Nutrition for Recovery and Injury Prevention

Jolie Watson RD, LD

Unfortunately for athletes, injuries, whether minor or severe, tend to come with the job. While there is no way of avoiding injuries entirely, there are preventative strategies from a nutritional standpoint that can be taken to help minimize the athlete’s overall risk of sustaining an injury as well as increase recovery rate for a faster return to play.

According to the American College of Sports Medicine (ACSM), “the primary goal of the training diet is to provide nutritional support to allow the athlete to stay healthy and injury-free while maximizing the functional and metabolic adaptations to a periodized exercise program that prepares him or her to better achieve the performance demands of their event.”¹ As a sports dietitian, this statement voices my responsibility as a healthcare professional to help the athlete create a nutrition plan that best fits their individual needs to maximize performance and recovery.

Calories

While it may seem that energy needs decrease after an injury, your body may actually require an increase in energy demands. A 10-20% increase in caloric intake following trauma or a minor surgery is recommended, while a major surgery may require an even greater increase.² Yes, you may need fewer total calories due to the decrease of high-intensity training and volume, but compared to your sedentary baseline, you definitely need more.

Depending on the severity of the injury, athletes may require orthopedic surgery. Of course, this comes with its own set of obstacles involved with the recovery process.  Immobilization and casting are common treatments for bone fracture-related injuries as well as chronic inflammation. These treatment methods also typically require a decrease in use of the injured limb or area for efficient healing. While consuming more than your energy demands can lead to an accumulation of body fat during immobilization, it is imperative that the athlete avoids undereating as this will delay recovery. Low energy availability can lead to loss of muscle mass, sub-optimal bone density, increased risk of fatigue and injury, as well as impaired adaptation to training and a longer recovery process.¹ This is why having adequate energy intake is crucial for any athlete who is recovering from an injury. Whether that recovery is from an orthopedic surgery, a non-operative injury, an active infection, or something else, sufficient energy intake is imperative.

Low energy availability can lead to loss of muscle mass, sub-optimal bone density, increased risk of fatigue and injury, as well as impaired adaptation to training and a longer recovery process

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It is important that the athlete focuses on hitting the following key nutrients during the healing process to ensure a speedy recovery and return to sport. Use this information to help determine how much you should be eating or supplementing with in order to support your recovery.

Protein

Protein intake is a major component in the process of repairing damaged muscle tissue. Compared to the recommended daily allowance (RDA) of 0.8 gram/kilogram of body weight per day for the “average” healthy person, athletes are generally advised to consume anywhere from 1.2-2.0 g/kg of body weight of high-quality protein per day.¹ However, in the event of an injury, the daily intake for protein during the healing process could reach as high as 2.5 g/kg of body weight, with the higher end typically seen in athletes who undergo surgery or experience complications like infection. The increased protein needs during the recovery process are warranted to help prevent muscle atrophy and promote repair within the body.

Athletes should aim to eat 4-6 meals/snacks per day while spacing the meals to about every 3-4 hours. Each meal/snack should aim to provide 20-30 grams of high-quality protein.² For reference, a 20-30 g portion of protein equates to each the following food items:

• 1 cup of cottage cheese
• 3-4 ounces of poultry, meat or fish
• 3 eggs

If it becomes difficult for an athlete to get an adequate amount of protein for their dietary needs strictly from food sources, it may be necessary to supplement with protein powder or ready to drink protein shakes. Orgain is a great company that has some fantastic choices to fit these protein needs. “Most Orgain products are Certified Organic, gluten free, non-GMO and made without soy or artificial ingredients.” They also have products that are strictly plant-based if you have athletes with specific dietary preferences.

As discussed in the previous section, adequate energy intake is essential in order to optimize the metabolism of protein, support muscle protein synthesis, and retain lean mass during the healing process.¹

Carbohydrates

As the body’s preferred source of energy, carbohydrates play an important role in injury recovery and prevention. By consuming an adequate amount of carbohydrates in your diet, you’re allowing the body to utilize that energy as fuel and ensure that protein intake is maximized to heal and repair your muscles. In addition, maintaining adequate carbohydrate availability within the body (pre-exercise, during exercise, recovery), can help delay exercise-related fatigue and decrease the risk of injury.³

Depending on the severity of injury, athletic activity is likely reduced and/or stopped completely. With the idea that athletes periodize their carbohydrate intake by increasing intake during hard training days, and, you guessed it… limiting intake during light activity days, it makes sense that carbohydrate intake would be reduced after sustaining an injury. This reduction in energy intake is essential in preventing unwanted gains in body fat. Again, note that when reducing energy intake, it is important to maintain a high protein intake in order to prevent the loss of lean muscle mass during recovery.

