Injury Recovery: Nutrition To Speed Up Healing - Part 2

The right food and supplements to speed injury recovery

Video filmed at the Fit Pro Convention in Loughborough, England. 

Three physiological targets

Once we understand how healing works, we can look for different therapies to help the process along, using a three-pronged approach:

• Inflammation support (and management) through nutrition
• Immune system support through nutrition
• Regeneration and anabolic support through nutrition

Let’s start by talking about inflammation.

Inflammation

Treating acute injuries requires a tricky balance of managing inflammation while allowing it to do its important job.

Don’t try to avoid the inflammatory process in the acute phases of an injury. It’s critical for Stage 1 recovery.

But don’t make inflammation worse, either. Excessive inflammation could increase total tissue damage, slowing down the repair process.

While managing inflammation in the early stages, we want to reduce pain, as this can cause biomechanical compensations and changes that may lead to secondary injury.

However, again, strategies that eliminate pain often target inflammation. Rushing to eliminate inflammation (and pain) too soon may also reduce healing. Again, it’s a tight balancing act.

Dietary fat for inflammation control

A diet high in trans-fats, omega-6 rich vegetable oils, and saturated fat will be pro-inflammatory (in other words, it’ll worsen inflammation). A diet high in monounsaturated fats and omega-3 fats will be anti-inflammatory.

The ratio of omega-6 to omega-3 in the diet is important for overall inflammation in the body — especially during normal periods of healthy living when we definitely want to keep inflammation under control.

In these circumstances, the omega-6 to 3 ratio should be anywhere from 3:1 to 1:1, which should lead to a balanced inflammatory profile.

Of course, overall fat balance is important here. With a good balance of saturated, monounsaturated, and polyunsaturated fats (about 1/3 of total fat intake each), the body’s inflammatory profile will look pretty good.

However, purposely decrease omega-6 fats and increase omega-3s (specifically fish oil). High omega 6:3 ratios reduce collagen production while a low 3:6 ratio supports healing.

Even though relatively higher omega-3s create an anti-inflammatory response in the body, this response doesn’t interfere with repair; rather, it only helps with injury healing and collagen deposition.

Unfortunately, we haven’t yet determined the exact omega 6:3 ratio, nor the amount of fish oil supplementation required to manage inflammation during injury.

Studies with low dose fish oil (~450 mg to 1 g/day) have shown no effect on inflammatory or immune markers while other studies have shown that high dose fish oil (12-15 g/day) may reduce immune cell function in certain populations.

As a result, some authors have recommended anywhere from 3-9 grams of fish oil (salmon oil, sardine oil, menhaden oil, krill oil, etc.) per day.

In addition to the omega 6:3 ratio, research has shown that increased nut and seed consumption, as well as olive oil consumption, can mildly reduce inflammatory biomarkers.

Nuts, seeds, and olive oil likely share a common mechanism. The monounsaturated fats found in all three contain compounds that can mildly reduce COX enzyme activity (something these foods share with ibuprofen). But again, be careful. Too high a dose of any anti-inflammatory may reduce acute healing.

Thus: Improve omega 6:3 ratio while adding in healthy monounsaturated fats and balancing saturated, polyunsaturated, and monounsaturated intake. Here are some simple strategies to do this:

To balance your fats:

Increase intake of olive oil, mixed nuts, avocados, flax oil, ground flax and other seeds, etc. Get some of each fat source each day. These foods will balance out the saturated fats naturally present in your protein sources, leading to a healthy profile without needing a calculator. (Bear in mind that you may need to reduce overall portion sizes if you are inactive because of the injury.)

To balance your 6:3 ratio:

Add 3-9 grams 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.

Dietary herbs and phytochemicals for inflammation

Beyond healthy fat balance, certain dietary herbs can help manage inflammation.

Tumeric

A flowering plant in the ginger family, turmeric has long been used as an anti-inflammatory agent and in wound healing. Current research shows that the active ingredient, curcumin, is responsible for some of the benefits of turmeric. While adding turmeric to food every day is a good strategy, using 400-600 mg of supplemental turmeric extract 3x per day (or as described on the product label) is probably more manageable for most people.

​
Garlic

Garlic has been shown to inhibit the activity of the inflammatory enzymes cyclooxygenase and lipoxygenase and affect macrophage function. Again, though, while eating additional garlic is likely a good strategy, garlic extracts may be required for more measurable anti-inflammatory effects. Typically recommended dosing is 2-4 g of whole garlic clove each day (each clove is 1 g) or 600-1200 mg of supplemental aged garlic extract.

​bromelain

Bromelain is another anti-inflammatory plant extract from pineapple. While best known for its digestive properties, bromelain is an excellent anti-inflammatory and analgesic compound although its mechanism of action is poorly understood. Typically bromelain is given in doses of 500-1000 mg/day for the management of inflammation.


