantly increased collagen synthesis in adults.
At this point, before loading up on amino acids, it's important
to note that many of the studies discussed in this section were
performed in either the elderly or in hospitalized patients. In
both cases malnourishment is common. Therefore it's likely that the
amino acid supplements above were eliminating relative deficiencies
rather than being added to a healthy diet that's already adequate
in dietary amino acids.
Of course, this point doesn't necessarily disqualify amino acid supplementation as a viable option for an athlete experiencing a sports injury. Indeed, many athletes may be poorly nourished as well, under eating both total calories and protein. As a result, in such cases, the first priority is to increase calorie and protein intake during recovery as discussed above (including about 1g of protein per pound of body weight).
However, even in well-nourished individuals, it's likely it's still beneficial during sports injury to supplement with amino acids in order to stimulate collagen deposition and injury healing. The combination of arginine (7g 2x per day), HMB (1.5g 2x per day) and glutamine (7g 2x per day) will likely preserve lean body mass while recovering from injury. At the same time, this approach may accelerate collagen synthesis and injury repair.
In summary, sports injury recovery is characterized by an organized response to the acute trauma. First, inflammation is provoked to remove damaged tissues. Next, cells proliferate to replace the damaged tissue. And finally new cells replace the intermediary cells to strengthen the repair process and lead to injury resolution.
During each step of the repair process, specific nutritional strategies can be employed to both support and enhance this repair process. The following are most useful:
1. Eat every 2-4 hours.
2. Each meal/snack should contain complete protein including lean meats, lean dairy, eggs, or protein supplements (if whole food is unavailable).
3. Each meal/snack should contain 1-2 servings veggies and/or fruit (1/2 - 1 1/2 cups or 1-2 pieces) with a greater focus on veggies.
4. Additional carbohydrates should come from whole grain, minimally processed sources like whole oats, yams, beans, whole grain rice, quinoa, etc. The athlete should eat fewer starches when not training, and more when training. Although a no carbohydrate or no starch diet is unwarranted.
5. The athlete should eat each of the following good fats each day - avocadoes, olive oil, mixed nuts, flax seeds, and flax oil. In addition 3-9g of fish oil should be added to the diet.
6. The athlete should include the following anti-inflammatory foods: curry powder/turmeric, garlic, pineapple, cocoa, tea, blueberries, and wine.
7. The athlete should include the following supplemental vitamins and minerals for 2-4 weeks post-injury — vitamin A, C, copper, and zinc.
8. A combination of arginine, HMB, and glutamine should be supplemented to help preserve lean body mass while accelerating collagen deoposition.
Of course, when faced with an injury, nutrition isn't the only thing athletes should consider. Progressive rehab centers are using additional adjunct therapies including prolotherapy, intra-articular and/or site specific injections of hyaluronans, autologous platelet concentrates, and other therapeutic compounds to speed up injury repair and to improve chronic injury/pain prognoses. And, of course, conventional rehab and physical therapy is conventional because it works.
In the end, if you're faced with an injury, it's important not to just sit it out with rest, ice, and Celebrex and hope for the best. Rather, be proactive with your nutrition, your therapy, and with your adjunct treatment strategies so that your healing is rapid and complete.