Being laid up in a hospital bed is the absolute worst experience for any athlete. Any form of injury presents an unexpected disruption to training regimens, the rhythms of preparing for competition, and just life in general. This experience can be gut wrenching because all of a sudden the game has changed. There are now a whole new set of rules and a truckload of new expectations to unpack. The unknown is the worst part.
This article is Part II of a series exploring all the facets of what it takes for an amateur athlete to return to rugby following a traumatic leg injury. In the first segment - Traumatic Phase - I shared my personal story of sustaining a spiral-displaced compound fracture to my right tibia and fibula and the early medical and surgical intervention experience. Here I will transition to the Immobilization Phase and break down both the mental and physical challenges of preliminary rehabilitation and offer some insights to maximize your recovery during the process. For every athlete competing at the amateur level, this phase will require an immense amount of personal discipline and internal fortitude. To be frank, your journey back to the rugby pitch will only be successful if you have the stubborn guts for it. And it is this phase in particular where the outcome will be won or lost.
Following my Intramedullary Nailing procedure to repair my broken tibia and fibula on April 16, 2016, I spent the next day and a half in the hospital, primarily for pain management. My discharge was a bit of a balancing act because I was being administered some pretty high doses of narcotic pain medication that worked great for the pain, but also kept me extremely fatigued and neurologically loopy. About 12 hours post-surgery, I had my first visit from the Physical Therapist who explained that before I could be released I would have to prove I could self-sustain my mobility with the use of crutches. The type of surgery I had did not require a brace, cast, or boot and the surgeon assured me that from a structural standpoint, my leg was completely fixed. So he encouraged me to begin to attempt weight-bearing on my leg.
My first physical therapy session just involved getting up on the crutches and walking to the end of the patient hallway and back. That first trip was exhausting! I was only up for about 5 minutes, but when I got back to my bed, I collapsed and spent the next two hours sleeping off the effort. The next morning I was taken to the PT room and challenged with scaling a flight of 3 stairs up and down. Physically I knew I should be able to do it, but the real test was in my head. Partly due to the medication, partly due to the trepidation of losing balance and fear of a excruciating misstep. After a couple of shaky attempts, I really had to dig deep and push past my fatigue and anxiety. With a final gritty surge I completed the exercise. A flood of accomplishment swept over me as my first milestone was surpassed and my discharge ticket home emphatically punched.
Once at home, getting situated took some effort as my wife and I sorted out how some of the basic functional processes were going to work. Having a shower chair and detachable shower head was a huge help since I had to keep the stapled incision site dry for the first week, giving it time to scab over. The first 72 hours were the most helpless. But thanks to my wife who is an ER/NICU Nurse and 3 daughters who were on the hop to make sure I was well cared for, I was in very capable hands. Every single daily routine was now being dictated by what my leg needed to heal. And I was going to have to make peace with the slow incremental steps of my own physical capabilities.
The Rebuilding Process
The Immobilization Phase of recovery is primarily focused on creating the optimal environment for the body work through its own steps of healing. There are 4 physiological responses to any musculoskeletal injury they are:
During the inflammation period, swelling at the injury site is caused by the accumulation of fluids as the body attempts to flush irritants and control the tissue damage. This response while necessary, also needs to be managed so the tightness does not create so much pressure that it inhibits circulation.
The standard medical recommendation for inflammation management is the R.I.C.E. Method. (1)
- Rest - This is the hardest part. Because despite being immobile it is incredibly fatiguing to go from a performance regime at a competitive sporting level to physically stagnant. Your body's stress hormones can also lead to a high level of irritability and inability to get comfortable. Creating a routine can help. Get up at the same time every day, eat at the same intervals, keep a routine to your daily hygiene and go to bed at a set time. It sounds counterintuitive, but resting effectively demands some hard work!
- Ice - Get yourself a medical grade ice pack which will minimize the condensation and keep your wrap dry. It is recommended to limit application to no more than 30 minutes at a time every 2 to 3 hours.
- Compression - Again, a medical grade compression sock is going to be most beneficial for use. The traditional ACE wrap provides inconsistent pressure over the injury site. Compression serves two purposes, to provide stability and support to the injury site as well as restrict the expansion of the soft tissue due to swelling.
