Treating an injury can be as simple as putting a bandaid on a boo-boo or as complex as multiple trips to the hospital. In the fitness world, most injuries are related to joint health and muscle function, with most treatment methods usually looking something like an ice pack and time off. But what exactly are the dos and don’ts of working out with an injury?
Growing up as a competitive runner, I remember our coach making us ice together as a team for 20 minutes after every single practice. As a professional dancer, I always felt guilty for not foam-rolling my body every day. At times I’ve been injured, I rested so much that I lost muscle mass, which usually led to more injuries.
Injury prevention and treatment can get into some dogmatic territory, depending on the nature of your community, but today we know more than ever about working out with an injury. For example: Dr. Gabe Mirkin, the doctor who first coined the “R.I.C.E.” method in 1978 (rest, ice, compress, elevate), redacted the idea in 2015 when emerging research suggested that R.I.C.E. delays the healing process.
My typical treatment regimen, as recently as my fractured big toe in 2021, was strongly based on recommendations from a physical therapist, past doctors, rehearsal directors, friends, and colleagues: “Rest it, ice it,” for months! Only recently did I learn of all the misconceptions and contradictions we’ve been operating with. And earlier this year, when I became a mobility specialist, I learned that movement is the best medicine when working out with an injury. Let me explain.
A 101 on How Workout Injuries Happen
An injury occurs when the impact or load on a muscle tissue is more than what that muscle is prepared to handle. Working out safely means loading the muscle fibers enough to make a change, but too much strain will cause an injury—and we’ve all been there.
The right amount of strain, or progressive overload, will build back stronger muscle fibers, and we need these types of challenges to keep our bodies conditioned. To build muscle and enact hypertrophy, we must safely and progressively insult our muscles; this is a strength training fundamental. Overloading the muscle fiber is an insult that our brain remembers as a demand for more strength for the future, a lesson learned.
While eccentrically contracting muscles (like lowering on a dumbbell curl) is where the magic of hypertrophy occurs. It’s also where injuries can happen. Insulting the muscle fibers is imperative to muscle growth, and these insults are like little injuries. Like stretching a rubber band, an eccentric contraction extends the muscle to its safest capacity. Resistance training, weight training, running, and dance, all rely on the control of our eccentric contraction protecting our muscles and our joints as we land a stride or lower a weight to the bottom of a lift.
Hypertrophy is when you overload the rubber band to the point of failure, leading to micro-tears in the “tissue” of the band. Unlike a rubber band, our muscle fibers then grow back stronger and more prepared for the load that caused failure before. We are all playing the game of pain: too much of a good thing, or too much of a new thing, and we end up hurting.
The Relationship Between Pain and Injury
Muscles signal pain when there’s too much pressure, stress, or stretch on the muscle fibers. Sometimes we call it a “tear,” sometimes a “pull,” a “spasm,” or just soreness. It’s all on the spectrum of the same type of insult to the muscles that are also required for hypertrophy.
Joints protect themselves by signaling pain when they don’t feel enough support. Decoding joint pain can be more neurological and have more to do with the surrounding muscles’ ability to support them. Over time, extensive misuse of a muscle or joint complex will lead to injury: excessive stress, and not enough support.
An injury is sometimes the outcome of our best efforts, sometimes it’s an accident. It’s not always Kerri Strug at the 1996 Olympics landing the vault for the gold on a busted ankle— I’ve thrown my back out taking off my shirt! When the goal is to be active and stay active, understanding how to work through pain is part of the experience.
How to talk about the pain we feel takes practice. Communicating my pain and knowing how to treat myself have drastically changed in the last two years. Our bodies learn through failure, and exposing ourselves to the right type of muscular insult that promotes growth, while avoiding injury, is a journey we’re all on together.
Don’t: Rest Indefinitely After an Injury
Injuries are bound to happen. But how do we continue working out with an injury without making things worse? Our bodies are incredibly adaptive, and whatever movement patterns we repeat on a regular begin to shape and mold our physique over time. The same is true for lack of movement, which begets the opposite of hypertrophy: atrophy.
Atrophy begins to set in around two weeks after an individual underuses a muscle group. When we stop moving our joints, we lose range of movement, and joints become de-conditioned. Muscle loss will almost always result in the loss of support for a joint and often dysfunctional kinetic chains of muscles.
In college, I had a traumatic knee injury that happened onstage during a performance. It was painful enough to prevent me from dancing for 6 months. During that time away from dance, I leaned into my mechanical compromises, favoring my “good side,” and relied on the opposite knee/leg to help me up and down the stairs, sit, stand, and do other daily tasks.
