Trauma is a serious shock to living tissue caused by an external force or agent. Some types of trauma are random and completely unexpected, while other types may be anticipated. No one expects to get hit by a car crossing the street, for example, but the trauma of elective surgery is an example of tissue trauma that might be anticipated. Some tissue trauma is minor-- the muscle shock to living muscle tissue from the act of achieving a 3-rep max back squat, for instance-- while some tissue trauma is major, such as sustaining a full thickness quadriceps strain (tear), or a complete disruption of a knee ACL in a football injury.

With these above considerations in mind, it is evident that healing from intense athletic training or overt athletic injury is distinct in that it in part affords the unique opportunity to nutritionally prepare for tissue injury beforehand, in order to preemptively optimize the body’s ability to heal and recover. This is a circumstance that the serious athlete should leverage to their best competitive advantage, but how? The first step is understanding some basic concepts of tissue repair and recovery. The next step is understanding how to strategically use macronutrients, vitamins and micronutrient co-factors, the most fundamental and natural agents an athlete can engage to facilitate fastest and most complete tissue repair.

So, step 1 is recognizing that athletic trauma to living tissue can be minor, from that routine interval workout, or major, from that full-thickness rotator cuff tear. Let us first consider overt or severe tissue injury as a most extreme example in understanding some basics about tissue repair and recovery.

Muscle and musculoskeletal tissue repair are complex processes. They involve the interactions of different organs, tissue types, cell types, growth and inflammatory factors, and extracellular matrix components. These processes also occur in combination with factors that include an athlete’s baseline biologic health and other competing metabolic demands and stresses. The phases of normal tissue healing are distinct across tissue types, as well as within tissue types. These processes are nonetheless continuous and overlapping, progressing in a complex cascade of healing events that lead to a final patient outcome. For the athlete, this desired outcome is a return to peak training capacity and performance. Because the overall success and quality of tissue healing requires adequate nutrients to be delivered to the area of injury, the overall health and nutritional status of the entire athlete influences the ultimate potential for healing of damaged or injured tissue. As an example, many clinical experts in complex wound healing recommend a combined holistic and focused approach, to treat, so to speak, “not only the whole patient, but the hole in the patient” in an integrated, combined fashion. This same approach can and should be applied to treating not just the athletic injury, but also the whole athlete.

Training and competition impose markedly increased nutritional and metabolic demands. These include dietary demand in protein, energy sources and hydration, as well as micronutrient vitamins and minerals. Vitamin, mineral, and other micronutrient cofactors are of particular interest given their remarkable potential to foster and accelerate healing, and to help meet the unique physiologic demands of the training, or the injured athlete.

As mentioned, there is a broad range of tissue trauma, and there are many types of wounds with a wide range of physiologic character. Surgical wounds are distinguished as a purposeful and organized form of tissue injury, with the greater patient good as the desired outcome. Although the higher goal of training, like surgery, is the repair or restoration of some other compromise, the high intensity training itself is indeed a form of imposed tissue trauma, and necessarily results in organized tissue damage as a result. In this way, high-intensity athletic training often imposes all the increased nutritional and metabolic demands on a patient that are well known to occur in the setting of generalized trauma. Also remember, an additional principal element distinguishing surgical wounds and exercise-induced structural damage from a more typical trauma is that surgery and training are carefully organized and planned. This is particular in that elective surgery and planned training affords the stated unique clinical opportunity for patients to nutritionally prepare for tissue injury beforehand in order to preemptively optimize the body’s ability to heal and recover to its best possible potential.

Wound healing must occur in a physiologic environment that is conducive to tissue repair processes and regeneration. A multitude of factors are known to impede healing, including hypoxia, mechanical factors, infection, neoplastic and or metastatic disease in cancer, underlying medical conditions (such as diabetes), and/or medications (such as prednisone or other chronic steroids). This list continues to include dietary deficiencies in protein, energy sources, hydration, and micronutrient vitamins and minerals. Vitamin, mineral, and other micronutrient cofactors are of particular interest, given their remarkable and often untapped potential to foster and accelerate healing, and to meet the needs of the recovering athlete.

