Healing Tissue

By Kelly Starrett

In ExPhysiology, Medical/Injuries, Videos

July 05, 2009

Video Article

Strength and conditioning can only normalize tissue permanently changed by injury. You can never undo what’s been done, Kelly Starrett told participants at a one day seminar at CrossFit Santa Cruz on March 14, 2009. Starrett is the owner of San Francisco CrossFit and a Doctor of Physical Therapy.

A bad ankle sprain can take four to six weeks to heal. CrossFitters may be supermen, but they can’t outrace the body’s tissue healing times or physiology.

Factors that can impede healing include age, nutrition, sleep, stress, and inactivity. So can diabetes, use of anti-coagulant medication and use of the corticosteroids used in asthma inhalers.

It is not up to trainers to suggest athletes use ibuprofen. Tylenol is preferred. But physicians may recommend use of ibuprofen for certain acute joint strains. Finally, inflammation is best treated with ice.

12min 10sec

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27 Comments on “Healing Tissue ”

1

wrote …

What about naproxen?

2

wrote …

It's an NSAID, anaproxsodium if I remember correctly.

3

wrote …

it is my understanding that over the counter doses do not reach levels where anti-inflammatory properties kick in. What does that mean for the embargo on NSAID? Are NSAID's useful at low doses? And are over the counter doses so low that they are largely useless as pain relievers?

4

wrote …

naproxen sodium is an NSAID. anti-inflammatory effects with motrin are usually achieved at 600-800mg doses, so technically a 'prescription dose' is what is needed. i put that in parenthesis because the prescription you receive from your doctor and get filled by your pharmacist is the same as taking 3 or 4 200mg over the counter motrin. there is nothing extra or special in prescription motrin.

kelly is correct about not wanting to take this stuff for long periods for obvious reasons like increases in risk of bleeding, impinged healing, but for some people it's necessary. i still suffer from back pain after surgery to repair two herniated discs and spinal stenosis, and NSAIDS are the only thing that releives my pain, and refuse to take narcotics. i know it's not optimal, but for the time being, and until it is determined if i need more surgery or not, i take Celebrex, which is also an NSAID but has a lower risk of bleeding.

5

wrote …

Fortuitous timing for this segment, I strained my hamstring yesterday playing rugby and was searching for some good information on rehab. I did the same thing a few years ago and it took forever to heal...probably because I liberally dosed myself with ibuprofen, had a poor diet, and little sleep. How little I knew...

Great stuff Kelly!

6

wrote …

I find the discussion of NSAIDs wholly unsatisfactory and encourage others to wait until they know more to change their habits.

I've read the relatively recent technical literature that says NSAIDs hinder recovery. The question I have is whether this is the basis for this recommendation. In fact, my question is fundamentally where in the hell this advice comes from. CrossFitters seem very happy to buck the trend of the 'establishment' so long as it's endorsed by a friendly face (not your horribly inept doctor) and I'm curious why this proviso isn't being questioned. There's a long history of NSAID dosing for people engaged in athletics -- especially in the lifting community. If we're not restricting the discussion to technical journals, why isn't that school of thought represented here (even if only to be refuted)? Also, people who follow Zone protocol might wonder why it is that they've been told eicosonoids are bad (answer: they cause inflammation). Also, perhaps we might wonder why fish oil is good (answer: it contains a favorable omega 3:omega 6 ratio that helps control inflammation). Should I stop with the fish caps and pomegranate juice too?

Tylenol is notoriously rough on the liver and cannot be used as a replacement for Advil. If one chooses to change his medication for aches and pains, it's damned important to know that fact; it's hard to hit 95 kipping pull-ups in liver failure, hand skin resilience be damned.

I don't want to be wholly negative, but I feel like there's very little in the way of evidence-based fitness being discussed here. If these suggestions are the result of evidence -- academic or anecdotal (not pejorative) -- I'd love to see it, especially the starred point about NSAIDs where the advice of doctors is mocked. Is any better, more informative wisdom offered? Nope. Do you know whether Advil will make your healing time 1%, 10%, or 100% longer? Nope. What does this video tell you? Almost nothing.

