Diet and nutrition make up vital components of healthy living, preventing chronic conditions and diseases, and improving our physical capacity (e.g. weight loss or muscle gain). For athletes (and active individuals), proper nutrition is fundamental part of a well structured plan (Smith et al., 2015). Although a high quality, ‘food first’ diet is the most important part of a nutrition plan (Close et al., 2019), supplements can serve a purpose, and are widely used by athletes at all levels (Maughan et al., 2018). I think it is important to note at this stage, that as a physiotherapist, diet and nutrition is not my area of studied expertise. However, I have a background in exercises science and fitness, along with a personal and professional interest in this area. I regularly incorporate the use of dieticians for nutrition plans where appropriate for certain athletes, as this is outside of my scope of practice. For the purpose of this evidence-based blog, I will be talking about the importance of diet and nutrition in the recovery from injury.
Nutrition for during and recovery after intense exercise has been well studied in the literature (Smith et al., 2015; Sousa et al., 2014). Supplementation after intense exercise is important, and the contents of the blog will likely apply to that situation. However, this blog will look into the recovery from injury, and what nutritional considerations can be made.
Initially post injury, there is an early inflammatory phase (can last a few hours to days) (Smith-Ryan et al., 2020; Tipton, 2010; Tipton, 2013). The length of the inflammatory phase will vary depending on the injury, however, a degree of inflammation in the early stages is normal is part of recovery. The significant aspect in the early phase is the immobilization or activity reduction that accompanies the injury (Smith-Ryan et al., 2020; Tipton, 2010). The impacts are shown in figure-1 below. This leads to a reduced muscle protein synthesis, along with causing an anabolic resistance which also reduces muscle synthesis (Glover et al., 2008; Papadopoulou et al., 2020; Smith-Ryan et al., 2020; Tipton, 2010; Wall et al., 2015). The net result of this is muscle loss (muscle atrophy), which can occur within 24hours, and at a rate of up to 0.5% per day (Magne et al., 2013; Wall et al., 2015). Furthermore, there is often a reduction in collagen synthesis which can negatively impact bones, tendons and ligaments (Tipton, 2010). Figure-2 highlights the mechanisms which occur following injury. A key focus in the early phase of injury should be reducing the loss of muscle mass (Wall et al., 2015).
Figure 1 (Smith-Ryan et al., 2020).
Figure 2. Impact of injury and immobilisation (Tipton, 2010).
After the initial inflammatory and immobilization phase, the focus moves to the second phase, which is centred around rehabilitation. The goal of the second phase is increasing muscle hypertrophy and function. These phases are not discrete and can cross over (Tipton, 2010). The figure below illustrates this phase.
Figure 3. Phase 2 (Tipton, 2010).
Nutritional considerations:
The term “rehabilitation nutrition” related to the use of nutritional and dietary strategies to minimise the impact of injury and maximise recovery (Papadopoulou et al., 2020). The goal of nutritional interventions are to reduce the impact of injury, and enhance recovery (Close et al., 2019; Tipton, 2010; Wall et al., 2015). The early inflammatory processes are often needed, beneficial, and maybe even critical for early recovery (e.g. from muscle strain), thus consider avoiding supplements that reduce inflammation in the very early/acute phase (Smith-Ryan et al., 2020; Tipton, 2010; Tipton, 2013). Ensuring a well balanced, healthy diet should be an initial priority (Tipton, 2013). Furthermore, the level of protein in the diet, along with possible protein supplementation, is crucial to maintain muscle mass (Tipton, 2013; Wall et al., 2015). The following paragraphs will summarize a number of key and possible nutritional interventions to consider to assist your recovery from injury.