- Elevation - To achieve proper positioning, the affected injury site must be at or near heart-level. This will make assist in the effort for full circulation of blood and keep oxygen and nutrient rich blood continuously flowing through the damaged leg. In the inflammation period you should not extend the amount of time without proper elevation for more than 30 minutes.
As the inflammation period passes, the body transitions into the repairing phase. This involves the growth of fibrotic scar tissue in and around the injury site. This is a lower grade tissue that lacks the structure and elasticity of healthy tissue, resulting in restricted flexibility and range of motion. Beyond the affected injury site, pain, tingling and stiffness can also radiate to other tissues and structures along the kinetic chain. In my case, I experienced feelings of pain and tightness from my ankle all the way up my leg past my knee.
Once the base layer of fibrous tissue is created, the final 2 phases of rebuilding come into play which are remodeling and maturation. In these periods the body is working to develop tissue that is more consistent with mature, healthy, and functional tissue, but even in this restored state, the final tissue is still structurally less flexible. This is important for the amateur athlete to take into account, while a full and complete return of strength, speed, power, and range of motion are desirable, the likelihood of this occurring physiologically is rare. (2)
One of the best methods for ensuring that your remodeled soft tissue is the healthiest form it can be is to incorporate massage at and around the injury site, only after the inflammation phase has passed. You can employ your thumbs, fingers, hands or utilize a roller-bar. The goal is to get to the deep tissue which will facilitate improved circulation, range of motion, faster recovery time, and assist in the overall healing process by flushing toxins and the production of higher levels of fluids necessary for tissue repair. 3 There is some evidence to suggest that soft-tissue injuries can heal faster when the body has greater oxygen carrying capacity caused by an increase in nitric oxide. Ruck Science offers two such supplements, in the form of nitrate powder (Beet Elite) and L-arginine capsules (No2 Max).
Shake It Off
Obviously how you treat your body during the immobilization phase is very important but equally significant is what you are putting into your body. Again, this is not the time to get lazy! How disciplined you are in your nutritional approach to recovery will also play a huge factor in the quality and efficiency of your rehabilitation. While you may initially experience a dramatic drop in appetite, it is essential that you continue to provide your body with healthy nutrients and proper hydration. During my first week post-op, eating full meals was difficult for me. So my wife created a high-calcium, high-protein, high-anti-oxidant smoothie concoction that got me over the hump.
Carissa's Warrior Protein Smoothie
- 1 1/2 cup 2% Milk
- 1 scoop Rugby Whey
- 1 tbsp Peanut Butter
- 3/4 cup Fresh Baby Spinach
- 1/2 cup Frozen Berry Mix
- 1/2 Fresh Banana
Calcium and Phosphorus are the two primary minerals found in bone. In the form of calcium hydroxyapatite crystals, this compound helps regulate the elastic stiffness and tensile strength of the bone structure. A healthy diet should take care of adequate Phosphorous levels, but increasing Calcium can be supplemented. 4 One dietary supplement I immediately implemented into my daily regimen was Jarrow Formulas BONE-UP.
Bone Up® provides StimuCal™ ossein MicroCrystalline HydroxyApatite (MCHA) (from free-range New Zealand calves), which includes the superior combination of the inorganic calcium lattice of MCHA within an organic protein milieu. StimuCal™ is rich in native type I collagen—the predominant protein found in bone—and has been clinically demonstrated not to disproportionately spike calcium blood levels as do other forms of calcium, such as the carbonate and citrate salt forms. (5)
Get Yourself Some Sunshine
Vitamin D has been shown as an essential vehicle for orthopedic healing and can benefit the recovering athlete in the following ways. The endocrine function of Vitamin D facilitates the absorption of calcium in the intestines and also assists the reabsorption of calcium in the bones. Additionally, the autocrine function on the cellular level can work as an anti-inflammatory. (6)
A 2010 research project led by Joseph Lane, M.D., professor of Orthopedic Surgery and chief of the Metabolic Bone Disease Service at Hospital for Special Surgery identified the essential role that Vitamin D plays in expediting the healing process of bone fractures. According to Dr. Lane, bone remodeling or bone tissue formation, a part of the healing process, occurs about two to four weeks after surgery. This is the critical stage when your body needs vitamin D. In the Sports Medicine Service, 52.3 percent had insufficient levels and of these, one-third of these or 17 percent of the total had deficient levels.
