Dietary supplements are widely used to enhance performance and body composition during training programs. Utilizing supplements while recovering from musculoskeletal injury hasn’t really been investigated. Clinical experience shows that as soon as someone gets injured, they immediately stop taking any form of supplementation1. Many people think that the use of these performance enhancing supplements are no longer required until they totally recovered from their injury. Wrong!
I will highlight and discuss the use of two specific supplements (whey protein and creatine) regarding their promise during rehab after sustaining a musculoskeletal injury. The intent is to highlight the potential to trainers to better advise their clients in the use of supplements during the rehabilitative phase.
Protein Supplementation During Musculoskeletal Rehab
Typically, musculoskeletal injury occurs due to a deficiency of muscles and tendons. As such, rehabilitation focuses on the prescription of exercise to facilitate synthesis and maturation of newly constructed muscle tissue. However, we know the consumption of protein and amino acids enhances muscle protein synthesis and is apparent in both younger and older skeletal muscles2.
It is obvious that not having enough protein in the rehab phase may delay regeneration of muscle tissue. For example, a muscle injury caused by a strain or tear involves the destruction of the extracellular matrix and muscle tissue cells, followed by resynthesis and production of new muscle tissue cells. This results in a negative nitrogen balance3. Nitrogen balance is a measure of nitrogen input minus nitrogen output. Nitrogen Balance = Nitrogen intake – Nitrogen loss.
Sources of nitrogen intake include meat, dairy, eggs, nuts and legumes, and grains and cereals. Examples of nitrogen losses include urine, feces, sweat, hair, and skin.
This measurement of nitrogen input and loss is used to study protein metabolism. Therefore, rehabilitating an injury should include rest, rehabilitation, and nutrition. This ensures muscle protein synthesis is optimized and a positive nitrogen balance occurs, allowing effective tissue repair4.
What the Evidence Shows on Protein
Preliminary evidence shows that improvements in rehabilitative potential can be facilitated with appropriate protein supplementation during post-injury exercise training with enhanced degree of muscle synthesis and tensile strength produced5. It’s important to note that this research used carbohydrate with the high amount of protein, which likely provides sufficient insulin to modulate the protein synthesis process6 and is shown to be more effective than protein on its own7.
Protein supplementation in the elderly following hip fractures also demonstrated enhanced recovery8.
Proposed intake of 20-25 grams of protein in healthy tissue after training9 is warranted in the period of rehabilitation post injury to sustain positive net protein balance supportive of rehabilitative exercise.
Creatine Supplementation During Musculoskeletal Rehab
The benefits of creatine supplementation in a healthy population undertaking resistance training is clear. The benefits include improvements in muscle size and strength10, increases in serum testosterone and reduction in cortisol11, improvements in physical performance and body composition12. However, there is scant evidence of creatine’s potential during musculoskeletal rehab.
We can substantiate the use of creatine during a period of rest and immobilization to counteract the disuse that occurs during this time and preparing for when active rehabilitation begins. Also, the use of creatine to facilitate greater metabolic efficiency warrants further applied research
What the Evidence Shows on Creatine
Evidence shows that a group of immobilized subjects consuming creatine had a 10% increase in a glucose transport protein found primarily in striated muscle (skeletal and cardiac). The group without creatine had a further reduction of 10% in this protein13. This study concluded that using creatine supplements both increased the level of this protein in muscle tissue during rehab and prevented further reductions. These results indicated creatine use during rehab post injury can enhance the muscle tissue’s ability to create energy efficiently, and may prevent fatigue.
Another study immobilized subjects for 2 weeks followed by a 10-week exercise rehab program supplemented by either creatine or placebo (maltodextrin)14. Results showed both groups caused equal detriments to muscle size and strength during immobilization, but the creatine group showed a more rapid recovery in both size and strength during the rehab phase. Although there isn’t much evidence available in this population; the research that was done indicated potential benefits for commencing or continuing a cycle of creatine consumption during a period of immobility post injury and through the rehab phase.
Take Home Points
- The current evidence demonstrates that utilizing protein and creatine supplementation enhances the recovery process during rehab post injury.[spacer height=”20px”]
- A common misconception is people think that because their exercise intensity is not high enough during rehab, they should abstain from supplementation.[spacer height=”20px”]
- It’s clear that the biological state of tissue injury and the effect of immobility will leave them in a deficient state for muscle tissue repair and synthesis.[spacer height=”20px”]
- Preliminary evidence suggests protein and creatine supplementation counteracts these deficits in muscle tissue repair and synthesis.[spacer height=”20px”]
- I recommend the creatine cycling strategy (recommended by Dr. Cribb) is utilized during a post injury rehab period.
1. Tack C. Dietary Supplementation During Musculoskeletal Injury: Protein and Creatine. Strength and Conditioning Journal. 2016;38(1):22-26.
2. Drummond MJ, Dreyer HC, Pennings B, et al. Skeletal muscle protein anabolic response to resistance exercise and essential amino acids is delayed with aging. Journal of applied physiology. May 2008;104(5):1452-1461.
3. Crozier SJ, Kimball SR, Emmert SW, Anthony JC, Jefferson LS. Oral leucine administration stimulates protein synthesis in rat skeletal muscle. The Journal of nutrition. Mar 2005;135(3):376-382.
4. MacLain TA EK, and Kerksick CM. Protein applications in sports nutrition—Part I: Requirements, quality, source, and optimal dose. Strength Cond J 2015;37:61-71.
5. Holm L, Esmarck B, Mizuno M, et al. The effect of protein and carbohydrate supplementation on strength training outcome of rehabilitation in ACL patients. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. Nov 2006;24(11):2114-2123.
6. Byfield MP, Murray JT, Backer JM. hVps34 is a nutrient-regulated lipid kinase required for activation of p70 S6 kinase. J Biol Chem. Sep 23 2005;280(38):33076–33082.
7. Hartman JW, Tang JE, Wilkinson SB, et al. Consumption of fat-free fluid milk after resistance exercise promotes greater lean mass accretion than does consumption of soy or carbohydrate in young, novice, male weightlifters. The American journal of clinical nutrition. Aug 2007;86(2):373-381.
8. Avenell A, Handoll HH. A systematic review of protein and energy supplementation for hip fracture aftercare in older people. European journal of clinical nutrition. Aug 2003;57(8):895-903.
9. MacLain TA EK, and Kerksick CM. Protein applications in sports nutrition—Part I: Requirements, quality, source, and optimal dose. Strength and Conditioning Journal. 2015;37:61-71.
10. Dempsey RL, Mazzone MF, Meurer LN. Does oral creatine supplementation improve strength? A meta-analysis. The Journal of family practice. Nov 2002;51(11):945-951.
11. Arazi H RF, Hosseini A, and Asadi A. . Effects of short term creatine supplementation and resistance exercises on resting hormonal and cardiovascular responses. Sci Sports 2015;30:105-109.
12. van Loon L OA, Hartgens F, Hesselink M, Snow R, and Wagenmakers A. . Effects of creatine loading and prolonged creatine supplementation on body composition, fuel selection, sprint and endurance performance in humans. Clin Sci (Lond) 2003;104:153-162.
13. Shepherd PR, Kahn BB. Glucose transporters and insulin action—implications for insulin resistance and diabetes mellitus. The New England journal of medicine. Jul 22 1999;341(4):248-257.
14. Hespel P, Op’t Eijnde B, Van Leemputte M, et al. Oral creatine supplementation facilitates the rehabilitation of disuse atrophy and alters the expression of muscle myogenic factors in humans. The Journal of physiology. Oct 15 2001;536(Pt 2):625-633.