The art of dealing with sickness, injury and adversity

All athletes have at some point in their career had to deal with illness, injury or some form of overload condition. How should you react when you find yourself in such an undesirable situation?  Obviously, the best thing is to avoid all illness and injury through preventive and precautionary measures, but no matter how careful you are, at some point you will have to deal with an undesirable situation and adversity. In this document, we look at strategies for how to recover from illness, injury and/or a "non-functional" situation, and hopefully also inadvertently create some strategies for prevention.   It is important to emphasize that each athlete and situation is unique, and that it is therefore important to seek advice from medically qualified personnel before and during the training process to recover and get back to a normal state.

Good health and proper training decisions that lead to continuity are crucial to ensure success/prevent failure of a season or sports career.  Illness, injury and poor training decisions can lead to unnecessary interruptions in the training process and, worst case, be career ending.   Some injuries and illnesses are easily diagnosed and 'visible', while other conditions are invisible and not possible to “explain”.  The latter are often only discovered when performance is not in line with what is normal/to be expected. If the training load and/or other stress factors over time have been too great in relation to the body's tolerance, athletes may enter into a "non-functioning" state. Typical characteristics are that the athlete feels that something is not "right" and experiences prolonged periods of poor performance and/or is unable to compete. This is often referred to as a "non-functioning athlete". A non-functioning condition is different from, and more serious than, a short break due to, for example, a cold or flu, as it takes much longer to reach a competitive level again. In addition, the "road to recovery" is often not easy to clearly define.  If the athlete reacts in time and correctly to a "normal" illness, the consequences are often not so serious, and the athlete can return to a normal performance level relatively quickly.  Prior to, and during, this year's Tour de Ski, several of the best athletes got sick and were unable to start or finish the Tour.  Getting sick and ignoring the illness, or overtraining, can lead to a non-functioning condition.


Sickness

When the ski season starts, sickness seems to be synonymous with being an athlete.  The reasons for this can be many and intricate to understand. In general, winter is the season of colds, flu and COVID-19.  Cross-country skiers and others who compete outdoors are also at increased risk of illness due to the strains of competing in cold climates. 

Some athletes are lucky enough to have an innate "talent" that makes them less predisposed to illness/injury. BUT it is also important to recognize that the best athletes are often cleverer, and as a result make fewer mistakes. This means that they are better, and have sufficient confidence, to listen to their body, accept the signals, and immediately react with the right measures (often this means to reduce or eliminate training and other stress factors).  Unfortunately, many athletes ignore the signals that the body sends.  Have you ever experienced a slightly itchy throat, a slightly altered voice, or woken up with a stuffy nose, BUT despite the symptoms you have completed a hard workout or competition?  Most people have trouble accepting that they are about to get sick and therefore often ignore the early/small signs of sickness.  Our advice is to listen and react immediately when your body whispers that something is going on, in order to avoid having to listen to your body “screaming” when you're lying sick in bed.   If you reduce/eliminate training early enough, the course of the sickness is usually considerably shorter. In other words, it's better to take a few days off from training BEFORE you get really sick, than to be prevented from training for many days or weeks afterwards. You must face the problems early, recognize the problem swiftly and react accordingly.

The "best medicine" is of course to avoid sickness.  Unfortunately, this is not always realistic, and it is therefore important that you and those around you (your team) create a strategy and plan for how to stay healthy, as well as how to jointly deal with sickness/injury in the team.  Team Aker Dæhlie have developed a plan and guidelines that everyone is obligated to follow.  Such guidelines and "rules" can certainly be perceived as a “straitjacket”, but they are important to ensure that athletes who have trained and prepared well, are given a chance to achieve their goals - "one for all, all for one"! And yes, we have a plan, but despite this, our team also experiences illness and injury (Team Aker Dæhlie’s health policy can be found at the end of this document).

 

If you experience sickness, it may be wise to consider the following points:

  1. If in doubt, rest: If you look at training decisions as "risk management", the risk of training/competing when sick is very high (with no reward).  In our experience, it is better to take one too many rest days than to train/compete when you are sick or about to get sick.