"We frequently see stress fractures in the Sports Medicine Service and if you want to heal, you have to fix the calcium and vitamin D," Dr. Lane said. "We recommend that people undergoing a procedure that involves the bone or the muscle should correct their vitamin D if they want to have an earlier faster, better, result." (7)
Absorption of natural sunlight is the most efficient source of Vitamin D and to achieve recommended levels requires no more than 5-10 minutes of sensible sun exposure 2 to 3 times per week. This may or may not be feasible to your rehab situation, especially in the first week or two of the immobilization phase. If this is the case, Vitamin D in supplemental form Vitamin D can also be implemented. (8)
The recovery of range of motion in your leg is a top priority and steps can be taken to immediately begin working the affected joints along the kinetic chain. Despite breaking my tibia and fibula mid-shaft, the radiating pain, swelling, and stiffness extended from my ankle to my knee. By incorporating lightweight resistance bands, you can begin recovering your joint mobility.
A couple of basic routines involve wrapping the band around the top of the foot, holding each end and performing single leg (seated) leg extensions. This exercise provides both flexion tension to the ankle as well as activating the muscles, ligaments, and tendons surrounding the knee. Similarly, again wrapping the band around the top of the foot, extending the leg and rolling the ankle in all directions and holding tension at each point. Seated physical therapy with resistance bands should be done 2 to 3 times a day until you are able to get up and around under your own power and remember, the sooner strength and mobility are achieved, the sooner you will be crutch-free.
You Do It
The best advice I can give you that will expedite your return to rugby is this - As soon as you are physically capable, when you need something, get up and do it yourself. When it's time to refill your ice pack, you do it. When you need to take your pain medicine, you get up and get it. Don't miss any opportunity be up and around. You will not be able to do much for the first few days following surgery, but a challenge I made for myself was this. I will do one new thing today that I couldn't do yesterday. This created for me daily psychological wins, and I was able to track my improvement with tangible activity. I became tenacious in my recovery and knew that my daily milestones would one day lead me back to the jersey that I had worked so hard for.
Keep Your Head in the Game
Exactly two weeks following my leg break, I was back at the pitch supporting the boys for our final home match of the spring rugby season. It was so therapeutic for me to see the fellas, and be close to the action again. I was able to talk with the field paramedic and update her on my status and assure her that I was well on my way to a full recovery. The encouragement I received that day from the club was amazing. One thing I have learned about amateur rugby is that the effort required is massive, and most people will not make the necessary sacrifices just for their own sake - you do it for your mates. I have discovered that I will always do more, if I am doing it for someone else. In my mind, my return to rugby was becoming less about me and more about what it means for my club and the game itself.
Throughout my immobilization phase, I set my mind to learning the game better. For the two weeks that I missed work, I watched A LOT OF RUGBY, and I committed my time to becoming a mental student of the game. This opportunity generated so much of an intrigue that I made the decision to complete Level 200 Training and get my Coaches Certification through USA Rugby.
I still had no idea what the timetable would look like or when I would be fit to play, but I was making sure every day I was doing everything I possibly could to be mentally ready. What I would soon discover is that my successful return to rugby was going to have less to do with by body and more to do with my mind, and if I was going to win, it was going to be essential that I have my head in the game.
- Miller, John How to Treat an Acute Soft Tissue Injury
- Active Release Techniques (ART) for Soft Tissue Rehabilitation
- Sports Massage Therapy for Recovery, Injury Rehabilitation and Better Athletic Performance
- Brown, PhD, Susan E. How to Speed Fracture Healing
- Haussler PhD, Mark The Nuclear Vitamin D Receptor: Biological and Molecular Regulatory Properties Revealed March 1998
- Hospital for Special Surgery. (2010, October 7). Vitamin D deficiency rampant in patients undergoing orthopedic surgery, damaging patient recovery. ScienceDaily. Retrieved November 19, 2016 from
- Ware RDN LD, Megan Vitamin D: Health Benefits, Facts and Research April 2016