How to avoid injury: my best guesses
Tips from a guy with bad knees
I've been injured a number of times in my athletic career. That's led to a lot of reading and a lot of thinking about how to avoid future injuries. I'd like to help my friends, readers, and the players I coach avoid the same fate.
Let's get the introductory stuff out of the way. First, I'm not a doctor. These are free ideas for you to experiment with, if you feel so inclined. They are not official medical advice. Some of the tips below cite real research, others just share my (hopefully logical) way of thinking about how sports and injuries work.
Second, injuries are never completely avoidable. There will always be that one day when your foot lands on someone else's foot. Or in a divot. Or we slip on some wet grass. There will always be those days when we push ourselves a little too hard in the heat of a great game. The weekend tournament structure of club frisbee pushes players to exercise more than is healthy.
Third, I've torn my ACLs three times. And had other knee injuries on top of that. Should you mistrust my advice because I've been injured more than most people? Or should you trust it more because I'm still one of the more athletic ultimate players you know after all those injuries? That's up to you! It's free advice, after all. And as always, feedback is welcome.
As I wrote in a recent article, I'm in the process of slowly recovering from a meniscus/cartilage injury in my knee. Some of the advice here reflects what I've learned since that injury. The real proof will be in whether I'm still healthy five years from now.
These tips are tailored to slightly advanced athletes so I've skipped some very obvious truths like "do a warm up", "do a steady training program", and "wear the right equipment for your sport" that you'll find in other articles, like this one or this one. If you're a sports beginner, that more basic advice is worth checking out first. "Good form" is another must-have that I'm going to skip over here—for a first course on good form, I'd suggest the two-part Ultiworld series by Ian Engler on avoiding ACL tears in ultimate (part one, and part two).
With that introduction out of the way, here are the ideas I've been experimenting with.
This got long so here's a summary
Don't want to read all my rambling and research? Here's the bullet point version:
Take time off. Take 3 weeks once or twice a year without working out at all. Take a season (~3 months) off competing intensely.
Get more athletic slowly. Ligaments, tendons, and bones only strengthen very slowly. Trying to get huge gains in athleticism quickly is a recipe for injury.
Don't overtrain running straight ahead. Improving your straight-ahead speed seems risky if you're not equally improving your ability to safely stop from those faster speeds.
Train for strong joints. There's reasonably good evidence that "Knees Over Toes Guy"-style workouts can help safely strengthen our joints & the muscles closest to them.
Get cartilage/gelatin in your diet. The evidence isn't definitive but some studies suggest gelatin helps our bodies maintain and repair our cartilage/ligaments/tendons.
Practice balancing. Again the evidence isn't definitive, but some studies suggest better balance helps avoid injury. (And logically it makes sense)
Do your rehab. Boring but important. Many nagging injuries are only that way because we don't patiently rehab them back to 100%
Manage your weight, if possible. It's hard to ignore that more weight on our frame (i.e. fat tissue) means more forces being transmitted through our joints when we change direction.
If you're just here for the takeaways, those bullet points cover it. If you'd like to know my sources and get a more thorough explanation of my logic, read on:
1. Take time off
Taking an extended break once or twice a year is one of the biggest changes I've made since my most recent injury. I used to just assume that I would keep lifting and keep running and I would continue getting stronger and faster, a straight line sloping upwards. I think about it differently now.
I've come to the conclusion that if I train 11 months in a row, I'll end up injured and have no choice but to rest and rehab the 12th month. If I give my body a few weeks to rest and recover before I get hurt, I'll still train the same amount but I'll be able to actually enjoy my time off instead of being frustrated with an injury.
If you're a frisbee player like me, don't play spring, summer, fall, and winter league. Take at least one off. Once or twice a year, take roughly three full weeks off from working out. As shared by Brad Stulberg in Peak Performance, runner Bernard Lagat sets aside 5(!) weeks at the end of each season where he does "little to no exercise".
We need the stress of exercise to push our bodies to become stronger, but that same stress can also prevent some injuries from getting the rest they need to fully heal. Give your body some time to rest.
2. If you get more athletic, do so very slowly
In a 2021 Ultiworld article, Melissa Witmer says it takes:
“six years to make an athlete.”...there are some athletic adaptations — such as in bones and tendons — that take a very long time.
She's absolutely right. And it should take that long. Like she says, our bones, tendons, and ligaments can adapt—but only relatively slowly. If we train hard, we can end up in a situation where our muscles have gotten stronger but those other tissues haven't had time to catch up. This is a recipe for injuries.
Melissa didn't provide any sources in her article, so I wanted to dig into it a little bit to make sure the research actually matched the conventional wisdom. Here's a paper that suggests it takes two months of training to start to see changes in the tendons. In this paper on resistance training and bone density growth in young women, the researchers found that training led to increased bone density after 15 months. Interestingly, a few of the study groups had slightly lower bone density after 5 months.