​boswellia

A type of tree, Boswellia also has anti-inflammatory uses and has been shown to offer benefit through the inhibition of 5-lipoxygenase and potentially other cytokines. Typically supplemental Boswellia is taken in 300 mg doses 3x per day.


flavonoids
​
Found in cocoa, tea, red wine, fruits, vegetables, and legumes, flavononoids can help manage inflammation through their antioxidant actions. These powerful compounds likely act in other beneficial ways by affecting cell signaling.

It’s probably good to eat more flavonoid-rich foods in general, and during acute injuries. Yet it’s often easier to supplement with things like blueberry or grape extracts, green tea extracts, citrus extracts (hesperedin, naringin, etc), and bioflavonoid supplements containing quercetin/dihydroquercetin and rutin, which may lead to more powerful anti-inflammatory effects.

Again, with all of these nutrients, use caution. During acute phases of injury we don’t want to completely suppress the inflammatory response. Don’t stop inflammation from happening; just keep it under control.

And don’t load up on all of these anti-inflammatory supplements at once. Rather, focus on foods rich in natural inflammation-modulating agents such as these:

• Curry powder/turmeric
• Garlic
• Pineapple
• Cocoa
• Tea
• Blueberries

Only supplement if inflammation becomes a major/chronic problem. This would likely be discussed with your physician first.

What about NSAIDs?

In sport, it’s very common to use non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, celecoxib, etc. as the first line of defense against acute injury, pain, and inflammation. They come over the counter, docs prescribe them readily, and they reduce pain.

Yet new research suggests in some cases, NSAIDs might actually hinder injury healing in the mid-term. Celebrex, for example, reduced ligament strength in rats recovering from injury by about 32%. In another study, the same thing happened with both Celebrex and Indocin.

Not all studies show these effects, but enough of them do to cause some concern. That’s why we recommend moderating NSAID use in acute injury or muscle pain.

Beyond interfering with ligament healing, NSAIDs also may interfere with muscle strain healing, weight training adaptation, and bone healing in the mid-term. Of course, there are also the side effects (such as GI bleeding with many types of NSAIDs). Again, the data are mixed, but suggest that NSAIDs should be used sparingly.

Use caution when taking NSAIDs or any other anti-inflammatories for pain management during acute injury. In some cases the risks (GI problems, reduced healing rates, incomplete healing prognosis) may outweigh the benefits (pain management).

Inflammatory questions

This discussion of the cost/benefit ratio of NSAIDs raises the question of whether any inflammation strategy is beneficial during acute injury. After all, we want the inflammation process to occur. And NSAIDs may negatively impact healing because they block an important step in the recovery process.

So why even use NSAIDs, fish oil, turmeric, garlic, and other anti-inflammatory nutrients? Well, for starters, if used in moderation at the right time, they get results. These compounds help reduce pain, reduce excessive inflammation (which can damage local, non injured tissues), and help with later stages of injury repair.

As discussed above, we want to manage inflammation during injury, not eliminate it. That’s why we recommend moderate use of NSAIDs (if at all) and healthy use of nutraceuticals.

Remember from ​part 1 that inflammation and healing proceed on a timeline.

Following a soft tissue and/or bone injury, the acute phase of inflammation can last from the time of injury to 4 days (soft tissue) or 14-21 days (bone). During this time, we expect and want inflammation.

More aggressive anti-inflammatory strategies are best reserved for after the acute inflammatory phase. During the proliferative and maturation stages, these agents may help keep excessive, chronic inflammation at bay, speeding up the healing process.

Wrap-up and today's takeaways

That’s it for PART 2 of our series: Injury Recovery: Nutrition To Speed Up Healing.

For now, here are some key points.

• There are three nutritional targets for injury recovery: inflammation management, immune support, and anabolic support.
• Inflammation is a critical step in the injury recovery process. But it must be managed. Supplementing with omega-3 fats, reducing omega-6 fats, and balancing out saturated, monounsaturated, and polyunsaturated fat intake is a key strategy.
  
• As we’ll show you in the next few videos, other foods and nutraceuticals may also help with inflammation management. For now, on to part 3, calorie and macronutrient needs during recovery.
  

Injury Recovery: Nutrition To Speed Up Healing - Part 1

The right food and supplements to speed injury recovery

Video filmed at the Fit Pro Convention in Loughborough, England. 

All about soft tissue repair

With all the pain, swelling, redness, and dysfunction, injury can seem like a chaotic process. Yet at the physiological level, injury recovery is highly organized and consistent.

That allows researchers and clinicians to classify three distinct stages of repair:

STAGE 1: INFLAMMATION
Regardless of the type of injury, there’s usually damage to muscle, bone, and vascular tissue. When these tissues are injured, they’re deprived of their normal flow of oxygen and nutrient-rich blood. Reduced blood flow, as well as the actual physical damage, leads to cell death.

The body then initiates the inflammatory process to clear out the damaged/dead cells and lay down new ones.

