Injuries happen. From tripping on a curb and spraining an ankle, pulling a hamstring during a game of football, to suffering a knee injury such as an anterior cruciate ligament tear. Injuries can happen to anyone, but are more common in individuals who engage in regular physical activity and specifically those who play or compete in sports.
Scandinavian studies show that sports injuries account for 10-19% of all acute injuries seen in accident and emergency rooms1 with the majority of injuries occurring from sports like football, basketball, volleyball and hockey.2 Other injuries requiring treatment include burns, ulcers and pressure sores.
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Risk factors for injury
Risk factors include; ageing, gender, body composition, history of previous injury, current physical fitness, skill levels as well as external factors such as weather conditions and potential protective equipment such as pads and guards.3
Poor nutritional status may also be considered a risk factor for injury. For example, nutritional deficiencies such as calcium and vitamin D that may contribute to reduced bone density can make people more prone to breaks and fractures. This is more common in the elderly.4 Other common micronutrient deficiencies among the elderly include zinc, and vitamin B12 which may have a significant impact on wound healing.5
Low protein and low calorie diets may result in poor nutritional status, this is also more commonly seen in elderly nursing home populations.5 Poor wound healing may occur in persons with diabetes as a result of a lack of blood flow to the area due to diabetic neuropathy.6
Almost any part of the body can be injured, including bones, muscles, joints and connective tissues (tendons and ligaments). Ankles and knees appear to be particularly prone to injury.
Signs of injury
Pain in the area is the most common and obvious sign of injury, whether this is sudden or comes on afterwards, as well as tenderness, bruising, swelling and stiffness or restricted movement of the area. Whilst it might be tempting to keep playing, or finish a game, continuing to exercise through injury may cause further damage and slow recovery time. Provided you do not require more intensive medical treatment such as stitches, or x rays, NHS advice is to use PRICE therapy at home (“Sports injuries – Treatment – NHS.UK”).
P – Protect the area from further injury, for example using a support or splint.
R – Rest as much as possible for 2 days following the injury. Avoid putting weight on the area.
I – Ice, apply a covered ice pack to the area for 10 minutes and repeat regularly over 48 hours.
C – Compression of the area, ideally using a snug (but not tight) medical bandage.
E – Elevation, trying to keep the area raised when you’re not icing the injury.
Whilst PRICE is useful in the initial instance, could there be further, more targeted nutritional and supplementary approaches to aid recovery and support repair?
Firstly we need to understand what happens immediately after an injury and the stages of repair.
Soft Tissue Repair happens in several phases:
Phase 1. The initial response to an acute injury is inflammation, and haemostasis, the aim being to control cellular damage and blood loss, clear debris from the site, and try to prevent and control invading bacteria. This phase may last up to 4 days from the time of injury, and includes vasoconstriction to eventually stop bleeding and form a clot. The injury may look red and swollen during this phase, and feel warm to touch.
Phase 2. Proliferation. New blood vessels are formed, fibroblasts produce collagen, wound edges start pulling together and the wound is covered in a new layer of epithelial tissue. This process may start around day 3 after injury and continue for up to 2-3 weeks.
Phase 3. Remodelling. Collagen and other proteins become more organised in structure, and a stronger type II collagen replaces type I. This phase can take up to 2 years to be complete. Scar tissue may be only 70-80% as strong as previous tissue.8
Bone Repair also happens in stages:
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
Pain and swelling decrease. The site of the fracture will stiffen, with new bone forming. New bone is weaker than uninjured bone, it is also not complete and cannot be seen on x ray.
Stage 3: Hard callus formation
New bone begins to bridge the fracture during this phase, covering the incomplete soft callus. This bridge can be seen on x-rays.
Stage 4: Bone remodelling
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 several years.10
What can be done to support healing with nutrition?
Whilst it might be tempting to have a few days on the sofa eating pizza and ice cream, ensuring a balanced ratio of macronutrients and using specific foods and nutrients may reduce recovery time and support healing. Research suggests that the therapeutic usage of certain nutrients in dosages above the Government’s recommended intakes (i.e. nutrient reference values – NRV) may help wounds to heal5.
Proteins are fundamental structural components of all cells and tissues, and are required for repair. During phase 2 of repair when new tissue is being created and laid down, protein requirements increase. Depending on the type of injury, large amounts of protein may be lost each day. The presence of a chronic wound (such as a pressure ulcer) may increase protein requirements by as much as 250% and calorie requirements by 50% in order to preserve lean body mass.11
The British Nutrition Foundation recommends a daily protein intake of 0.75g/kg body weight for healthy adults and there have been suggestions for differing protein amounts depending on the type of injury (“How dietary protein intake promotes wound healing – Wound Care Advisor,”).