This sort of matches my personal experience—when we've newly reached new athletic heights we're often at our biggest injury risk, because we're doing things more explosively than ever before, but at the same time our bodies are tired from all the training it took to get there.
I couldn't actually find a paper that measured ligament stiffness, but the "common knowledge" (e.g. see here) seemed to be that they do get stronger, the same way tendons do. This study found that the study participants' ACL size increased over the course of a college soccer season, but the authors made it clear that they weren't claiming that larger ACLs are necessarily stronger ("The increase in volume may be related to the accumulation of microscopic tears over the course of the season which induce inflammation and edema.")
Overall, these results seem to match the "common knowledge", (e.g. the top answer on this Quora question) that suggests 6 months for bones/ligaments and 3-6 months for tendons.
So think of it this way: your muscles get stronger based on what you were doing three weeks ago, your tendons based on what you were doing three months ago, and your ligaments/bones based on what you were doing three seasons ago. And then there's cartilage, which changes even slower than that (but does change—a little bit).
There's a famous "10 percent rule" in distance running that says to avoid injury you shouldn't increase your workout load more than 10%, week over week. Strictly speaking, that seems to be something of a myth. However, the general point is true—sharp training increases are a risk factor for injury. Here's what Jeff Bercovici says in Play On:
A number of studies have shown that sudden jumps in training volume or intensity lead to injuries. According to one study of Australian-rules football players, when an athlete’s “acute load” in a given week exceeds his “chronic,” or average, load by more than 50 percent, his risk more than doubles. A similar analysis, drawing on two years of data, found that doubling a player’s acute load results in a five- to eightfold increase in noncontact injuries. “Large week-to-week changes in load (rapid increases in intensity, duration or frequency) have been shown to place the athlete at a significantly increased risk of injury,” concluded the authors of an International Olympic Committee consensus paper in 2016.
So the 10% rule is more like a 50% rule. But on a long-term scale, even the more conservative 10% ramp up per week is impossibly fast. Getting 10% faster per year is beyond most people's wildest dreams—imagine going from running a 7:00 mile to a 6:18 mile (and then a 5:40 mile after another year of 10% improvement). If you want to get 10% faster in a year, you only need to get about 0.2% faster per week (1.002 compounded 52 times equals 1.1)! Work 0.2% harder each week and be proud of yourself!
Given our bodies change slowly, it seems safest to get stronger slowly as well. Spend a couple months pushing hard to reach a new level of athleticism—but then spend the next few months simply maintaining.
Our body's slow growth is another reason why it's so useful to take time off during the year. It's an easy way to help make sure we don't train too quickly for what the slower-growing parts of our bodies can handle.
3. Don't overtrain running straight ahead
To go with the general advice of "don't get too athletic too quickly", here's a specific suggestion for developing a well-balanced athleticism: don't overtrain straight-ahead running. In my experience, it can be easy to do this. It's so easy to put together a track workout. You just need to decide on the distances and the number of repetitions. The lines are marked for you. Tracking your progress is straightforward.
But sports are not all about running forwards. The book Play On shares that, based on accelerometer data, NBA players are rarely just running straight ahead:
Almost 85 percent of what [Golden State Warriors] players do in games, it turned out, is backpedaling or lateral shuffling,
Sports played on larger fields (soccer or ultimate frisbee) will likely feature a higher percentage of running forwards—but it still won't be 100%.
I worry that when we train too much running forwards without a well-balanced amount of training our change-of-direction ability, our injury risk increases. Injuries often occur when we change direction. If we get faster, those moments will involve more force. We need to train our body to handle that increased force. Don't over-focus on getting better at running straight ahead—give your body the practice it needs to safely change direction at those increased speeds.
4. Train for strong joints
As I covered in a previous article on sports science, there's pretty good evidence that tells us "knees over toes" workouts are good for building up our knee strength, and thus hopefully good for preventing knee injuries. I wouldn't call the evidence definitive yet, but it's good enough that I feel OK helping propagate these ideas.
In my article, I quoted PainScience.com, saying:
I’ve called VM isolation [the idea that you can isolate the muscles near your knee] a “pernicious myth,”...Such professional opinions have been common for a decade and they are still out there.
We were wrong-ish.
More recent evidence has mostly changed my mind...
just the right exercises do indeed preferentially engage the VM...[for example:]
—squats with a wedge (standing on a wedge so that the toes are pointing down)
I like some of the Knees Over Toes Guy workouts. I also like the static leg extension that was introduced to me by YouTuber Jake Tuura. Start slowly and progress slowly—this is a whole new type of workout that your body won't be used to if you haven't tried it before.