  2. If your heart rate in the morning is 8-10 beats higher than normal--> rest or train extremely easy (if it's on a competition day the advice is to skip the race)

  3. If you have a fever, stay indoors.  After the fever has subsided, you can go for light walks to get some fresh air.  Wait until the symptoms have disappeared before exercising.

  4. When the symptoms have disappeared, you should start with gentle training.  If the easy training works and your body/heartrate is normal, you can do a light level 2-3 session after 5-6 days of easy/light training.  If you have completed a series of "standard sessions/standard tests" in your training preparation, you can do such a physical test instead of an intensity session to check if your body is ready.  If the test is "normal" then you can train normally again.  Start with a light week.  If your body reacts positively to the light week, you can continue with a medium week, followed by  a hard week.  If the body does not react positively, you must reduce your training and "go back to the start".


Injuries

It's frustrating to suffer injuries that prevent you from participating in training or competitions.  Some injuries are acute (such as a broken bone), while others are more chronic (such as back pain, stress fractures or inflammations).  Acute injuries cannot always be controlled, but safety and the right equipment (such as a helmet) are good preventive measures to avoid serious and time-consuming injuries.  In the event of an accident, it is important to contact a doctor or hospital to ensure that the injury is diagnosed and treated properly as soon as possible.  The length and type of training after an injury must be carefully planned together with a doctor and/or other medically qualified personnel.  It is important to keep your spirits up in such a situation and turn the "negative situation" into something positive.  What activities can you do? How can these activities help you in the long run to develop in a positive direction as an athlete? Sometimes you can use this time for things other than training.  You can watch videos and learn more about your own and others' techniques, read books and acquire knowledge about training, review your own ski equipment, visit friends and relatives, or do other things that you otherwise do not have time to prioritize during your busy training schedule.  The motto is "when life serves lemons, make lemonade". If exercise/activity is possible, all you need is a little imagination.  Remember that your heart and lungs don't know whether you're skiing or swimming (or another endurance sport).  A forced break from normal exercise can be an excellent time to exercise alternatively. What other activities can you do to strengthen your weaknesses?  There are many alternative training activities that can work well in the event of an injury - check with your doctor or physiotherapist to make sure that the training does not lead to a prolonged injury downtime. Swimming, cycling, running in the pool (aqua-jogging), sit-ski, rowing, kayak, strength training, mobility exercises, technique imitation exercises, arm-bike, double pole machine, yoga, climbing, etc. are activities that can be good alternatives to “normal” training.  It is often best to combine several such activities in one workout to avoid overload or new injuries.  When you are ready to resume "normal" training again, it is important not to start too abruptly with a too heavy workload.  Start with short sessions in combination with the alternative activities that have worked for you.  Gradually increase the number of hours and intensity in consultation with your coach, doctor and/or physiotherapist. A break from injury is a golden opportunity to analyze your weaker sides as an athlete and use the opportunity to work on, and even develop, certain areas. Often you don't need to train less, just differently.

Chronic injuries are often the result of incorrect or monotonous loads over a long period of time. An overuse injury can, for example, be pain under the foot, leg, hips, back or shoulders. The pain may be caused by muscles, tendons or a stress fracture. Some common causes are too much load/strain, too rapid increase in load, incorrect technique, limited mobility, muscular imbalance, lack of strength or specific/general muscle weaknesses.  Preventive training, varied training/load and correct technique and equipment are important to avoid such injuries.  Preventive training can be strength training, mobility training, or training for the parts of the body where you could potentially become injured, or which are particularly vulnerable in your sport.

It is also important to emphasize that there is no set formula for exactly what to train. One form of training is not necessarily better than the other. It must be individualized to the athlete and the situation. Varied training in varied terrain is of course important.  3 hours of running on asphalt is hard on the body, while the same number of hours on a soft surface can be "balm for the body".  You can also combine roller skiing and running so that you get a longer session in total, with less strain than, for example, only running.  Correct technique in the weight room and during general training is important to avoid injuries.  Work on your technique no matter what you do!  "if it is worth doing, it is worth doing it right". If you experience pain in your back, for example, you can first reflect on whether there is something you can/should change with your technique.  For cross-country skiers who run a lot, it is fundamental to have footwear that fits the body, the surface, and the running stride.  It's important to have a selection of shoes that suit you and the specific training environment.  If you are not sure, you should contact a sports shop that can provide good advice and tips.