1 – 1.5g protein/kg although this may vary depending on the extent of the surgical wound
1 – 1.5g protein/kg although those with deep ulcer sites or multiple pressure sores may need close to 2g protein/kg.
Large burn wounds may require 1.5 – 3g protein/kg
Injured athletes may require 1.5-2.0 g protein/kg. To ensure a quick recovery, this higher protein intake would likely need to be consumed consistently. At a minimum, injured athletes would be best to aim for 1 g of protein per pound of body weight.13
Whilst there are variations in protein requirements depending on the injury, it would be wise to ensure your intake following injury is adequate. Eating a source of good quality protein such as egg, meat, poultry or high protein dairy such as whey, yoghurt or cheese at each meal should suffice. Vegans would likely need to ensure a combination of sources such as tofu, plant based protein powders, legumes and nuts and seeds to ensure they consume an adequate amount.
Specific Amino Acids
Collagen is the most abundant protein in the body and helps compose the extra-cellular matrix. Over 20 different types of collagen have been identified in humans, the most abundant being types I, II and III which make up 80% of the body’s collagen. In repair phases 2 and 3 collagen is produced and laid down. More recent research has focused on whether collagen may have a role to play in topical application, such as the use of dressings.14
Eating a diet rich in protein, particularly in connective tissues, from animal products and using home made bone broth may support collagen requirements. However the body is capable of synthesising its own collagen provided you have enough lysine, methionine (essential amino acids that must be obtained via dietary protein), vitamin C, zinc and copper.
Arginine and glutamine may also be beneficial for tissue repair. Arginine stimulates insulin release and Insulin Growth Factor action. These are anabolic hormones which increase protein synthesis and collagen deposition. Glutamine is an amino acid essential for the metabolism of rapidly turning-over cells such as lymphocytes and enterocytes. During injury glutamine needs increase. Glutamine has been hypothesised but not yet conclusively proven to speed up wound healing, however some studies showed that combining arginine and glutamine as supplements for 2 weeks did significantly increase collagen synthesis in adults.15
Bone healing support
Vitamin D, calcium, boron, magnesium and vitamin K are all essential nutrients for bone repair and remodelling.16 As these nutrients may be lacking, due to low dietary intake and, in the case of vitamin D insufficient sun exposure, they may be supplemented for those with bone injuries, and potentially in older populations or those in high risk groups for bone injuries.
Soft Tissue Support
Cartilage tears, cuts and sprains may benefit from the use of glucosamine, especially when paired with an omega 3 fatty acid.17 Glucosamine is an important basic natural component of cartilage and synovial fluid. It is naturally formed by the body, but can also be found in food. More commonly used in cases of arthritis, its role in soft tissue support may help strengthen connective tissue, increase synovial cells to improve viscosity of synovial fluid, which may prevent ligament tears and support new tissue being laid down after injury.
MSM (methylsulphonylmethane) is an organic form of sulphur with a range of biological effects. High levels of sulphur are found in the muscles, skin and bones as well as concentrated amounts in the hair and nails. Sulphur is a component of keratin, collagen and elastin, providing flexibility, tone and strength to muscles, bones, joints, skin as well as hair and nails.
Inflammation itself is a useful and necessary part of healing, therefore rushing to combat inflammation in the first instance may be counter productive. However for longer term recovery, once the inflammatory phase is over, further support may be required in order to keep ongoing and/or chronic inflammation under control.
Having a diet rich in omega-3 fatty acids from fish, flaxseed and vegan algal sources and monounsaturated fats like olive oil, and low in trans fats, and omega-6 rich vegetable oils such as sunflower and canola, may help support a healthy balanced inflammatory profile. High omega 6:3 ratios may reduce collagen production required for repair, whereas a low 6:3 ratio may support repair. Dosages of between 1-3g of omega-3 fatty acids daily have been shown to improve repair time to blister injury, however most of the benefits in wound healing were in the group who had taken fish oil for 4 weeks prior to injury.18 This may support the case for regular daily consumption of fish or an omega-3 product for overall health and to support tissues in the event of injury.
Other phytochemicals with anti-inflammatory actions include turmeric (curcumin), garlic, bromelain (from pineapple), boswellia and flavonoids.19 Ensure the diet is rich in the following foods:
- Pineapple and Papaya (although care on quantities as also high in sugar)
- Cocoa (unsweetened)
- Turmeric – fresh or dried
- Green Tea
- Rosemary and Sage
Vitamins A, B, C, and D as well as the minerals calcium, copper, iron, magnesium, manganese, and zinc are all important for injury recovery.
