Rest, Ice, Compression, Elevation … and Kale?

Monica Van Winkle, MS, RD | Seattle Mariners 

Optimizing nutrition during the rehabilitation process is a new frontier in sports science. Studies are ongoing and while the current research cannot directly correlate specific nutrients with a faster return from the disabled list, science consistently demonstrates the positive role nutrition plays in muscle and bone tissue health and recovery. Studies also show that deficiencies of energy, micronutrients, and macronutrients, particularly protein, will impair wound healing and provoke loss of muscle and tendon mass and function¹.

Therefore, nutrition interventions that alter the response of muscle and tendon to injury, with or without immobilization, may support a faster return to full activity and training. An injured athlete has an opportunity to use nutrition as medicine to repair and strengthen the body against future injury; athletes without a nutrition plan may create additional and potentially avoidable damage. Without proper nutrition, an athlete may lengthen his stay on the DL, experience unwanted weight gain, accelerated muscle loss, and increased risk for future injury.

Athletic trainers working with any injured athlete should know that the number one nutrition priority during reduced muscle activity and/or immobility is to avoid nutrient deficiencies.

Additional targets of medical nutrition therapy to facilitate injury recovery should include:

• Managing muscle loss
• Ensuring adequate, but not an abundance of, calories to support healing and to prevent increased body fat accumulation
• Supporting, while managing, acute inflammation
• Augmenting long term tissue healing and regeneration
• Strengthening the immune system

MANAGING MUSCLE LOSS AND ENSURING ADEQUATE CALORIES: Immobilization of a limb causes reduced muscle strength and function, as well as decreased muscle mass. Muscle loss can begin to occur within five days of immobilization¹. This is due largely to anabolic resistance, when skeletal muscle cells respond abnormally to nutrition and exercise. In the injured state, muscle cells are more resistant to these particular anabolic, or tissue building stimuli. Additionally, immobilization is detrimental to tendon structure and function. Sports injuries that damage muscle and other soft tissues, without necessarily immobilizing these tissues, still require specific nutrients to minimize muscle loss.

The stress response to injury is characterized, in part, by increased secretion of pituitary hormones, activation of the sympathetic nervous system, and an overall increase in catabolism which increases calorie needs (especially during the acute phases of injury). There is a greater risk for muscle loss if the right amount of calories and nutrients are not provided post injury or post-surgery. The sooner nutrients are provided, the better. There is a strong consensus in the literature on military trauma patients to initiate nutrition support as soon as possible post injury². Muscle loss, along with decreased tendon mass and function, could be further exacerbated if there is a deficiency in protein.

During an injury, protein catabolism is stimulated due to increased cortisol concentrations. A major consequence of protein catabolism is muscle wasting and weight loss. Protein and amino acids have been the most extensively studied in muscle tissue injury recovery and have been shown to enhance repair by increasing muscle protein synthesis³. The branched chain amino acid (BCAA) content of protein may be responsible for the observed positive effect^4,5. Highly-bioavailable protein sources support the preservation of muscle mass, immune function, and healing. Additionally, numerous studies exist on the safety and efficacy of creatine supplementation to promote improved strength and muscle mass gains; for this reason, it is worth examining the use of creatine to slow muscle atrophy rates during limb immobilization. In individuals who had their right leg casted for two weeks, Hespel and coauthors studied the effects of creatine supplementation (20 g/day x5 days reduced to 5 g/day for 10 wks.) on rehabilitation outcomes and atrophy rates⁶. Participants performed three sessions per week of knee extension rehabilitation, over a 10 week rehabilitation period. Individuals in the creatine group had greater changes in the cross-sectional area of muscle fiber (+10%) and peak strength (+25%)⁷.

SUPPORTING, WHILE MANAGING, ACUTE INFLAMMATION: Following an injury, an inflammatory response is initiated to begin the healing process. Omega-3 fatty acids (n-3FA) are well studied in the context of healing from injury. Not only do n-3FA have the ability to reduce inflammation⁸, they have been shown to positively impact healing via several other mechanisms: slowing muscle tissue loss during a catabolic state⁹, decreasing muscle soreness/pain¹⁰, and improving outcomes during depression¹¹.

Omega-3s may be especially helpful if inflammation is excessive or prolonged¹². Inflammation is an important component of wound healing, so it is important to mediate, rather than halt inflammation. Excess n-3FA have the potential to impede healing. Therefore, decisions on supplementing and dosing should be manage­­d by medical staff on a case by case basis. Ball players requiring surgery and/or PRP should hold off on n-3FA supplementation until bleeding risk subsides. There appears to be a sweet spot for finding the correct n-3FA dose. Studies with low dose fish oil (~450mg – 1g/day) have shown no effect on inflammatory or immune markers while other studies have shown that high dose fish oil (12-15g/day) may reduce immune cell function in certain populations¹³. As a result, some scientists recommend anywhere from 3-9 grams of fish oil per day for both healthy conditions and injury repair¹³. One approach is to start with 3 g/day of high quality “NSF for Sport” certified fish oil and increase slowly, if needed, not exceeding 9 g/day.

AUGMENTING LONG TERM TISSUE HEALING AND REGENERATION: A more conservative plan is to take the ever-reliable food first approach, understanding that supplementation can only support, not replace, a healthy diet. During the most acute stages of inflammation, all injured athletes should be encouraged to avoid pro-inflammatory foods. Similarly, the importance of consuming anti-inflammatory fats and unprocessed whole foods should be emphasized. The value of bright colored fruits and vegetables, for their phytonutrients and natural healing properties, cannot be overestimated.  Athletes may also benefit from education on the negative impact that alcohol has on healing.