Whole grains, fruits, and vegetables are all fiber-rich sources of carbohydrates that also provide essential vitamins and minerals such as vitamins A and C which aid in keeping inflammation low and boosting the immune system.

Omega-3 Fatty Acids

After sustaining a musculoskeletal injury, the body’s first reaction is to bring inflammatory chemicals to the injured area. This inflammatory response helps to mitigate the severity of damage by signaling the body to limit movement via pain. After the body’s initial response to tissue damage, the focus falls on reducing the inflammatory markers within the blood to begin the healing process. This is where omega-3 polyunsaturated fatty acids (n-3 PUFA) are useful, due to their anti-inflammatory properties. Research suggests that the proposed anti-inflammatory properties found in n-3 PUFA’s may speed up the healing process during rehabilitation from an injury and reduce muscle soreness. One study found that omega-3 fatty acid supplementation lessened immobilization-induced muscle atrophy and decreased the rate of decline in muscle protein synthesis over a 2-week recovery period.⁴

There are two main types of omega-3 fatty acids: long-chain and short-chain. The long-chain omega-3 fatty acids include both eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA). These compounds are found in fish oil, primarily from fattier fish such as salmon, mackerel, tuna, and herring. The short-chain omega-3 fatty acids, or alpha-linolenic acid (ALA), are found in plant sources including nuts, seeds, avocados, and plant-based oils. While both types contain omega-3 fatty acids, EPA and DHA have a higher concentration compared to ALA. In other words, you would need to consume a far greater amount of ALA-rich foods to gain the same amount of omega-3’s that EPA and DHA sources provide in a single serving.

While it is proposed that the approximate intake of 1-2 g/day EPA and DHA (at a 2:1 ratio of EPA to DHA) may be beneficial in attenuating exercise-induced inflammation in athletes, dosing recommendations are unclear and should be given with caution.³ An assessment of the athlete’s dietary fish oil intake and/or blood testing should be considered prior to supplementation. A good rule of thumb is to meet the recommendation of 3.5 ounces of fatty fish at least two times a week in the rehabilitating athlete. Overall, during periods of muscle disuse, the supplementation of omega-3 fatty acids present a promising strategy for decreasing muscle atrophy and supporting the recovery of muscle.

Vitamin D

I learned at an early age that vitamin D and calcium are widely recognized for their important role in bone health. Vitamin D, primarily obtained from sunlight, aids in the absorption of calcium from the diet and helps maintain bone mineral density and regulates the regeneration of skeletal muscle. Due to a lack of adequate sunlight exposure, it is understood that many athletes are deficient in vitamin D. In addition, deficiencies in both vitamin D and calcium show a linear association with an increased risk of stress fractures in athletes.⁵

On top of its significant role in injury prevention and bone health, vitamin D also proves valuable during the injury recovery process. Vitamin D possesses immunomodulatory effects that help to reduce inflammation and optimize muscle function during the healing process.

It is recommended that athletes aim to maintain adequate vitamin D status via regular sun exposure, dietary intake, and supplementation. While there is not a target level identified for muscle repair, it is suggested that at-risk athletes supplement with 2,000-4,000 IU of Vitamin D₃ daily during the winter months and ensure serum levels are greater than 75 nmol/L in addition to plentiful sun exposure in the summer.⁶ While the best source of vitamin D is through exposure to sunlight, it can also be obtained from food sources including fatty fish, eggs, and fortified foods (milk, cereal, orange juice, etc).