Vitamin A has been used topically for the repair of several skin conditions such as acne, psoriasis and sun damage, and has been shown to stimulate epithelial growth as well as provide anti-inflammatory effects in open wounds. Studies are not conclusive for the optimal doses of vitamin A but suggest it may be between 10,000 – 20,000IU per day. Vitamin A above 5,000IU may cause birth defects and cause liver damage if taken prolonged so we would not recommend high dose vitamin A intake without supervision from a healthcare professional.5
The amount of vitamin C required for wound healing varies, but research suggests that for small wounds or pressure ulcers 500 – 1000mg daily in divided doses is optimal. More severe wounds, such as large burns, may require closer to 1-2g of vitamin C per day.5
Zinc is required for the production of over 200 enzymes including those required for wound healing, antioxidant function, cell replication and tissue repair. Zinc supplements of up to 30- 40 mg/day for up to 10 days after injury may enhance wound healing.20 21
- Poor nutritional status is a risk factor for injury. For example, nutritional deficiencies such as calcium and vitamin D that may contribute to reduced bone density can make people more prone to breaks and fractures. Other common micronutrient deficiencies include zinc, and vitamin B12 which may have a significant impact on wound healing.
- Protein needs increase considerably following significant injury and requirements vary depending on the injury. Eating a source of good quality protein such as egg, meat, poultry or high protein dairy such as whey, yoghurt or cheese at each meal should suffice.
- Collagen is a protein that helps compose the extra-cellular matrix. The body is capable of synthesising its own collagen provided you have enough lysine, methionine (essential amino acids that must be obtained via dietary protein), vitamin C, zinc and copper
- Glutamine is an amino acid essential for the metabolism of rapidly turning-over cells such as lymphocytes and enterocytes. During injury glutamine needs increase. Glutamine has been hypothesised but not yet conclusively proven to speed up wound healing.
- Vitamin D, calcium, boron, magnesium and vitamin K are all essential nutrients for bone repair and remodelling. Glucosamine and MSM are useful for soft tissue support. Vitamins A, B, C, and D as well as the minerals calcium, copper, iron, magnesium, manganese, and zinc are all important for injury recovery.
Relevant Cytoplan Products
Wholefood Multi – Wholefood multivitamin and mineral supplement made from minerals that have been hydroponically-grown into a cruciferous vegetable resembling broccoli. Ideal for adults and children (12+) in an easy-to-take daily capsule and including antioxidants, Vitamin D and Chromium.
Vitamin A – A form of Retinol Palmitate and is a vegan product. Vitamin A has been shown to be essential for the integrity of mucosal membranes and therefore plays an important role in supporting the digestive and immune systems as well as brain health.
Cherry C – Rich in vitamin C and carotenoids, with the cherry-like fruits being one of the richest-known natural sources of vitamin C.
Food State Zinc & Copper – This product is presented to the body in a probiotic complex and thus is a gentle and well absorbed supplement. Food State Zinc is combined with copper to prevent a possible risk of copper deficiency during long-term usage.
L-glutamine – The amino acid Glutamine may be helpful for maintaining a healthy digestive system and can provide a role in the immune system. Glutamine is stored in the muscles of the body and is involved in the repair and building of new muscle.
Glucosamine Hydrochloride – Glucosamine, which is naturally synthesised within the body but rarely found in natural food sources, provides raw material for the building block of cartilage tissue around joints. When there is excess wear, more raw material is needed for the joints and surrounding structures in our bodies.
MSM (Organic Sulphur) – necessary in the formation of keratin collagen and elastin – which give flexibility, tone and strength to muscles, bones and joints, internal membranes, plus skin, hair and nails.
Bone Support – Multi-nutrient formulation specifically tailored for those who are concerned about bone health and bone mineral density, providing calcium along with other nutrients that are important for bones – magnesium, boron, vitamin D3 and K2.
Cell-Active Curcumin Plus – Contains curcumin from turmeric and gingerols from ginger root. Phyte-Inflam is a natural phytonutrient complex.
Boswellia – Used in traditional Ayurvedic medicine, our Boswellia comes at a potency of 400mg per capsule, providing 260mg Boswellic acids.
High Potency Fish Oil Capsules – guaranteed to be clean, stable and free from pollutants. Fatty acids (EPA and DHA) contribute to the normal function of the heart (beneficial effect is obtained with a daily intake of 250mg of EPA and DHA).