7

wrote …

patrick-

good points and i am particularly with you here on this one. it's very easy for some to say just don't take them, but if it's the difference between between being able to function normally or be in pain, for me the answer is obvious. i think the scary thing here is what a bunch of people will take from this is they will go out and tell all their clients to stop taking the stuff and start preaching how bad the stuff is, just from hearing this one clip and not looking into it more themselves, when most of them probably have no medical background/education/training whatsoever. but in defense of the other side, there are a lot of physicians and healthcare professionals who don't know what they are talking about as well, and spout out things they know nothing about (a wonderful example is the orthopedic surgeon or sports medicine doc telling a patient that deep squatting is the worst thing you can do for your knees when we all know that couldnt be more far from the truth). like kelly said, you really need to speak to your physicain here on this one, and if you dont like him or trust what he is telling you take the initiative to educate yourself and if need be get a new doc. the unfortunate thing is most primary care physicians are worthless and more often then not the PCP will tell the patient that comes to them if it hurts when you do that then dont do it, and most of our health care providers are overweight, sedentary people who probably dont see much in the way of exercising themselves.

the other rather shocking point that i disagree with here in this piece is kelly basically states that it's ok to take medication to help you sleep but its not ok to take NSAIDS for pain! i have to disagree on this one. instead of relying on a drug to help you sleep it would benefit you more to find out why you arent sleeping, and what's causing your sleepless nights, be it stress, or whatever and try and correct the things and make changes to your sleep patterns/environment before going to something as nasty as ambien that has a whole slew of very unfavorable side effects.

8

wrote …

http://www.boston.com/news/health/articles/2009/06/22/nsaids_inhibit_bone_healing/
This is just an article that i found quickly on the internet. Doesn't go into too much depth but i think you are correct in asking for more of an explanation on this topic...I would like one too.

9

wrote …

I love seeing the questions on concepts.
Two articles that support what Kelly is saying:

1. The use of therapeutic medications for soft-tissue injuries in sports medicine; MJA 2005; 183 (7): 384-388

2. NS-398, a Cyclooxygenase-2-Specific Inhibitor,Delays Skeletal Muscle Healing by Decreasing Regeneration and Promoting Fibrosis; Am J Pathol. 2005 Oct; 167(4):1105-17.

It is important to realize that there are many different combinations of factors that may or may not warrant the short term use of NSAIDs. The important thing to remember is not whether or not drugs for sleeping or pain-relief are great or the devil, but that the main focus of rehabilitation from any injury is the "normalizing of tissue". Normal tissues don't need NSAIDs or Ambien. Always strive to improve to the point where all you need is proper fuel (paleo/anti-inflammatory diet) to feel good.

If you think you need a little drug induced relief or something to knock you out for half a day...whatever; as long as you progress to kick butt without them.

10

wrote …

Patrick,
Please allow me to clarify a few items.
1) I do not mock or intend to mock doctors. My point in the video to "check with you doctor" is to clarify that taking anti-inflammatories of any kind, and at any time is serious business and should be made with the guidance of a physician. Period.

2) The technical evidence about NSAID's affecting tissue healing IS what I'm basing my discussion on. My friends know that I was all about the Ibu until I began working as a physical therapist in a world class Sports Medicine clinic where:
Minimizing NSAID's use was the clinical standard for care (ligament ruptures, tendon ruptures, tendonopathies, surgical reconstruction, etc). This is directly in response to the literature (best practice) and the clinical experience of nearly 20 years of treating high level sports injuries. (About a billion famous high end athletes were treated there as well as normal folks). This clinical experience coincides with the literature: For example, the following is a study that reports faster return to duty with the use of NSAID's in a good study.
But reports (even in the abstract) that quote: "Interestingly, subjects treated with piroxi cam showed some evidence of local abnormalities such as instability and reduced range of movement."

A Randomized Controlled Trial of Piroxicam in the Management of Acute Ankle Sprain in Australian Regular Army Recruits
The Kapooka Ankle Sprain Study
Mark A. Slatyer, BMedSci, BMed, PhD, FAFPHM

3) Tylenol is horrible stuff. So dangerous in fact that the FDA changed the dosages because it is the number one way to kill your liver. No question here.
Again, the best practice in the clinical setting in which I was part was to treat swelling with ice, and tylenol (under an Md's guidance) for pain. Never, never drink and take tylenol.

4)You bring up an excellent point about the "other issues" of taking anything for pain. Ibuprofen has been shown across the board to be murder on the stomach and be the number one cause of bleeding stomach ulcers. I have personally witnessed several athletes in the clinic taking hidden ibu (not cleared with their doc and not cases of poly-pharmy) end up in stomach surgery after becoming anemic secondary to GI bleeds.

5) There is good evidence that Ibu/nsaids mess with renal function and may lead to hyponatremia.