Protein:
Protein is a key macronutrient found in meat, fish, and other non-animal sources. Protein should be considered numero-uno post injury. Evidence supports the use of protein to assist with improving muscle mass, attenuating the loss of muscle mass with immobilization, improving the recovery of muscle damage (e.g. after eccentric exercise or sprints), assists with tendon healing, and possibly with wound healing (Glover et al., 2008; Hespel et al., 2006; Magne et al., 2013; Maughan et al., 2018; Papadopoulou et al., 2020; Rennie et al., 1982; Scott & Nordin, 2016; Smith-Ryan et al., 2020; Sousa et al., 2014; Tipton, 2010; Wall et al., 2015). Increased protein intake is recommended during the early/immobilized/deload state, along with during the rehab period (Wall et al., 2015). Whilst specific dosage falls outside the scope of this article, studies recommend between 20-30g protein per serve, taken after workouts and at multiple stages during the day (Maughan et al., 2018; Papadopoulou et al., 2020; Sousa et al., 2014; Wall et al., 2015). It is also recommended to consider protein supplementation prior to sleeping to maintain muscle mass (Papadopoulou et al., 2020). Where possible, the protein should contain the amino acid luciene, otherwise consider luceine supplementation (Tipton, 2010).
The informative grphic from YLM Sport Science below highlights further information around protein and its use.
YLM Sport Science (https://ylmsportscience.com).
Creatine:
Creatine is an organic compound synthesised from amino acids. It is only found in small amounts in the body, and mostly obtained from meat, fish, and supplementation (Smith-Ryan et al., 2020). Creatine supplementation has been found to improve muscle size (hypertrophy), increase strength and power, reduce muscle soreness (DOMS) and markers of muscle damage, along with importantly reducing muscle loss during immobilization (Hespel et al., 2006; Maughan et al., 2004; Maughan et al., 2018; Rawson et al., 2018; Smith-Ryan et al., 2020; Tipton, 2010; Wall et al., 2015). Specific dosage is outside of the scope of this article, however studies have recommended a “loading dose” of up to 20g per day (in 4 even serves of 5g) for 5-7 days, followed by a maintenance dose of 3-5g per day thereafter (Maughan et al., 2018; Wall et al., 2015). Consider seeking individualized advice prior to commencing creatine supplementation.
The figure below by YLM Sport Science provides more information around Creatine usage.
YLM Sport Science (https://ylmsportscience.com).
Energy Expenditure:
Often, post injury, athletes and individuals reduce their energy intake to avoid putting on excess weight. However, with injury energy expenditure is increased by up to 20% just from the healing processes, and even more if using gait aids like crutches. This is especially prevalent during the early phase of injury (e.g. first few days). It is important to maintain energy balance, especially protein levels and complex carbohydrates (e.g. vegetables). In certain athletes, food intake should be increased above pre-injury levels, however consultation with a dietician is recommended (Papadopoulou et al., 2020; Tipton, 2010; Tipton, 2013).
Anti-inflammation/High sugar:
This area is not the purpose of this blog, and could form a whole article on its own. However, high sugar and “western” diets have been shown to increase the susceptibility of chronic inflammation, linked with chronic diseases, affect tendon healing, increase body weight, reduce muscle mass and negetively influence injury recovery (Bosma-den Boer et al., 2012; David et al., 2014; Korntner et al., 2017; Smith-Ryan et al., 2020; Totsch et al., 2017).
It is recommended to consider a well-balanced diet high in vegetables and fruit (Seaman, 2012; Tipton, 2013). Furthermore, adopting an “anti-inflammatory” diet, or at least reducing “pro-inflammatory” foods (e.g. sugar, omega-6 fatty acids like processed meats and vegetable oils) may also assist with recovery and resolution of inflammation (Seaman, 2012; Smith-Ryan et al., 2020). Typically, an anti-inflammatory diet includes high vegetables and fruit, low GI foods, adequate omega-3 fatty acids, foods rich in antioxidants, and reducing sugar and certain grains/flour products (especially processed and high GI) (Seaman, 2012).