Lem-O-3 – Delicious, lemon-flavoured fish oil (Omega 3) with a lovely tangy lemon taste. This Fish Oil is a totally clean, stable, whole body fish oil with 7% extract of green lemon and no other flavourings or artificial ingredients.
- Ytterstad B. The Harstad injury prevention study: the epidemiology of sports injuries. An 8 year study. Br J Sports Med. 1996;30(1):64-68. doi:10.1136/BJSM.30.1.64.
- Lindqvist KS, Timpka T, Bjurulf P. Injuries during leisure physical activity in a Swedish municipality. Scand J Soc Med. 1996;24(4):282-292. http://www.ncbi.nlm.nih.gov/pubmed/8983100. Accessed May 24, 2018.
- Bahr R, Holme I. Risk factors for sports injuries–a methodological approach. Br J Sports Med. 2003;37(5):384-392. doi:10.1136/BJSM.37.5.384.
- Gennari C. Calcium and vitamin D nutrition and bone disease of the elderly. Public Health Nutr. 2001;4(2B):547-559. http://www.ncbi.nlm.nih.gov/pubmed/11683549. Accessed May 29, 2018.
- Molnar JA, Underdown MJ, Clark WA. Nutrition and Chronic Wounds. Adv wound care. 2014;3(11):663-681. doi:10.1089/wound.2014.0530.
- Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. 2007;117(5):1219-1222. doi:10.1172/JCI32169.
- Sports injuries – Treatment – NHS.UK. https://www.nhs.uk/conditions/sports-injuries/treatment/. Accessed May 29, 2018.
- Martin P, Nunan R. Cellular and molecular mechanisms of repair in acute and chronic wound healing. Br J Dermatol. 2015;173(2):370-378. doi:10.1111/bjd.13954.
- Robi K, Jakob N, Matevz K, Matjaz V. The Physiology of Sports Injuries and Repair Processes. doi:10.5772/54234.
- Raggatt LJ, Partridge NC. Cellular and molecular mechanisms of bone remodeling. J Biol Chem. 2010;285(33):25103-25108. doi:10.1074/jbc.R109.041087.
- Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc. 1993;41(4):357-362. http://www.ncbi.nlm.nih.gov/pubmed/8463519. Accessed May 29, 2018.
- How dietary protein intake promotes wound healing – Wound Care Advisor. https://woundcareadvisor.com/how-dietary-protein-intake-promotes-wound-healing-vol2-no6/. Accessed May 29, 2018.
- Tipton KD. Nutritional Support for Exercise-Induced Injuries. Sports Med. 2015;45 Suppl 1:S93-104. doi:10.1007/s40279-015-0398-4.
- Gould LJ. Topical Collagen-Based Biomaterials for Chronic Wounds: Rationale and Clinical Application. Adv wound care. 2016;5(1):19-31. doi:10.1089/wound.2014.0595.
- Williams JZ, Abumrad N, Barbul A. Effect of a specialized amino acid mixture on human collagen deposition. Ann Surg. 2002;236(3):369-74; discussion 374-5. doi:10.1097/01.SLA.0000027527.01984.00.
- Price CT, Langford JR, Liporace FA. Essential Nutrients for Bone Health and a Review of their Availability in the Average North American Diet. Open Orthop J. 2012;6:143-149. doi:10.2174/1874325001206010143.
- Jerosch J. Effects of Glucosamine and Chondroitin Sulfate on Cartilage Metabolism in OA: Outlook on Other Nutrient Partners Especially Omega-3 Fatty Acids. Int J Rheumatol. 2011;2011:969012. doi:10.1155/2011/969012.
- McDaniel JC, Belury M, Ahijevych K, Blakely W. Omega-3 fatty acids effect on wound healing. Wound Repair Regen. 2008;16(3):337-345. doi:10.1111/j.1524-475X.2008.00388.x.
- Thangapazham RL, Sharad S, Maheshwari RK. Phytochemicals in Wound Healing. Adv wound care. 2016;5(5):230-241. doi:10.1089/wound.2013.0505.
- DESNEVES K, TODOROVIC B, CASSAR A, CROWE T. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: A randomised controlled trial. Clin Nutr. 2005;24(6):979-987. doi:10.1016/j.clnu.2005.06.011.
- Saghaleini S, Dehghan K, Shadvar K, Sanaie S, Mahmoodpoor A, Ostadi Z. Pressure ulcer and nutrition. Indian J Crit Care Med. 2018;22(4):283. doi:10.4103/ijccm.IJCCM_277_17.