NSAID use increases the risk of developing hyponatremia during an ironman triathlon
WHARAM Paul
(1) ; SPEEDY Dale B. (1) ; NOAKES Timothy D. (2) ; THOMPSON John M. D. (3) ; REID Stephen A. (4) ; HOLTZHAUSEN Lucy-May
Medicine and science in sports and exercise 2006, vol. 38, no4, pp. 618-622

Additionally, the evidence is strong that NSAID's like ibu put significant downstream load on the kidneys. Since many of us are running around with high CPK levels secondary to our hard training, taxing kidney function probably isn't necessary.

6.) My doctoral training includes courses in pharmacology and histopathology. The mechanisms of prostaglandin suppression and the subsequent halting of the inflammation cycle are well known. What is not well known, because the long term longitudinal studies in humans are hard to come by, is what the long term effects of nsaid use are. Clinically, first hand, I've seen stress fractures, heal cord ruptures, rotator cuff tears that existed in the presence of athlete typical self-medicating nsaid dosages. (I know it's only "black box" clinical experience and not and RCT.

7) Are other alternatives to nsaids suggested in the this CLIP of a 7 hour lecture? No. In the other parts of the lecture, yes. Of course.

8) An excellent editorial from this Feb 2009 in the American Journal of Sports Medicine draws many of the same conclusions.
Feeling No Pain
Bruce Reider, MD
Am J Sports Med February 2009 vol. 37 no. 2 243-245
--Nsaid use is extremely widespread
--Nsaid use should be used cautiously because of potential downstream effects.

9) Where the "hell" this advice comes from: Kelly Starrett DPT, formerly a full time sports medicine practicing therapist a world class sports medicine clinic called The Stone Clinic. Now in private practice. Everyone in that lecture knew this. I'm sorry it's not clear. I can certainly see that it would be even more disconcerting if this was just coming from Kelly Starrett Crossfit Coach.

10) Good point about hand ripping and liver failure.

11) This video tells you several other factors that affect tissues healing times.
Again, it is the opinion of the practice group (MD's) of which I'm part that due to the scientific literature and long/vast clinical experience, NSAIDS affect tissue healing.

Effect of ibuprofen and diclofenac sodium on experimental would healing.
Dvivedi S, Tiwari SM, Sharma A.
Indian J Exp Biol. 1997 Nov;35(11):1243-5.Links

The Role of Nonsteroidal Anti-Inflammatory Drugs in the Treatment of Acute Soft Tissue Injuries
Jay Hertel, MEd, ATC
J Athl Train. 1997 Oct–Dec; 32(4): 350–358.

Indomethacin and Celecoxib Impair Rotator Cuff Tendon-to-Bone Healing
David B. Cohen, MD*, Sumito Kawamura, MD§, John R. Ehteshami, MD|| and Scott A. Rodeo, MD
The American Journal of Sports Medicine 34:362-369 (2006)

Effect of ibuprofen on the healing and remodeling of bone and articular cartilage in the rabbit temporomandibular joint.
Obeid G, Zhang X, Wang X.
J Oral Maxillofac Surg. 1992 Aug;50(8):843-9

Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies.
Almekinders LC.
Sports Med. 1999 Dec;28(6):383-8.

Inhibition of tendon cell proliferation and matrix glycosaminoglycan synthesis by non-steroidal anti-inflammatory drugs in vitro.
Riley GP, Cox M, Harrall RL, Clements S, Hazleman BL.
J Hand Surg Br. 2001 Jun;26(3):224-8.

The Mechanisms of the Inhibitory Effects of Nonsteroidal Anti-Inflammatory Drugs...
Harder and An J Clin Pharmacol .2003; 43: 807-815
And:

Comprehensive Sports Injury Management
By Jim Taylor, Kevin R. Stone, Michael Mullin, Todd Ellenbecker, Ann Walgenbach
Pg.s 77-85
Isbn 0-89079-891-5


Overall, I'd like our athletes to understand that they should follow the nutrition healing guidelines outlines by the experts like Robb Wolf. They should diligently ice and use other recovery modalities at their disposal (arnica, soft tissue mobilization, etc) before they short cut to using an Nsaid of which they cannot be sure of the effects.

Pain and discomfort are badges of honor in any legitimate training community. Even Eric Cressey claims that if you aren't on the verge of a tendonitis, you probably aren't really training hard. But we have to take the peripheral responsibilities seriously as well. Nsaids, tylenol, Asa are all serious business, and we need to ingest them in a serious, well informed manner.


Scott,
I should have been more clear. Poor sleep secondary to post surgical pain is the only reason I think it is prudent for an athlete to use Ambian under an MD's orders for a night or two. And yes, they should try and NOT use it if they can.

