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There is nothing more frustrating than being stuck in a boot or a leg cast for weeks.
But then you have to watch as all that leg strength disappears before your eyes.
Fun fact: you lose muscle up to three times faster than you gain it!
To add to the drama, you’ll tend to gain body fat as you lose muscle, making the challenge of a successful return seem even harder.
So if you spend six weeks in a boot, the rebuilding process can take up to 18 weeks! And that’s assuming you don’t have any joint stiffness or pain to slow you down.
This frustrating statistic often leads our Physiotherapy team to get asked “What exercises can I do in a boot?”, “Can I still squat in a walking boot?” and (my personal favourite) “Is running definitely not allowed while I’m in the boot?”
(Spoiler alert: the answer is a definite “NO RUNNING” to that last one).
For every question, there’s an answer and it’s actually more possible than you realise.
Our Physio experts have listed the key features to look for when buying a cam walker boot (aka. medical boot or moon boot).
The recommendations make it simple to get the right boot first time, to speed up your recovery.
The strength plan
The good news is that there are still plenty of strength exercises you can do, including squats while in the walking boot.
They’ll maintain or even improve your strength while you are non-weight bearing or partial weight bearing in the boot or leg cast.
(It depends on how well trained you were beforehand – non-trained people get stronger, well trained people will still lose strength but not as much as sitting around and not exercising.)
And if it seems pointless because you can’t put weight through your injured leg, remember these points:
- Your good leg will be working harder on your return and needs to be stronger than your injured side to effectively compensate
- The injured side actually gains about 15-20% of the performance improvement from a strength exercise performed on the good leg – you get stronger on the injured side even if you don’t load it directly!
- You need to keep a training routine for your mental as much as physical health
You’ll need to manage your body weight during the recovery as well – it’s more than just not gaining weight on the scales, it’s about providing your body with the nutrition it needs to build muscle and repair the injury.
Good nutrition has been shown to speed up injury recovery and tissue repair, but good nutrition can also be quite calorie-dense.
That means it’s prone to adding additional bodyweight if the portion sizes aren’t spot on.
Injuries you can train through
Strength training with injury is not as simple as not putting weight on the cast or boot and throwing some weights around.
Some injuries won’t react well to muscle loading across the injury, even is the injured foot isn’t touching the ground.
Be cautious and always ask your medical team about muscle loading across the injury if you’re not sure.
Here’s a general guide to loading different types of injuries
Ligament injuries around the ankle can be safely loaded if the joint is stable and in a neutral position.
So if you’ve got the boot on, you can be guided by your symptoms.
Fractures in the foot won’t like any pressure on the toes or ball of the foot, regardless of the fracture location within the foot.
Pressure on the heel is OK after 2-3 weeks and based on symptoms, as it will exert muscle loading across the foot.
Fibular fractures can be loaded after 1-2 weeks as the bone isn’t exposed to much bodyweight loading.
It is under pressure in dorsiflexion so it’s best to leave the boot on to maintain a neutral ankle.
Tibial fractures need a more cautious approach as it’s exposed to bodyweight loading and calf muscle loading.
You’ll generally need to stay away from any bodyweight loading for 4-6 weeks and avoid excessive calf muscle loading (due to resisted knee bend, such as a hip bridge or thrust) for 2-4 weeks.
Any surgery is taken on a case-by-case basis as there are slight variations.
Consult your surgeon and rehab team for specific restrictions.
Goal of modified strength work
This type of program differs in some ways from your typical gym program. But it’s also got a lot in common.
Both normal and modified gym programs should focus on quality movement patterns.
Smooth, well controlled movement will always beat ugly, heavy lifts.
Work on controlling the movement throughout your range before you add or increase the load.
And there’s no need to clench or squeeze muscles just so you can feel them!
Clenching a muscle doesn’t add anything to the gains from an exercise but it can compromise your movement patterns.
If you can’t feel the exercise in the intended muscles, choose a different exercise.
Normal gym programs focus on building strength. This modified program may focus on maintaining strength, or even slowing the loss of strength.
Just because you’re sliding backwards doesn’t mean it’s a waste of time. You’d go backwards at a much faster rate if you didn’t train.
Remember to constantly adjust your loading to account for potentially declining strength in the early stages of injury recovery.
This may mean less reps and/or lighter weights.
You will probably end up doing a different number of reps on each side, with the unaffected side doing double of the injured side.
As a guide to cutting down on your reps, if you can’t maintain the speed of movement of a rep, stop the set there.
Pushing on will only lead to technique issues and additional injuries.
Balance and symmetry
Normal gym programs should focus on balanced strength work, both between sides and between muscle groups.
This program will probably be focused on training the good leg and affected areas.
That good leg is going to be doing the bulk of the workload on your return so it needs to prepare for it.
So don’t be afraid to do some exercises just for the unaffected leg.
Remember that some of that strength will cross over to the unaffected leg, even if you don’t or can’t train it!
Sure, it will lead to asymmetrical strength gains – but the later stages of your recovery will have asymmetrical demands on the legs, so you’re training for purpose.
Our list of potential exercises and modifications
Remember that this isn’t a complete program. Use your normal strength program as much as possible and hand pick options from this list to fill gaps due to injury restrictions.
Modified mountain climbers
Elevated side plank leg raise holds with band (aka. Side plank star hills)
Modified single leg elevated hip bridge (aka. Hip thrust)
Supported single leg deadlift
Supported single leg squat
Single leg Pallof press (aka. Anti-rotation holds)
Modified load and lift
Single leg goblet box squat
How often and how heavy? What works best?
The exact weight that you use depends on your lifting background and current strength levels.
Just keep in mind that you may have already been out of action for a few weeks so start lighter than you think.
You can always play if safe on the weight and ramp up the reps to produce the fatigue required to build strength.
For any strength-building (or strength-preserving) exercise, such as the Single leg goblet box squat, three sessions per week is enough.
If you don’t feel fatigue in the legs the day after training, you can ramp that up to five sessions per week but the extra gains aren’t that much.
For any exercise focused on movement patterns or mobility, such as the modified load and lift, you can perform this every day.
For sets and reps in an “ideal” world, you’ll find the best results with 4-6 sets and as many reps as you can perform with good technique/control and maintaining a steady cadence (ie. Not slowing down).
Rest breaks between sets is “ideally” 2-3 minutes to allow for a decent recovery.
The reason that “ideal” keeps appearing in inverted commas is that there’s a big difference between “ideal” and practical!
The program would take over an hour with ideal numbers. Great if you’ve got the time but life often gets in the way.
More practical numbers are three sets to loss of form or speed with 30 seconds between sets, or your rest break can be performing an exercise set for a different muscle group (like performing an overhead press in your rest between squat sets).
Start easier than expected. That time away from training with the initial injury reduces your capacity (read about how fast you lose strength and fitness).
Frustration and motivation don’t change that fact.
Never risk aggravating your injury (or worse, getting reinjured!) in trying to chase some training gains.
Play it safe and if in doubt, ask your medical team.
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