A recent conversation with a patient revealed an uncomfortable truth that is worth exploring. After an injury in a running event, the client sustained a multifactorial injury, one to the knee and one to the ankle. With some time, proper rest and a bit of guidance and treatment from physical therapy the ankle issue is resolved. The knee injury proved to be more complicated. A gait analysis was performed and errors were seen. Strategies to resolve coordination, strength and form deficits were given and practiced. Gradual impact was smartly reinserted into the athlete’s training and on the whole things were going well. Interval scheme run: walk workouts were gradually building. Pain remained low, even while adding more load. Seemingly out of the blue, despite a lack of an exact perturbation to the knee, pain ramped during one bout of exercise. The next one was only minimally better. Following these two episodes, pain has again been low. So why the unexpected setback? Does this mean something was missed? How do we proceed forward? These are all reasonable questions, so let’s dive into the answers.
The Body’s Complexity: Healing Is Not Linear
The human body is an incredible system, composed of many interconnected tissues, nerves, joints, and muscles that work together in ways we are still learning to fully understand. When an injury occurs, it affects more than just the specific site of pain. For example, a sprained ankle doesn’t just impact the ligaments in your ankle—it can alter your gait, affect your balance, and place increased demands on other parts of your body like your knees, hips, or lower back. Healing involves coordinating the repair of tissues, restoring mobility and function, and retraining movement patterns to prevent future issues. Because of this complexity, progress often comes in waves rather than a straight line. Some days will feel like major wins, while others might bring discomfort or fatigue. This fluctuation is entirely normal.
Why Setbacks Happen
- Overloading Too Soon: It’s natural to feel eager to return to your previous level of activity, but sometimes we push our bodies a bit too far, too fast. Rehabilitation is about finding the sweet spot between challenging your tissues enough to promote healing and not overloading them to the point of aggravation. Overload does not only refer to volume but can be any variable influencing the load on the tissue. In our running example, this could be duration/mileage, intensity/pacing, surface, elevation change, shoe selection, etc. It does
- Compensatory Patterns: As you heal, your body might develop compensatory movement patterns to avoid pain or weakness. These patterns can stress other areas, leading to temporary setbacks as we work to retrain your movement.
- Life Happens: Stress, lack of sleep, or even unrelated activities can influence your body’s ability to heal. For example, as we come off the holiday, it would not be unusual to see a flare in symptoms depending on the life stress associated with the recent holidays. If sleep quality or quantity was insufficient, dietary intake was substantially changed, activity demand was either significantly increased or decreased, the body may not tolerate stress that was previously tolerable. We often times can trace these poor outcomes back several days leading up to the event.
- Systemic Inflammatory Responses: Healing involves inflammation, which is a normal part of tissue repair. Other sources of inflammation such as illness, dehydration or introducing highly reactive foods can push the body over the edge as it is trying to budget its energy towards the healing process. This is one reason it is so important to eat a very good- diet high in protein, complex carbohydrates and fruits and vegetables for the micronutrients, and get plenty of good sleep while recovering from a musculoskeletal injury, so as to set yourself up for success in the repair process.
Embracing the Setbacks
Rather than viewing setbacks as failures, try to see them as communication from your body. They provide valuable information about what your body is ready for and where it might need additional support. Here are some ways to navigate setbacks effectively:
- Communicate Openly: Let your physical therapist know about any setbacks. Together, the client and the provider can adjust your treatment plan to better suit your current needs. A simple restructuring of the plan might be in order, or a further, more in-depth analysis as bodies are always changing.
- Focus on the Big Picture: Progress isn’t about perfection; it’s about moving forward overall. A few steps back don’t erase the strides you’ve already made. Frequency, intensity and duration are all factors that can be examined in order to see if progress is being made. Frequency refers to how often, or what percentage of the day/ time of activity, is the discomfort present. Intensity can be both the rate of perceived discomfort (ie: 8/10 goes to 4/10) or the quality changes (sharp, stabbing goes to dull/achy). Duration examines how long the symptom takes to dissipate. If any or all of these factors are changing for the better, you’re moving in the right direction!
- Practice Patience and Kindness: Healing takes time. Remember that your body is doing the best it can, and setbacks don’t mean it’s failing. It is hard to stay objective and remove emotion from the journey, especially at pertains to an adjustment to a loved activity, and it is not abnormal to feel one’s mental health impacted by the recovery process. Speaking with a mental health professional or a sports psychologist, as appropriate, might be a great addition to the team.
- Stay Consistent: Even when it feels like you’ve hit a roadblock, sticking to your rehab plan (with adjustments, as needed) is crucial. Consistency helps rebuild strength, mobility, and confidence. This is why it is very unusual for complete rest to be warranted, with the exception of a few types of injuries. Bodies adapt and align to stress- it’s Wolf’s law. If we want to slowly march our way back to health, we need to enjoy the small wins and look for pain-controlled activity.
About the Author
Jackie Sanders is a licensed Physical Therapist. She graduated from Wright State University with a Bachelor’s Degree in Exercise Biology. She then earned her Doctorate in Physical Therapy from the University of Cincinnati. In addition to being a physical therapist, Jackie is also a Certified Running Coach, with a special interest in video gait analysis. Her favorite part of physical therapy is working with patients to find creative solutions to meet their goals. She is passionate about treating patients holistically and determining the root cause of their impairments.