Tart Cherry Juice

Tart cherry juice (TCJ) contains antioxidants and anti-inflammatory compounds which are shown to be advantageous in the body’s ability to recover. In recent years, TCJ has become more widely understood for its value in both athletes and weekend warriors, as it can help accelerate the recovery process from exercise-induced stress and muscle damage experienced after working out or getting injured.⁷ Research on TCJ has found supplementation beneficial in decreasing the inflammatory response detected in blood biomarkers as well as reducing overall muscle soreness in athletes for both endurance and strength exercises.^8,9 In addition, TCJ was found to reduce symptoms of muscle damage, including strength loss and biomarkers for oxidative damage, improving recovery after intensive strength training exercise.¹⁰

An intake of 8-12 ounces of TCJ juice, 2x/day, loading 4-5 days prior to competition and 2 days following competition is recommended to promote recovery.⁷ I would recommend consuming one 8-12oz serving of TCJ 30 minutes before or after a training session due to its anti-inflammatory effect and the second serving an hour or so before bedtime, as it has also proven valuable in regards to improving sleep quality.¹¹ More research is warranted with regard to TCJ and its overall health benefits. Nonetheless, TCJ has shown great promise in its use to help enhance recovery in athletes, resulting in a more efficient return to sport.

Hydrolyzed Collagen

Creatine

As one of the most widely used supplements to support gains in strength and lean mass, creatine monohydrate shows promise in supplementing the injured athlete during recovery. Creatine is most effective in explosive, high-intensity activities such as powerlifting, jumping, and sprinting. Research to date has demonstrated its ability to attenuate loss of lean muscle mass and strength, as well as increase muscle hypertrophy following limb immobilization due to injury. However, while creatine increases lean muscle mass, it also causes an increase in the accumulation of intracellular water within the muscles, which means your body may retain more water. In addition, some research suggests that creatine supplementation has shown benefits that may offer protection from traumatic brain injuries, concussions, and neurodegenerative conditions, often seen in contact sports.¹³

It is suggested that a loading dose of 20 g/day of creatine monohydrate be implemented for an initial 5 days during recovery followed by a maintenance phase of 5g/day thereafter.⁶ However, it is important to note that further research is warranted in order to understand if creatine supplementation truly proves beneficial for the rehabilitating athlete.

Sleep

While sleep is obviously not a nutrient, it is an extremely important part of staying healthy and ready for competition. For athletes who endure the high physical and psychological demands expected of them during training and competition, adequate duration and quality of restorative sleep is essential. While sleep has been recognized as an essential component of the recovery process, its use as a practical intervention is often overlooked. Inadequate quality sleep and sleep disturbances directly contribute to increased inflammation, muscle soreness, decreased immunity and reductions in cognitive and motor performance.¹⁴ Furthermore, quality sleep is especially important in situations where the athlete is healing from injury, traveling, or in phases of high-volume training or competition. On average, 7-9 hours of restful sleep at night is recommended for maximized physiological and psychological recovery.¹⁴

There are multiple actionable recommendations for incorporating good sleep hygiene. Maintaining a regular schedule for bedtime and waking up, avoiding television, computer and cell phone (screen) use close to bedtime and keeping a cool and comfortable temperature in the bedroom are identified behaviors that can promote quality sleep. In addition, implementing certain nutritional strategies is critical in maximizing recovery through sleep. Avoiding caffeine and alcohol in the hours before bed is important to limit stimulation prior to bedtime. Pay attention to meal timing prior to bed, as large meals later in the evening can lead to poor sleep due to increased digestion demands. Consuming carbohydrates with a high glycemic index about 4 hours prior to bed may increase melatonin synthesis. Finally, consuming protein from dairy sources may assist in increasing sleep duration.¹⁴

Some athletes may benefit from supplementation to assist with getting high-quality sleep depending on their individual needs and sleep behavior. Ingestion of melatonin has been shown to have a positive effect on sleep quality and duration in doses up to 3 mg in the hours before bedtime.¹¹ In addition to the beneficial use of tart cherry juice in post-exercise recovery, the high concentrations of naturally occurring melatonin found in tart cherries offers an added benefit on promoting quality sleep. Research investigating the effect of tart cherry juice on sleep enhancement demonstrated an improvement in sleep time and quality in healthy adults.¹⁵ Magnesium, Vitamins A and E, as well as B vitamins have also shown potential in promoting sleep but require more investigation at this time.

…

There is no question that nutrition plays a significant role in recovery from exercise and preventing injury. Injuries are both unfortunate and frustrating, but there are ways to be proactive in order to stay as healthy as possible, for as long as possible. By following these dietary recommendations, athletes can maximize training adaptations and enhance recovery; shortening the time spent on the sidelines and getting back in the game.

Note: It is important that athletes ALWAYS seek professional advice from a qualified sports dietitian to ensure that supplements have been tested by a third party to verify that they do not contain any banned substances in order to proceed in a safe and effective manner.