STRENGTHING THE IMMUNE SYSTEM: Some athletes may experience depression and/or increased anxiety during an injury. Encouraging all ball players, healthy or injured, to consume 3 oz fatty fish at least 3 times/week may boost their mental health status and ward off depression during vulnerable times. Researchers have shown that within many international populations, fish consumption is associated with lower risk of depression¹⁴.

Persistent psychological stress can cause excess inflammation in the body and has been linked to depression, along with decreased immune cell function¹⁵. For this reason, the mental stress of any injury alone can impede the recovery process. A referral to the team’s mental skills coach may provide an added layer of protection against depression. It can also facilitate healing through the employment of stress management tools to combat chronic inflammation and fight illness. Remind athletes of the role that sleep plays in empowering them to stay positive, strengthen their immune system, and heal.

NUTRITION REFERRAL AND BOTTOMLINE: Stressors such as surgery and injury can increase the body’s metabolic rate by 10-20%. Inactivity leading to weight gain and muscle loss are potential nutrition-related concerns.  It is important for athletes going through surgery and/or rehabilitation to meet overall calorie, macronutrient, and micronutrient needs for optimal recovery. Ball players should be encouraged to meet with their team’s Sports Dietitian as soon as possible after injury and into the recovery process.

                                                          Quick Reference Guide for Baseball Players

Your Sports Dietitian can help identify your specific nutrition goals for weight maintenance and optimal recovery.

Protein needs will increase.

Carbohydrate needs will likely decrease to match reduction in physical activity and training. A baseline of carbohydrates will still be necessary to support the rehab process. Choose whole, unrefined carbohydrates whenever possible.

Fat: Foods that are fried or high in saturated fat can increase inflammation and slow the healing process. Unsaturated fats decrease inflammation and may help speed up the healing process.

Alcohol is a central nervous system depressant, impedes healing and needs to be limited, especially during the initial stages of injury.

Sleep needs will remain at 10 hours or more    .

Vitamin A – promotes bone development and immune function. Food sources: sweet potatoes, carrots, mango, turnip greens, spinach, papaya, bell peppers

Vitamin C – is essential for strengthening bones and repairing ligaments and tendons. Food sources: oranges, broccoli, bell peppers, blueberries, strawberries, grapefruit, baked potatoes (with skin), cabbage, tomatoes, papaya, cantaloupe

Vitamin D – is needed for bone and muscle health, preventing depression, and supporting the immune system. Food sources: eggs (including yolk), milk, mushrooms, salmon (Other: sunlight)

Vitamin E – prevents excess damage to cells. Food sources: avocado, eggs (including yolks), milk, nuts/seeds, unheated vegetable oils, whole grains

Zinc – necessary for wound healing and healthy immune function. Food sources: meat, seafood, sunflower seeds, almonds

Calcium – needed to build and support strong bones. Food sources: milk, yogurt, leafy greens

Omega-3 Fatty Acids – help reduce pain and inflammation, prevent depression, and support neuro-cognition. Food sources: salmon, tuna, sardines, walnuts, pecans, (ground) flax and chia seeds

Tipton, KD. Nutritional Support for Exercise-Induced Injuries. Sports Medicine. 2015; 45(1), 93-104.2.

References

1. Jansen JO, Turner S, Johnston AMcD. Nutritional management of critically ill trauma patients in the deployed military setting. Journal of the Royal Army Medical Corps. 2011, Vol.157(3 Suppl 1), p.S344-S349
2. Pasiakos SM, Lieberman HR, McLellan TM. Effects of protein supplements on muscle damage, soreness and recovery of muscle function and physical performance: a systematic review. Sports Med. 2014; 44:655–70.
3. Jackman SR, Witard OC, Jeukendrup AE, et al. Branched-chain amino acid ingestion can ameliorate soreness from eccentric exercise. Med Sci Sports Exerc. 2010; 42: 962–70.
4. Howatson G, Hoad M, Goodall S, et al. Exercise-induced muscle damage is reduced in resistance-trained males by branched chain amino acids: a randomized, double-blind, placebo controlled study. J Int Soc Sports Nutr. 2012; 9:20.
5. Kreider B, Kalman D, Antonio J, et al.  International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr. 2017; 14:18.
6. Hespel P, et al. Oral creatine supplementation facilitates the rehabilitation of disuse atrophy and alters the expression of muscle myogenic factors in humans. J Physiol. 2001; 536(Pt 2): 625-33.
7. Kantor E, Lampe J, Vaughan T, Peters U, Rehm C, White E. Association between Use of Special Dietary Supplements and C-Reactive Protein Concentrations.
8. Smith GI, Julliand S, Reeds DN, et al. Fish oil–derived n–3 PUFA therapy increases muscle mass and function in healthy older adults. The American Journal of Clinical Nutrition. 2015; 102(1), 115-122.
9. Tartibian BB, Maleki H, Abbasi A. The effects of ingestion of Omega-3 fatty acids on perceived pain andexternal symptoms of delayed onset muscle soreness in untrained men. Clin. J. Sport Med. 2009; 19: 115-119
10. Adams PB, Lawson S, Sanigorski A, Sinclair AJ. Arachidonic acid to eicosapentaenoic acid ratio in blood correlates positively with clinical symptoms of depression. Lipids. 1996; 31: S157-S161.
11. Calder PC, Albers R, Antoine JM, et al. Inflammatory disease processes and interactions with nutrition. British Journal of Nutrition. 2009; 101(S1), 1-45.
12. Berardi J, Andrews R. Nutritional Strategies for the management of sports injuries. Strategies for Success.
13. Oliver JM, Jones MT, Kirk KM, et al. Effect of docosahexaenoic acid on a biomarker of head trauma in American football. Medicine and science in sports and exercise; 2016.
14. Cohen S, et al. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. PNAS; 2012.