Anti-oxidants:
Antioxidants are present in a large number of foods, typically the colourful fruits and vegetables. There is significant mechanistic evidence, however not many studies in human populations, especially injured populations (Sousa et al., 2014). Foods such as cherries, grapes & berries are high in phytochemicals and polyphenols which have antioxidant properties. There is some evidence that these foods (and other antioxidants) reduce muscle damage and improve recovery (Hespel et al., 2006; Magne et al., 2013; Maughan et al., 2018; Rawson et al., 2018; Sousa et al., 2014). It is also thought that antioxidants have a potential effect in reducing the anabolic resistance to building muscle that can occur during the early stages of injury (Magne et al., 2013). Finally, green tea, which is high in antioxidants, has shown to have benefits in tendon healing and tendon aging. This has potential benefits for use in tendon injuries such as tendinopathy (Scott & Nordin, 2016; Vieira et al., 2015). Overall, more evidence is needed, however including high amounts of anti-oxidant rich foods in your diet may provide some benefit and is unlikely to cause harm.
The following figure from YLM Sport Science highlights some benefits of certain fruit supplementation on muscle damage.
YLM Sport Science (https://ylmsportscience.com).
Other supplements:
Omega 3: In the context of injury recovery, Omega-3’s should be limited in the early/acute stage of injury (Smith-Ryan et al., 2020). The proposed benefit of Omega-3’s is primarily around the reduction of inflammation (inflammation is beneficial in the acute stage to aid recovery). However, following the acute stage of injury, Omega-3’s (2-4g per day) have been shown to increase protein synthesis, adding muscle development and reducing atrophy (Papadopoulou et al., 2020; Smith-Ryan et al., 2020; Tipton, 2010; Wall et al., 2015). This is thought to be due to the attenuation of the muscle anabolic resistance that can occur post injury (Papadopoulou et al., 2020; Wall et al., 2015). Furthermore, they have been shown to reduce inflammation (especially chronic inflammatory diseases), assisting the immune system, and reducing muscle damage (e.g. post eccentric exercise) (Papadopoulou et al., 2020; Rawson et al., 2018; Sousa et al., 2014; Tipton, 2010). Consider: increasing foods high in Omega-3’s (e.g. salmon, walnuts, avocado, extra virgin olive oil etc), Omega-3 supplementation, and/or reducing Omega-6 intake after the acute injury phase.
Collagen supplementation has been shown to increase collagen production and cartilage thickness, with this giving possible benefit for joint and tendon pathology. Studies recommend pairing collagen with vitamin C to increased benefit. Gelatin is a possible source of readily available collagen. (Maughan et al., 2018; McAlindon et al., 2011; Rawson et al., 2018). Consider: potential use in tendinopathy, or after a joint injury.
Vitamin C: has been shown to be a potent inducer of collagen synthesis (DePhillipo et al., 2018; Scott & Nordin, 2016; Tipton, 2010). It is recommended to help prevent and recovery from tendon injuries such as tendinopathy (Scott & Nordin, 2016). Vitamin C has also shown preliminary evidence that it can accelerate bone healing (DePhillipo et al., 2018). Importantly, Vitamin C reduces the risk of chronic regional pain syndrome (CRPS) post fracture. A dose of 500mg for 50days post fracture is recommended (Aim et al., 2017; Zollinger et al., 2007). Finally, there is some thought that Vitamin C augments immunity (Maughan et al., 2018). Consider: use of Vitamin C post fracture and for tendon injuries/recovery.
Vitamin D: The use of Vitamin D is especially important post fracture, or recovering from a bone injury (Smith-Ryan et al., 2020; Tipton, 2010). This is especially relevant if you have low vitamin D levels, which can be assessed via blood test (Rawson et al., 2018). Furthermore, supplementation has been shown to improve recovery from eccentric exercise, some evidence that it improves collagen syntheses assisting tendons, and can impact on immunity (Maughan et al., 2018; Rawson et al., 2018; Scott & Nordin, 2016; Smith-Ryan et al., 2020). Consider: checking vitamin D levels through a GP or Sports Physician after a bone injury (e.g. fracture or stress fracture) could be advised.
Calcium: For bone synthesis, adequate levels of calcium (and vitamin D) are important (Tipton, 2010; Tipton, 2013). Consider: post fracture ensure adequate calcium levels in your diet.