References:

1. American College of Sports Medicine (ACSM), Academy of Nutrition and Dietetics, and Dietitians of Canada. Joint position statement: Nutrition and athletic performance. MED Sci Sports Exerc; 2016;48(3):543-568.
2. Clark N. Nancy Clark’s sports nutrition guidebook / Nancy Clark, MS, RD, CSSD (6^th ed.). Human Kinetics. 2020
3. Academy of Nutrition and Dietetics. The Sports Nutrition Care Manual (SNCM). 2019. https://www.nutritioncaremanual.org.
4. McGlory C, Gorissen SH, Kamal M, et al. Omega-3 fatty acid supplementation attenuates skeletal muscle disuse atrophy during two weeks of unilateral leg immobilization in healthy young women. FASEB J. 2019;33(3):4586-4597. https://doi.org/10.1096/fj.201801857RRR
5. Bongiovanni T, Genovesi F, Nemmer M, et al. Nutritional interventions for reducing the signs and symptoms of exercise-induced muscle damage and accelerate recovery in athletes: current knowledge, practical application and future perspectives. Eur J Appl Physiol. 2020;120:1965–1996. https://doi.org/10.1007/s00421-020-04432-3
6. Close GL, Sale C, Baar K, Bermon S. Nutrition for the prevention and treatment of injuries in track and field athletes. International Journal of Sport Nutrition and Exercise Metabolism. 2019;29: 189-197. https://doi.org/10.1123/ijsnem.2018.0290
7. Vitale KC, Hueglin S, Broad E. Tart cherry juice in athletes: A literature review and commentary. Current Sports Medicine Reports. 2017;16(4): 230-239. https://doi.org/10.1249/JSR.0000000000000385
8. Levers K, Dalton R, Galvan E, et al. Effects of powdered Montmorency tart cherry supplementation on an acute bout of intense lower body strength exercise in resistance trained males. Journal of the International Society of Sports Nutrition. 2015;12, 41. https://doi.org/10.1186/s12970-015-0102-y
9. Levers K, Dalton R, Galvan E, et al. Effects of powdered Montmorency tart cherry supplementation on acute endurance exercise performance in aerobically trained individuals. Journal of the International Society of Sports Nutrition. 2016;13, 22. https://doi.org/10.1186/s12970-016-0133-z
10. Bowtell JL, Sumners DP, Dyer A, Fox P, Mileva KN. Montmorency cherry juice reduces muscle damage caused by intensive strength exercise. Medicine & Science in Sports & Exercise. 2011;43(8): 1544-1551. https://doi.org/10.1249/MSS.0b013e31820e5adc
11. Doherty R, Madigan S, Warrington G, Ellis J. Sleep and nutrition interactions: Implications for athletes. Nutrients. 2019;11(4): 822. https://doi.org/10.3390/nu11040822
12. Lis, D. (2020). Proactive Nutrition for a Healthy Return from Hiatus. Kinexon. [Youtube Webinar].
13. Dean, PJ, Arikan G, Opitz B, Sterr A. Potential for use of creatine supplementation following mild traumatic brain injury. Concussion. 2017;2(2): CNC34. https://doi.org/10.2217/cnc-2016-0016
14. Bird SP. Sleep, recovery, and athletic performance: A brief review and recommendations. Strength and Conditioning Journal. 2013;35(5):43-47. www.http://doi.org/10.1519/SSC.0b013e3182a62e2f
15. Howatson G, Bell PG, Tallent J, Middleton B, McHugh MP, Ellis J. Effect of tart cherry juice (Prunus cerasus) on melatonin levels and enhanced sleep quality. European Journal of Nutrition. 2012;51(8): 909–916. https://doi.org/10.1007/s00394-011-0263-7

About the Author – Jolie Watson RD, LD

Jolie Watson is a sports dietitian that primarily works with team sports at the professional level. She has been working in the field of sports nutrition since she became a registered dietitian in 2018 after receiving her B.S. in Dietetics from Purdue University. While working full-time in sports, Jolie is currently a M.S. candidate in Exercise Science with a concentration in Nutrition at California University of Pennsylvania through their distance-learning program.
Her nutrition philosophy utilizes her extensive nutrition knowledge as it relates to athletic performance in order equip athletes with the tools to achieve performance goals while being proactive in preventing injury. As a sports dietitian, Jolie prides herself in helping athletes understand optimal fueling strategies tailored to their needs in order to perform, recover, and feel their personal best.

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