Should you experience a chronic injury, you MUST, consult a doctor and/or physiotherapist for treatment and help. Don't wait too long to seek professional help. The earlier you address a problem, the quicker it can be resolved.  As with acute injuries, you may need to complete a longer period of alternative training.  It is of utmost importance that you are patient and take the time you need to become injury-free.  Unfortunately, there are no shortcuts or "magic bullet".  Take your time, train alternatively and stay positive!  Once you are injury-free, it is highly recommended that you continue with preventive exercises to prevent the problem from returning. Remember: your muscles/body must be carefully maintained every day!  Preventive exercises should become part of your everyday training - it must become part of your daily routine!



The non-functioning athlete

If the stress/strain on the body becomes too large over time, it often leads to a situation where the body is unable to train, recover and perform.  The reasons for such a "non-functioning situation" can be many and complex, and it is also a situation that is incredibly difficult to deal with for both the athlete and everyone else around. Here is a link to a study about a well-known Norwegian cross-country skier who has experienced such a situation. Researchers and other people working in the sports field have many different names that can be included under the "umbrella term" of a "non-functioning athlete", depending on the cause or duration of the problem(s).  Names commonly used to describe such conditions include: overtraining, overtraining syndrome, overload, improper training, functional overreaching, non-functional overreaching, unexplained underperformance syndrome and REDs (REDs can be a contributing factor to a non-functioning condition). What you call the condition or what symptoms you experience, are less important than how you react - the point (and the challenge) is that the athlete is not functioning optimally, and required measures directly targeting the possible underlying causes must be implemented to improve the situation and enable a return to a “normal” state.

Unfortunately, many athletes have long periods during their careers where they are unable to perform at their expected level.  The body is in some kind of “unexplainable” imbalance and does not function as it should.  Such an experience is extremely challenging and frustrating for everyone involved, as you often don't know what the underlying causes of the problem are.  Despite visits to the doctor, blood tests, respiratory tests, allergy tests, heart tests and other tests, few or no answers are found. The only thing that is clear is that the body is not functioning properly. If you break a bone in the hand or foot, everyone can see that there's a problem and you can rest assured that the “cause” of the problem has been found and you know roughly how long it will take before you can return to normal exercise.  When the body doesn't work and the tests show no signs of illness or problems, anyone can get frustrated. It is easy for the athlete (and for others around) to start pondering - am I just that bad or is it all "just" mental? (It should also be said that several athletes, before turning the spotlight on themselves, question the skis, the service/support team and/or the coach. This can of course be an obvious reason for lack of performance, but we do not discuss equipment in this article). In such a situation, it is important that the athlete and everyone around the athlete understands that: "Lack of evidence of illness/cause, is NOT evidence that the athlete is healthy."  The athlete therefore needs a team around him/her that accepts the condition and that has faith in the athlete.  Curt Richter showed with his experiments on rats that hope is incredibly powerful (experimented on how long rats could survive in water)- rats without hope gave up early and died, while those who had been given hope kept on fighting.  Although the extreme and brutal studies were conducted on animals, it is important to recognize that hope is an important mechanism also prevalent in humans.   Without hope, people lose motivation and give up.  We as coaches and support staff must give the athlete hope and faith!  The road back is long enough as it is – the road to full recovery only becomes "shorter" when the world around radiates patience, joy, respect and calmness.  As coaches, we must be aware that many athletes are extremely loyal (to the coach and training program) and will listen to our advice - use this trust to motivate the athletes to take the correct actions.  Coaches who make athletes feel guilty or push athletes to train more/harder are "poison" to the process.