The principle objectives in athletic training are to achieve complete recovery as well as gain muscular tissue, skeletal tissue, and CNS development and growth as rapidly as possible. Human studies have repeatedly demonstrated the clear advantages of optimizing nutrition and vitamin/mineral levels before and after surgery as a means of helping clinicians and patients meet these objectives. Researchers who have explored the complex dynamics of tissue repair have described a wide range of micronutrient factors that are required in novel levels by the surgical patient for optimal effect, and that have unique potential for interactive effect toward the demands of different types of tissue healing (i.e., skin, skeletal muscle, tendon, bone, peripheral and central nervous tissue, cardiac tissue, etc). This list includes specific forms and doses of vitamins A, B subtypes, C, D3, K1, and K2, as well as minerals such as copper, zinc and a roster of others. This body of research has also identified properties of vitamins that would make for unfavorable effects or would be frankly contraindicated in the peri-operative environment at their typically recommended daily intake levels. This same research can be applied to the recovery of the same types of tissues and structures in the athlete.

At its base, it is the novel integration and application of this knowledge to the understood and unique demands of an athlete serves as the evidence-based scientific foundation for a targeted vitamin and mineral regimen for the athlete. This targeted micronutrient effort is further encouraged by the particularly robust, beneficial micronutrient effects that are possible in the athlete, when the optimal doses and forms of the given micronutrients are used.

Phases of Healing

Before we delve into specific micronutrients, their effects on the body, and our recommendations for athletes, it is important to understand exactly how tissues and structures in the body heal. The human body responds to damaged tissue the same way, regardless of the stress that imposed the damage. This means that to a degree, the processes that the body goes through to repair the tissue share many similarities, regardless if the damage was caused by back squats, a car accident or surgery. This is admittedly an oversimplification, and the magnitude of tissue stress is a critical consideration in crafting an advanced training or recovery program, but for our purposes, we will discuss some of the more typical and common elements of soft tissue healing after extreme physical stress or injury.

Each tissue type, be it skin, bone, skeletal muscle, mucosa, etc., has a tissue-specific cascade of healing that is typically defined in phases. Skin and deep tissue healing is a ubiquitous requirement for nearly all training, and as such, wound healing is discussed here as a commonality among all tissue healing procedures. Wound healing also provides a concrete format to demonstrate the applied vitamin and mineral strategy that can be exacted across a range of tissue types in the training athlete (to include bone, tendon, ligament, muscle and other musculoskeletal tissue). This provides us with a well-studied and well-practiced medical basis to base our recommendations for athletes upon.

Let us consider overt trauma as an extreme example to look at the phases of healing after soft tissue injury. The four phases of wound or tissue trauma healing are as follows: the injury event & hemostasis, the inflammatory phase, the proliferative phase, and the remodeling and/or regenerative processes.

Phase 1: The Injury Event & Hemostasis

The tissue injury event, such as with a surgical incision or microtrauma induced by a training stimulus, initiates a response that prompts that body to clear the wound of devitalized tissue and foreign material, setting the stage for next steps. The initial vascular response involves a brief period of vasoconstriction and hemostasis. This typical six to 12-minute time of intense vasoconstriction is thereafter followed by active vasodilation and increased capillary bed permeability. There are multiple sources of growth factors, cytokines, and other micronutrient and non-micronutrient modulated factors are introduced, and set the stage for the orderly cascade of events that will lead to final tissue repair. The speed and quality of the final repair is influenced (and amplified) from the outset by the athlete’s pre-existing levels of micronutrients, as well as other exogenous factors, such as sleep.