Thinking the less I used my knee, the quicker I would heal, I almost exclusively used my injury-free leg. By the time my “bad knee” was pain-free, that entire same side of my body had lost conditioning. All this even though I rested and dutifully iced during those 6 months.
Don’t: Continue to Ice 6 Hours Post-Injury
Applying ice to a wound or injury reduces pain—a good thing—but it also takes the swelling down while restricting blood flow, which may not be ideal depending on the injury and how long ago it happened. Swelling is an immune system response to tissue damage, and it’s critical to the healing process by introducing a growth factor called Insulin-like Growth Factor (IGF-1).
When we apply ice to an injury, we prevent the release of the growth factor that helps repair damaged tissue. Thinking back on every injury I applied ice to for 20 minutes on, 20 minutes off, sometimes 4 times in a row, all I can think now is…yikes! Dr. Mirkin now recommends icing for 10 minutes on, 20 minutes off, and only if you need it, 10 more minutes. He also suggests not applying ice beyond six hours after the incident.
What I didn’t know then was that movement was medicine, and if I had continued to put my injured knee through healthy stress and appropriate exercises, I wouldn’t have had to start from scratch to build my strength back up once I was pain-free.
Do: Listen to Your Pain and Assess Personally
In the early stages of an injury, assessing pain is how we learn how to heal. “Let pain be your guide,” is one of the most helpful things I learned in injury rehabilitation. Some presentation of pain equals a no-go, a no-move-it, the body is saying “no.” I used to ignore this daily!
Understanding this within your pain tolerance takes practice, trial and error, and sometimes a professional (it’s important to note that consulting your doctor is always recommended.) Experiencing 10/10 pain (that you don’t know how or why occurred) may require medical attention.
Where this becomes nuanced is in our day-to-day aches and pains, where a 4/10 keeps flaring up when you squat or a 6/10 happened in your back when you picked your kid up. Joint pain is usually more complicated and multifaceted, and a doctor or a physical therapist could be exactly what you need. But no matter what, when the pain dies down enough to operate, your body is telling you it’s time to move.
For my personal pain tolerance, I’ve learned that I can work out with some pain, around a 4-5 on a scale of 10. I also know that I’ll be okay if I accidentally push it to a 6. If I do feel more pain the next day, I know the movement I tried to achieve was more than what my damaged muscle tissue could handle. Sometimes, I feel a dull pain for months, but I can use that pain to guide my posture and alignment to support the injury appropriately.
Remembering what caused a spike in pain informs me of my progress and how to regress my training to keep the pain down to a 4 or 5. As pain gradually subsides, I can increase the load on the injury until I’m pain-free. (Pain may take longer to subside when there’s a buildup of scar tissue. Eliminating scar tissue is uncomfortable and requires patient application of pressure to break it down, which can take months of tolerating lower-ish levels of pain. The less rest an injury has, the less scar tissue accumulation occurs).
Letting pain guide me took years of rehabilitation practice, and how I navigate it is specific to me and the demands of my active lifestyle. Most importantly, working out with an injury should progress gradually with minimal backtracking into more pain, but we have to start moving when we can.
Do: Follow a Strategic Progression While Working Out With an Injury
Ideally, the rehabilitation of the injury follows this progression: isometric bodyweight contraction, loaded isometric contraction; concentric bodyweight contraction, loaded concentric contraction; eccentric bodyweight contraction, and loaded eccentric contraction. That’s a lot, but I’ll explain below. Modifying and choosing appropriate exercise variations is the sweet spot for working out with an injury, regressing if you feel too much pain.
To avoid atrophy, continuing the work in the rest of your body is imperative. Often our injuries come from imbalances in support for what we hurt, and keeping the rest of our systems in shape can help the brain feel safe enough to continue healing the source of our pain.
Here is where one of my favorite fitness tools comes into play: isometrics. Before we can put tension on damaged muscle tissue, we need to test it by contracting it in a resting state, without loading it. An isometric contraction is when you squeeze the muscle and hold still, improving neurological pathways to the brain to promote healthy movement.
But first, we must hold still before we concentrically contract (shorten and squeeze) or eccentrically contract (lengthen and stretch). When an isometric (like a plank or wall sit) is too painful to hold body weight, rest is required. Graduating from this stage requires squeezing an isometric and assessing the pain level. If unbearable, higher on your pain tolerance scale, or more than you feel safe doing, keep resting it. For example, if your knee hurts at a 6/10 every time you stand, keep resting and operating under lower pain levels on the day-to-day. Once you’re okay to stand, try balancing on one leg: using an isometric to load the joint without movement.