Curcumin (aka turmeric): some evidence with reducing inflammation and muscle damage markers, however more evidence is needed, especially in light of injury recovery (Maughan et al., 2018; Rawson et al., 2018). Consider: potentially useful in a chronic disease or inflammatory condition.
Other Vitamins: other vitamins such as Zinc and Vitamin A may assist with wound healing, however further investigation is likely needed (Tipton, 2010). Consider: ensure your regular diet is micronutrient dense.
The following figure summarises a number of the key points from this article. If you are looking to educate yourself further, or want more information that is specific for yourself and your injury/recovery/training, please see an appropriately qualified health professional (e.g. dietician).
Disclaimer: this is an evidence based blog which provides an overview about nutritional strategies and injury recovery. This is in no way considered a prescription or treatment advice, and should not be used as such. I take no responsibility for anyone who makes alterations to their diet without consulting a medical professional. Furthermore, it is recommended to consult with a dietician if you have any further questions or require individualized advice.
Resources:
Maughan, R. J., Burke, L. M., Dvorak, J., Larson-Meyer, D. E., Peeling, P., Phillips, S. M., ... & Meeusen, R. (2018). IOC consensus statement: dietary supplements and the high-performance athlete. International journal of sport nutrition and exercise metabolism, 28(2), 104-125.
Papadopoulou, S. K. (2020). Rehabilitation Nutrition for Injury Recovery of Athletes: The Role of Macronutrient Intake. Nutrients, 12(8), 2449.
Scott, A., & Nordin, C. (2016). Do dietary factors influence tendon metabolism?. In Metabolic Influences on Risk for Tendon Disorders (pp. 283-289). Springer, Cham.
Smith-Ryan, A. E., Hirsch, K. R., Saylor, H. E., Gould, L. M., & Blue, M. N. (2020). Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. Journal of Athletic Training, 55(9), 918-930.
Tipton, K. D. (2010). Nutrition for acute exercise-induced injuries. Annals of nutrition and metabolism, 57(Suppl. 2), 43-53.
Brukner, P. (2018). Fat Lot of Good, A. Random House Australia.
References:
Aim, F., Klouche, S., Frison, A., Bauer, T., & Hardy, P. (2017). Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: a systematic review and meta-analysis. Orthopaedics & Traumatology: Surgery & Research, 103(3), 465-470.
Bosma-den Boer, M. M., van Wetten, M. L., & Pruimboom, L. (2012). Chronic inflammatory diseases are stimulated by current lifestyle: how diet, stress levels and medication prevent our body from recovering. Nutrition & metabolism, 9(1), 32.
Close, G. L., Sale, C., Baar, K., & Bermon, S. (2019). Nutrition for the prevention and treatment of injuries in track and field athletes. International journal of sport nutrition and exercise metabolism, 29(2), 189-197.
David, M. A., Jones, K. H., Inzana, J. A., Zuscik, M. J., Awad, H. A., & Mooney, R. A. (2014). Tendon repair is compromised in a high fat diet-induced mouse model of obesity and type 2 diabetes. PloS one, 9(3), e91234.
DePhillipo, N. N., Aman, Z. S., Kennedy, M. I., Begley, J. P., Moatshe, G., & LaPrade, R. F. (2018). Efficacy of vitamin C supplementation on collagen synthesis and oxidative stress after musculoskeletal injuries: a systematic review. Orthopaedic journal of sports medicine, 6(10), 2325967118804544.
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Korntner, S., Kunkel, N., Lehner, C., Gehwolf, R., Wagner, A., Augat, P., ... & Tempfer, H. (2017). A high-glucose diet affects Achilles tendon healing in rats. Scientific reports, 7(1), 1-12.
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Rawson, E. S., Miles, M. P., & Larson-Meyer, D. E. (2018). Dietary supplements for health, adaptation, and recovery in athletes. International Journal of Sport Nutrition and Exercise Metabolism, 28(2), 188-199.
Scott, A., & Nordin, C. (2016). Do dietary factors influence tendon metabolism?. In Metabolic Influences on Risk for Tendon Disorders (pp. 283-289). Springer, Cham.
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