5. Get collagen/cartilage/gelatin in your diet
Eating cartilage is another suggestion I covered in my previous sports science article. I don't think the evidence is ironclad, but the studies are trending in the right direction.
On another older article of mine, commenter Fiona linked me to this study, which found:
Levels of relevant amino acids in the bloodstream were higher after taking collagen supplements ("increased circulating glycine, proline, hydroxyproline, and hydroxylysine, peaking 1 h after the supplement was given.")
"Engineered ligaments" treated with blood samples from the study subjects showed increased collagen content and improved mechanics. (Essentially, they harvested ACL cells from a donor, treated them in a lab to make something like a fake ligament, and then tested them with the blood samples they took from study participants.)
So they’re not quite measuring the outcome we actually care about—real ligaments in real people not tearing—but perhaps it’s close enough.
In Play On, Jeff Bercovici says "Studies have shown gelatin supplementation during injury rehab results in faster return-to-play after ACL reconstructions and Achilles tendon ruptures." However, I couldn't figure out exactly which studies he was referring to. Most of my research (like this article, or this one) led me back to the same paper that Fiona linked me to, which worried me a bit.
Given these worries, I poked around a bit more and found this 2021 meta-analysis that says:
The results indicated that COL [i.e. collagen supplements] is most beneficial in improving joint functionality and reducing joint pain...Five studies observed positive effects of COL in reducing joint discomfort and knee pain, improving ankle and knee functionality, and accelerating recovery from Achilles tendinopathy...One study was conducted over 3 months, one over 4 months, and three studies over 6 months.
I'm not quite 100% convinced, but if you want to be proactive about avoiding injury, getting more gelatin in your diet seems like an intervention that's reasonably easy, safe, and likely-to-be-beneficial.
6. Practice balancing
Balance training has been a focus of research into injury prevention, especially ACL injury prevention—here's an ACL injury risk meta-analysis, for example. The evidence is somewhat unclear, especially because most studies include balance practice alongside other interventions (strength training, plyometrics, etc). The linked study found that either balance exercises or plyometrics exercises alone weren't enough to reduce injury risk, but the combination of both was effective. This section is about balancing and not plyometrics because I assume anyone trying hard to be good at a sport is already spending time practicing explosive motions.
Though the evidence isn't as clear-cut as I'd like, logically, it's easy to believe that improving our balance will help us avoid injuries. The better we get at maintaining stability in awkward, off-balance positions, the less likely our knee will give out in a similar situation in a game. At least that's the theory—but perhaps in reality balancing drills are not "similar enough" to the situations that cause our joints to fail.
Personally, I tend to believe there's enough transfer between the two situations for balancing drills to be useful. I have a balance board and a balance disc that I use regularly. Once you're used to them, you can practice balancing while reading, watching TV, or listening to a podcast.
7. Do your rehab!
If there's something wrong with your body, work on fixing it. I didn't want to start the article with this because it's kind of boring and obvious, but in terms of importance, it belongs near the top. I have a few too many friends who say they have "a bad ankle" or "a bad knee", but when I ask what they've been doing to fix it, they always reply "I know I should be doing my PT, but I've been so busy..."
Lingering issues will linger a lot less when you actually put the time in to treat them right. That includes taking a break from intense activity, as needed.
Here's my free physical therapy advice for minor injuries (again, I'm not a doctor):
Search online for "[X] rehab exercises", where [X] is your issue (e.g. "sprained ankle rehab exercises")
Click on a few of the links that come up and try some of the suggested exercises
From those exercises, make a list of 5 or so that activate the area you need to strengthen
Spend 5-10 minutes each morning and evening doing these exercises. Slowly increase the difficulty as the injured area gets stronger.
Please don't use this as an excuse to not go to the doctor or physical therapist when you need to. But for the same old minor injuries that we'll all experience from time to time, this process has worked very well for me.
8. Manage your weight
I feel very conflicted about including this point. One the one hand, all the studies suggest that it's incredibly hard for people to lose weight and keep it off. I'm not saying "lose weight" and expecting it to actually be a helpful tip for anyone. Having a healthy relationship with your diet and your body comes first.
But it's hard to deny that less weight on your frame means less stress on your joints when running, jumping, and cutting. It's just physics. (To make sure it's completely clear: when I say "weight", I'm referring to fat tissue. Losing weight from your leg muscles will not help keep your knee joints safe.)
I can think of one counterargument, though: heavier people are doing everything with that extra weight—so their body might adapt to it over time. But the evidence I've seen (here's a recent anecdote I came across, for example) tells me that this effect is small compared to the stress imposed by that extra weight.
Have a healthy relationship with your body. Have a healthy relationship with your diet. But to the extent possible within those bounds, try not to carry too much excess weight.