Inflammation itself is stimulated by the increased movement of inflammatory/immune chemicals (leukocytes, neutrophils, macrophages, phagocytes, etc.) into the injured areas. These chemicals take care of the cellular debris and attract plasma (fluid from the blood) and blood proteins to the site of injury.

This biochemical process removes injured tissues and starts the repair process.

Inflammation is characterized by three elements:

1. Pain. This is a function of two things: First, certain chemicals involved in injury repair (substance P, calcitonin, histamines, cytokines) may interact with local pain receptors to cause the pain associated with inflammation. As inflammation proceeds, pain may also result from the swelling/pressure placed on nerve endings.
2. Swelling. This is a result of fluid seeping through damaged — and now hyper-permeable — blood vessels into the damaged tissues. These vessels are typically damaged by the initial trauma. In addition, they’re often altered chemically during the inflammatory process.
3. Redness and heat. Vasodilation up-stream of the injury and constriction downstream shunts additional blood to the injured area, producing heat and redness. The upstream vasodilation is thought to be related to nitric oxide activity.

Although painful and irritating, we need the inflammatory process for repair. Without inflammation, injuries wouldn’t heal. So any attempt to eliminate inflammation is a mistake in the initial stages of an acute injury.

Chronic injury is different.

Excessive inflammation, especially if it’s prolonged, can lead to other problems, such as continued macrophage activity at the site of inflammation and ongoing tissue destruction. This is why inflammation management is an important concept in injury recovery. It’s also why anti-inflammatory drugs are often prescribed by physicians during chronic pain.

STAGE 2: PROLIFERATION

Once the inflammation of stage 1 begins to subside, most of the damaged tissues will have been removed from the site of injury, and new vasculature will have developed.

This restoration of oxygen and nutrient flow to the damaged area allows fibroblast proliferation/multiplication. Once this occurs, collagen and fibronectin are laid down. This forms what is commonly called “scar tissue.”

Importantly, scar tissue will lay down in alignment with the forces being placed on the area. (That’s why rehab and therapy is so important.) Further, this scar tissue will contract and shorten as it matures. This is due to fibroblast differentiation into myoblasts, which are similar to smooth muscle cells. This reduces the size of the injury.

STAGE 3: REMODELING

Eventually, the scar tissue (typically made up of type II collagen) will be degraded and type I collagen (much stronger) will be laid down in its place. Although this new tissue will never likely be 100% normal, it can become about 80% as strong as uninjured tissue.

Since this tissue is created along tension lines, functional activity (rehab and therapy) is critical throughout the recovery process, as it helps to maintain the length of the scar tissue. It’ll also help arrange the tissue in an organized pattern, in line with adjacent soft tissue fibers.

This predictable pattern of soft tissue healing can give us clues about how to manage injuries through the use of physical therapy, manual therapy, nutritional strategies, and drug interventions.

All about bone repair

Bone healing undergoes a similar, yet unique, process when compared to soft tissue repair.

STAGE 1: REACTIVE PHASE INFLAMMATION
Bleeding from the fractured bone and surrounding tissue causes the fractured area to swell. This is similar to the inflammation phase experienced in soft tissue injury.

STAGE 2: SOFT CALLUS FORMATION
At this point, the pain and swelling will decrease. The site of the fracture will stiffen, with new bone forming. New bone is weaker than uninjured bone. It’s also incomplete and, therefore, cannot be seen on x-rays.

STAGE 3: HARD CALLUS FORMATION
During this phase, new bone begins to bridge the fracture, covering the incomplete soft callus. This bony bridge can be seen on x-rays.

STAGE 4: BONE REMODELING
The fracture site remodels itself, correcting any deformities that may remain as a result of the injury. This final stage of fracture healing can last up to several years.

Like soft tissue injuries, bone injuries go through an early inflammation phase. This attracts plasma and inflammatory cells to the site of injury. These cells help to clear out the damaged tissue and revascularize the area.

After this occurs, other cells (in this case, periosteal cells) proliferate and differentiate into chondroblasts and osteoblasts to form new tissue (cartilage and woven bone). This eventually forms the callus.

As with soft tissue injury, this early tissue is eventually replaced again. This time, the cartilage and woven bone forms lamellar bone after a collagen matrix becomes mineralized.

Over time, lamellar bone becomes trabecular bone, which is nearly as strong as the original bone. During the last phase, this trabecular bone is resorbed and compact bone takes its place. This compact bone closely duplicates the original bone’s shape and strength.

Wrap-up and today's takeaways

That’s it for part 1 of Nutrition for Injury.

For now, here are some key points.

• Yes, the science can get heavy at times. But you don’t need to memorize it all. Instead, simply remember that injury recovery follows a highly organized and predictable pattern.
• In both soft tissue and bone recovery, inflammation is the first step in the process of clearing away damaged cells. After that, recovery is all about building up new, functionally equivalent connective tissue and/or bone.
• As we explore the recovery process, look for targets where therapy, nutrition, and supplementation can play a role. In part 2 of the series, we’ll talk about these targets and how nutrition can help.