And of course if you can't manage pain without the use of a Doctor monitored drug intervention, then don't. Use the drugs. Just be sure to understand that it may have unintended consequences to your disc healing. Know the compromise, be a well read and informed consumer. (ibuprofen is like a miracle elixer of pain removal, I know)


Kelly

11

wrote …

kelly,

thank you for taking the time to elaborate. as usual, awesome info, and hopefully the previous posts werent taken the wrong way. thanks again!

12

wrote …

I am actually a physician specializing in rehabilitation. We don't use NSAIDs for the reasons referred to in the lecture. I will not argue more than to provide my perspective. Our reasoning is based on the current peer review medical literature. The orthopedic surgeons in my referral base have almost wholly discontinued the use of NSAIDs for their post op patients. Take it how you will but this Crossfitter physician agrees with Kelly. Great lecture.

13

wrote …

My thanks to everyone who contributed. Puts a healthy scare into indiscriminate use of meds.

14

wrote …

Awesome information. And thanks for your comments, too. I have learned so much from you videos and blogging. Please keep it up.

15

wrote …

Kelly,

Thanks for the lit review...my library is ever expanding with solid info to combat common misconceptions.

16

wrote …

I have a bad disk in my spine. That's what happens when you let the curve in the spine flatten out at the bottom of a squat. I just got the MRI today and I can see a bunch of white disks then one black disk bulging out the back. I talked to my doctor earlier this morning about getting some meds for the pain, which has gotten worse in the last few months. He told me to take Ibu. I don't quiz him on NSAIDS but I'm really wondering what other options there are. The pain is horrible in the morning and it doesn't become tolerable until after lunch. I was taking Ibu but I stopped after this video. What can I do? What should I tell my doctor?

17

wrote …

Just read through the comments, and the major point that stuck in my head, is "DAMN! Those guys got to listen to 7 hours of K-Star!" I think I need some ibu to eliminate the jealously pains I'm getting all over.

18

wrote …

Kelly,

Absolutely great lecture!

I am one of the "older" CrossFitters at 58 and have suffered my fair share of tendon and muscle injuries, though in my case, we've been able to establish the presence of a high serum Uric Acid level in my body for a probable correlation to the tendon ruptures. Overall, I tend to heal very quickly, but find that I require longer warm-up periods than the average person. This is particularly evident with minor hamstring strains I've suffered in the nine months I've been doing CF.

I have also used NSAIDs (ibu and Aleve), though my dosages have been very low - - 1 or 2 200mg tablets just prior to or immediately after my workouts upon suggestion of my orthopedic surgeon, and then, only as necessary. Most of the time I take nothing.

I am a firm believer in "RICE," but also active recovery. Coach Rippetoe spoke of this in a short article titled "Muscle Injury Rehabilitation." I have utilized his program and previously, my own, where I exercised my injury and "ran" it through the full ROM.

One question persists, though. Is it safe to use even minimal amounts of NSAIDs to lessen (not inhibit) inflammation? Obviously, we WANT to encourage micro-tears in our muscles to increase muscle fiber and strength for example, but what of the situations where the serious inflammation goes beyond simple "RICE" and un-aided relief?

Steve

19

wrote …

Thanks for the invaluable information Kelly. I also like that there has been some discussion and questioning of Kelly's points. Kelly I certainly respect you as an expert but it is always good for people to question things. I think that your reasoning is sound, and I am of the general view that less medication is better because you are right you never know what the effects will be down the road.

I found this video and discussion very timely since I blew out me knee on the weekend wakeboarding. You made me laugh because I thought that my tendons were like steel cables from crossfiting and I was indestructible but when the force of doing an under-rotated 360 coming down from 6 or 7 feet in the air at 25-30mph with all of your weight on my right knee (my driving knee) even my steel cables gave out. So now I am in the process of recovering and I am doing all that I can do rehab quickly because I can't stand to be out of commission. I did take some Ibu the day of the injury for the pain but now that the pain has subsided I can stand the pain without it. Anyhow thanks for the information Kelly and I really respect your expertise and advice.

20

wrote …

Thanks to all who participated in this concluding discussion, especially Kelly who graciously responded to questioning.

21

wrote …

Kelly,
I just completely dislocated my right elbow (ball sitting side by side with socket) with 2 minor fractures on saturday the 4th. One should always keep a hand on the pullup bar especially when it is 12' or at least not extend an arm to stop the fall.

