Twisted your ankle - what now? Here you’ll learn what athletes need to know about injuries and healing phases.

Important to note: We are trainers, not physiotherapists or doctors. Medical fitness training/planning is always provided upon individual client request. For complex, acute, or painful conditions, we always recommend seeking professional help. We do not make diagnoses, nor do we recommend medication or physiotherapy treatments.

It goes without saying that the information provided does not constitute medical or professional advice and does not claim to be complete. We aim to provide a basic overview of the following topics:

  • Part 1: Wound healing phases after injuries
  • Part 2: Tissue regeneration times and types
  • Part 3: Signs of inflammation

Part 1: Wound Healing Phases

Unfortunately, injuries happen – often even during everyday activities. Fortunately, the body immediately initiates a repair process after every injury.

The wound healing process takes place in several phases, aiming to restore the damaged tissue and the body’s own protection against the environment as much as possible.

Each phase requires different training processes. These phases should not be viewed in isolation, as they overlap. Depending on the type of injury, injury size, and individual patient factors, the length of each phase can vary.

Important to know: While wound healing can be supported by passive or active measures, the time to full recovery cannot be significantly shortened (cf. Freese, J. Medical Fitness, Cologne, 2003).

The Inflammatory Phase

Vascular Phase: Days 1–2

This acute phase is characterized by rest and relief. In the first two days after an injury, the body attempts to minimize bleeding through vasoconstriction.

Cellular Phase: Approximately Days 2–5

The initial cleanup begins, and the wound starts to close. The tissue responds with the typical signs of inflammation: redness, swelling, warmth, and pain.

Edema formation is a natural response to injury. Swelling helps transport white blood cells to the injured area to eliminate bacteria and dead tissue. Some authors advise against reducing swelling through external measures (e.g., cooling) (cf. Bert A.M, van Wingerden PhD., 1996).

However, swelling can also have negative side effects, such as reducing synovial fluid ("joint lubricant") quality in joint swelling or extending rehabilitation time by limiting structures for a longer period.

General rule: In the inflammatory phase, muscles should not be stretched in cases of strains and fiber tears. A pulling or stabbing sensation clearly indicates that the load should be reduced.

The Proliferation Phase (approximately Days 5–21)

In this phase, the demand for oxygen and nutrients is particularly high – nonspecific collagen Type III (connective tissue) is already forming. Connective tissue is essential for the body as it maintains organ shapes, protects against damage, stores water, and plays a central role in immune responses to pathogens. Wound healing originates from connective tissue.

During this phase, moderate loading provides appropriate stimuli for the new tissue formation and its alignment (e.g., aerobic endurance training and isometric strength exercises).

Additionally, proprioceptive training stimuli must be introduced at this stage. Sensorimotor training involves coordination exercises on unstable surfaces such as soft mats, foam cushions, trampolines, or wobble boards.

What is proprioception?

Most people are familiar with the situation: A moment of inattention, and we trip over a stone – but at the last second, we regain balance and avoid falling. This "anticipation" of the body to initiate a compensatory movement is what proprioception refers to. Defined as the perception of body position and movement in space (deep sensitivity), proprioception comprises the following three abilities:

  • Position sense: What is the body’s position in space?
  • Force sense: How tense are muscles and tendons?
  • Movement sense: In which direction and at what speed is the movement occurring?

Small body receptors (proprioceptors) in muscles, tendons, ligaments, joints, and connective tissue transmit information to processing centers in the brain, which then trigger compensatory reactions in muscles and other structures during a fall.

How does proprioception work?

PNF (proprioceptive neuromuscular facilitation) is a treatment system that uses afferent nerve pathways to set muscular impulses based on feedback from the body’s own signals.

During muscle contraction, signals travel from the brain to the muscles via efferent pathways. Feedback from muscles to the central nervous system occurs via afferent pathways. This feedback is deliberately utilized by unstable surfaces to create system instability. The athlete is thus in an unbalanced state and must rely on feedback (afference) to maintain or regain balance. EMG measurements (electromyography) have shown that muscle fibers activate at deep levels during this type of muscle load.

Training should always be performed in a pain-free range to prevent excessive loads from causing re-injury to the tissue. The transitions between the phases are gradual.

The Remodeling Phase (approximately Days 21–300/500 – depending on the injury)

This phase is also called the remodeling or reconstruction phase. The nonspecific collagen Type III is replaced by specific collagen Type I (important for tissue structure and mechanical strength). The tissue gains stability and elasticity.

Only through repeated loading stimuli can the tissue sufficiently regenerate and return to its original form and load-bearing capacity. Now, controlled dynamic and isometric load stimuli should be applied to align collagen fibers. Training loads should be progressively increased. With increasing intensity of strength training, fast muscle fibers (FT fibers) are increasingly developed, which are crucial for future maximum strength and power performance.

Adaptation processes optimize healing when the body produces high-quality collagen and a load-stable muscle under high-weight loads (cf. studies conducted by Bert A.M, van Wingerden PhD., 2002).

All tissues undergo constant remodeling, known as turnover. Our daily activities help maintain the quality and quantity of our tissues.

A positive side effect of high-strength training stimuli is the regeneration of bone tissue, as it promotes calcium storage, making bones more load-stable (keyword: osteoporosis prevention) (cf. Dr. Axel Gottlob, Differentiated Strength Training, 3rd Edition, Munich, 2009).

The following factors can negatively affect tissue regeneration:

  • Use of ice and compression
  • Cortisone
  • Vitamin C deficiency
  • Lack of essential amino acids
  • Alcohol consumption, smoking

Implications of wound healing for practice:

  • Injured muscle tissue is not load-stable before a three-week period has passed!
  • Six weeks after a disc herniation, 50% of tensile strength in the disc is restored.
  • For ligament injuries, the remodeling phase can last up to 300 days (ligaments reconstructed surgically only reach pre-surgery strength after 9 months).

In part two, we provide an overview of "tissue regeneration times" and the resulting varied adaptation and healing rates.