Phase 2: The Inflammatory Phase

The second phase of wound healing is the inflammatory phase. It is characterized by erythema, swelling, increased tissue temperature, and pain or discomfort. There is increased vascular permeability, and cellular response in the area of injured tissue. Several factors can drive the prolongation of this phase, including hypoxia, infection, medical comorbidities (i.e., diabetes mellitus), and malnutrition of micronutrient, which is one of several deficiencies disrupting the late inflammatory phase. In this phase, monocytes are converted to macrophages to destroy remaining neutrophils, scavenge devitalized tissue, and eliminate bacterial or other pathogens. These same macrophages initiate the transition from the inflammatory phase to the restorative healing phase.

Phase 3: The Proliferative Phase

The proliferative phase of wound healing that follows is characterized by tissue re-epithelialization and granulation. The length of this phase is variable, as it is largely and directly related to the extent and relative volume of injured tissue. Growth factors and chemotactic factors are released from macrophages and platelets. This, in turn, prompts the activation of wound fibroblasts, which then produce and prompt substances further essential to wound repair, such as various collagen types (tissue dependent), hyaluronic acid, chondroitin sulfate, dermatan and heparin sulfate. Together, these form the described connective tissue matrix that is required for cell migration. Vascular and capillary in-growth is also critical to this phase, in order to provide a means to meet increasing local metabolic demands as healing progresses. The relative vascularity and collagen formation are highly dependent on micronutrient support, with often dramatic potential to modulate the tensile strength and overall quality of healing tissue, as well as more generalized biomechanical quality and compliance and other factors.

Phase 4: Remodeling and/or Regenerative Processes

The final phase of healing is remodeling. This includes the addition and reorganization of collagen fibers and other tissue to optimize wound tensile strength and tissue quality. There is capacity for this phase to continue up to two years for a serious wound or surgery, though 40% to 70% of tensile strength (versus undamaged tissue) is usually recognized in the first four weeks. These first four weeks, therefore, represent the critical healing window, upon which all further healing is entirely dependent.

Macronutrition, with appropriate levels of lipids, protein, and carbohydrates, is important in all phases of post-operative wound healing, and is well understood in this setting.

From the standpoint of optimized vitamin, mineral and co-factor micronutrition in the setting of athletics, the above can be considered by matching the four phases of wound healing to the nutrients that most impact each of the phases. The injury and hemostasis phase differs for training in that it is continuous, whereas wounds and surgery are punctuated events in a person’s life. Therefore, in keeping with both the medical literature and common sense, an athlete can never afford to be micronutrient deficient.

Ensuring proper nutrition notably includes forms of vitamin E, as well as non-vitamin herbal supplements and medicines. There is a clear positive role for optimized vitamin K in the inflammatory phase. The inflammatory phase can be positively modulated by increased doses and forms of vitamin A, which supports early inflammatory phase events, vitamin C, which fosters lymphocyte transformation and neutrophil migration, vitamin D, and others. The proliferative phase enhanced by vitamin A (cell differentiation), multiple B vitamins, vitamin C (collagen synthesis and crosslinking, vascular healing), zinc (cell division and DNA synthesis), copper and others. The remodeling phase is positively influenced by elevated doses of vitamin C (collagen remodeling), vitamin K (cell growth), and others.

The first step is understanding some basic concepts of tissue repair and recovery. Heavy stuff, for sure, and we have examined only the tip of it. Now you have some background, though, to consider step 2. The next step is understanding how to use macronutrients, vitamins and micronutrient co-factors to naturally engage fastest and most complete tissue repair. This will outline how to employ vitamin and mineral micronutrition to get the most out of every workout, or how most quickly return to training and competition after injury.

In our next installment, we will begin with the first of a series of articles discussing how to best harness the recovery benefits of dietary vitamin and mineral micronutrients. This is the critical material that any athlete that is serious about making efficient and optimal gains in strength, speed, power and endurance should know, as next we will address strategically using favored doses, combinations, and forms of safe and natural vitamins and minerals to optimize healing and recovery time, capturing the essence of “there is no such thing as overtraining…there is only under recovery.”