I am on ibu but stopping that now. I'm also on loratab for pain. I have awakened every night from pain, so I have not had sleep a full night. I am doing RICE all day way more than doctors orders and goto bed with ice on my arm. I hadn't thought of Ambien, I will speak to my doctor about that unless I sleep through the night today.

If you have any other suggestions or readings for healing and mobility I would appreciate them.

I am getting a ROM brace tomorrow, so I will begin moving it more soon.

Thanks for doing these videos, they are very helpful.


22

wrote …

Thank you Kelly for the great discussion concerning tissue healing in general. Thanks CrossFit community for the honest, open debate re: ibuprofen use. I confess that ibuprofen has been a miracle drug for me for over 20 years. It has consistently been the only drug that has helped me control 28 years of low-back pain. I am referring to pain anywhere from simply annoying to moderately severe to 6 months of agony with 2 hernitated discs. Now I try very hard to use IBU as a last resort only, a "secret weapon", if you will, when I am in the middle of an acute bout of pain and my usual remedies are not working. Question to the CrossFit community: has anyone heard of Profen, a topical ibuprofen/arnica cream? I am curious as to how effective it is. You can check it out at: profencream.com. Question to Kelly: I have listened to all your shoulder function series and they are very helpful. Where do you suggest I look for the resources to help me put together an effective warm-up, movement prep, pre-hab, preventive plan for shoulder & shoulder girdle strength & flexibility? And one more if you can: what exactly do you mean by T-spine flexibility work? Thank-you very much Kelly and the CrossFit community everywhere.

Very Sincerely,
Matthew Mullings

23

wrote …

Kelly,
I was curious what type of rehab is performed for medial epicondylitis.
I received the injury several years ago when the WOD was 100 chinups 3 days in a row. ( It was my first week of Crossfit)

I tried rest from chins 3 or 4 times for about a month with a slow build up. Then I'd reinjure the area.

Eventually I started adding external rotation work for and within a week the pain was for the most part gone.
Sometimes when I do a workout with > 100 chins, the left elbow will be sore for a few days.
I'll usually take a break from chins for a few days.

I've also been having a similar issue with achilles tendinitis( inside of leg, immediately below Gastrocnemius).
I have been rehab'ing that with negative calf raises. Then when the pain goes away, I start progressing with jumping rope.
It seems to be improving, then I re-injure myself by running to much too soon.

It seems one of the dangers of CrossFit is that your metabolic conditioning can be higher than your bodies ability to deal with the stress of impact.

I guess my question is, once an area has been injured, is it just normal for it to get sore from acute stress?
OR
Am I continuing to reinjure the area that may lead to further injury down the line?

thanks for the great video,
Bryan

24

wrote …

A few quick points (I'm an MD who does some pain management, BUT this statement is not a substitute for a DR visit):
Whether NSAIDS impede healing is still controversial, not dogma
NSAIDS are useful adjuncts for patients with chronic or severe pain
There is evidence that severe pain may itself impede healing
Undertreated chronic or severe pain can lead to debilitating syndromes such as CRPS

Kelly is absolutely correct that NSAID use is too widespread, should be reserved for more severe pain, and should be used sparingly by most people. The advertisements for Naprosyn are very misleading.
In my opinion it is best for serious crossfitters to consult with a physician who has a good understanding of athletic/fitness training. We are out here; some of us even have sub-4 Fran times and 950 cf totals

25

wrote …

Great video and talk. I watched this again due to my recent injury. I partially tore the rectus femoris in the muscle belly while initiating a sprint. I minimized Ibu with the blessing of the OrthoMD and Physical therapist. It was great to feel the daily progress of healing. I knew where my body was each day and what I could do. (12 days out, not doing much)

For years, I used Ibu to treat plantar fascitis and sore R shoulder. I used it as "Vitamin I" I will use Ibu when necessary, but I will never use it as a daily vitamin again. I think the lesson to take from the video is to know why you are taking a med, what you are gaining and what the possible side effects/unintended consequences are.

Thanks for the great info.

26

wrote …

I just broke my right wrist in two places and my pinky July 19. Had surgery to put a plate in the wrist and will have the pins in the finger until mid August. Am back working out doing squats, kettle bell with left hand, sit ups and riding the air dyne bike. Not taking any more pain meds. Using ice for the swelling. Any other suggestions?

27

replied to comment from George Raguz

I was just prescribed Naproxen for a ligement tear in my thumb.It is defenitly a NSAIDS!!! I never took any of it and I ICED for 2 days and I am already regaining Range of motion

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