Once you can operate a healthy isometric body weight contraction, graduate into a healthy concentric contraction. Starting with bodyweight, examples of this are bending the knee, bending the elbow, flexing the spine, or any other shortening of the muscle. This must be mastered without a spike in pain above your comfort level, with ample rest between sets. No better time to take things slow!
Do: Make Adjustments As You Go
When working out with an injury, avoid the type of movement that causes intolerable levels of pain at the injured location, but do choose pain-free movement for the rest of the body. Too painful to run? Keep walking. Shoulder screaming in push-ups? Regress to isometrics and hold a high plank.
Progressing from an isometric plank hold would be the descent of a pushup, which is classified as a concentric contraction. Leveling up from an isometric balancing on one leg would be progressing to a bending of a knee (concentric). Once bending the knee is pain-free, we can start loading the concentric contraction: picking up light weights, until the brain feels safe enough to lift heavier.
Lastly, depending on what type of painful feedback you get from the injury, you can begin eccentrically load these muscles with body weight: squatting, lunging, full bicep curls, and even hopping or running. If the injury isn’t being too fussy or the pain isn’t spiking above what you feel is safe, we can begin lightly loading the eccentric contractions. I like to start with resistance bands, light weights, and continue using more and more body weight. At this point in the rehabilitation process, there are more options and variables in choosing exercises—it all depends on what hurts and what doesn’t.
Do: Prioritize Active Recovery and Prehab
This step-by-step process is highly individual, based on the demands of your physical life and the type of injury. Working with a physical therapist or trainer who can help with regressing movement or providing modifications can be the optimal route. Active recovery with gentle exercises can help integrate the injured tissue within the context of the kinetic chain. This could look like Yoga, a Stretch class, a Prehab class, or Mobility drills.
My favorite method of regulating pain is prioritizing my joint health daily. To stay ahead of injuries, you have to prepare the muscles at the source of their function with a method called Prehab. Your mobility depends on the capacity of each of your joints to be safely loaded and your muscles to be stretched eccentrically without damage.
Life happens, and variables can’t always be predicted. Being prepared with muscles that can support the joints means we can live with less pain. To keep joints healthy, we have to move them every day, in every angle and direction we have access to. By consistently having a relationship with my joints, and continuing to let pain be my guide, I can learn a lot about how my body operates optimally and what types of movement cause me pain.
The lesson here is to not avoid pain entirely but to learn how to work out through the pain without making it worse. Every time I feel pain, my joints are teaching me a lesson. I learn how to adapt what I’m doing throughout my day to avoid getting injured.
Summarizing the Dos and Dont’s of Working Out With an Injury
Movement is medicine, and no outside input can replace healthy neuromuscular efficiency. We can certainly use whatever methods of outside input we feel necessary to help an injury along. Understanding when to use the principles of R.I.C.E. and when to progress away from them comes down to each person’s comfort level.
Perhaps the adage of “moderation in all things,” can help us as we move forward. Rest for sure, but not to the point of losing conditioning. Ice right after the injury happens to aid the pain, but not so much that you prevent the stimulation of growth factor IGF-1. Compression can help excessive swelling with blood flow and pain relief, but remember we want some swelling.
Foam rolling, which can be a healthy use of compression, is sometimes a touchy subject in fitness. I’m not going to tell you to stop foam rolling, but recognizing what foam rolling is good for (pain regulation, neurological pathway maintenance, and blood flow), and recognizing what it can’t replace (healthy joints and learning stronger movement patterns), helps us know when to use it as a tool, and when to focus on neuromuscular efficiency and daily joint progress.
As far as the “E” in R.I.C.E. goes, elevation can feel good on an injury, and when we’re in too much pain, we need to rest and promote constant blood flow. This can look like elevating your injury, but the best way to get blood flow is to keep moving. Just make smart choices on how you move.
A Final Reflection
It’s encouraging to see the fitness world adapt with the new technology and hindsight available to us. In college, as I began to train more in classical dance, I grew accustomed to pain. In the dance world, pain is often glorified, so it did not feel out of place.
There was a world of information I was unaware of at the time, but looking back now, it’s hard not to see the signs my body was giving me. Initially, I was conditioned to ignore pain, but it turns out that pain is my favorite teacher, and knowing how to decode my body’s language came from patience and experience.
I made a lot of workouts “easier” for myself by modifying or taking things slow (which kept me moving and helped me master the fundamentals of my form). I found that Epsom salt baths give me the most pain relief after wrecking my body in a dance performance. I learned when to push through the pain in my big toe, and when to back off while working out with an injury. Most importantly, my journey through all the pain has led to a deeper relationship with my body, more awareness, and so much more strength. Think of pain as a protective communication system you can learn from daily. Look out for your muscles, and they’ll look out for you!
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