Although it is often difficult to say what the underlying cause(s) of a "non-functioning condition" are, the research literature generally agrees that such conditions can be explained as a result of that the total stress load on the body has been too great over a long time period.  Stress can be many things: Too much or too intensive training, lack of recovery or sleep, lack of nutrition, major changes in body composition (growth, development, puberty and the transition from junior to senior), mental and social stress, illness and viral infections, etc.  When analyzing an athlete's situation, the goal is always to first identify the possible causes of the underlying problem through a thorough analysis. This will provide crucial knowledge that hopefully will solve the problem, as well as keen insights of how to avoid similar challenges in the future. 

What can you do to avoid such problems?  To reach your highest potential as an athlete, you need to train well over a long period.  What constitutes "good" training is widely debated in both the research literature and among coaches and athletes.  In their eagerness to become the best (as quickly as possible), many train too hard or take "shortcuts".  Unfortunately, many experience that the quest to achieve development and realize the max potential, is a "balancing act on a knife’s edge".  Training is not, and should not be, dangerous.  A good training program is sustainable, ensure continuity and development over time AND always safeguards the athlete's health. In previous articles from TAD, we have discussed the importance of proper training, intensity, technique and strength training.  Feel free to check these out to see if there are tips that can help you find the right training approach.  In addition to training, you need to make sure that all other factors are optimized for the athlete's individual needs (nutrition, sleep, mental state, the team around the athlete, social and financial security, equipment, etc.)  If everything around the athlete is optimal and the "stress level" is just right, the likelihood of achieving a good training response and performance development is high. A major challenge is that we don't really know what is right at any given time to achieve continuous improvement. To ensure continuity in training and positive development, it is important to QC (quality control) the training process, listen to the body's signals and test regularly.  If you react correctly to the test results and the signals your body gives (and everything else is correct), the risk of becoming "non-functioning" is greatly reduced. 

If you find yourself in a situation where your body is not working properly, this often triggers a lengthy "detective process" to identify possible causes and solutions to the problem.   For athletes who have kept a detailed training diary over time, carried out regular physical tests, undergone medical check-ups with blood tests and other tests, it is much easier to carry out a thorough analysis to identify possible causes.  Our advice is that all athletes should do the following as an "insurance” in case they should experience a prolonged period of imbalance and poor performance: Training diary with comments on how the training has been carried out and how you felt physically and mentally, resting heart rate in the morning, blood tests, endurance tests (preferably in the lab with a standardized protocol and registration of heart rate, perceived exhaustion, lactate and any drop in heart rate during breaks), health certificate and possibly DEX-A measurements.  This documentation and systematic approach are valuable for evaluating and planning training even when everything is going well.



Changes in the body

During puberty and through adolescence, junior and early senior age, major changes occur in the body.  Some changes are positive for athletic development, and some changes can lead to a stagnation or decline in performance, especially in women.  This is a completely normal and is to be expected!  The human body has not changed too much in the last 1000 years, so it is a paradox that coaches, parents, and athletes are not better prepared for this period.  We need to do a better job of educating everyone!  These changes are normal, desired and should not prevent us from continuing to train with passion and joy.  The body changes naturally, and as a natural consequence many athletes experience rapid changes in for instance weight and body composition.  During this period, it's important to adapt adequately when it comes to proper nutrition, training and, not to forget, performance expectations.  We can't do anything about the body's natural changes, but we can do something about how we adjust the training and our expectations.  Athletes should be informed about, and prepared for, this naturally occurring "nonfunctional phase". Coaches and parents should have open and honest conversations with the athletes about the topic. Fortunately, these “growing challenges” can be adequately solved with patience (time) and wise training decisions in a good and safe team environment.



The road back to a functioning state.

Although it is challenging to come up with specific and certain signs of a "non-functioning situation", it seems that there are some general signs and signals that must be taken seriously and responded to appropriately.  If an athlete has one or more of the following symptoms over time, there may be dangers lurking ahead and action should be taken: Fatigue/tiredness, frustration, low self-esteem, poor results in training and competitions, sleep problems, low energy balance, poor appetite, irritable, emotional instability, higher resting heart rate in the morning, muscle pain (stiffness), a lot of illness (especially upper respiratory infections), long recovery time, etc.

The first step is to accept that there is a problem and that you need help to solve it.  Then we recommend the following process to get back to normal:

  1. Visit your doctor (preferably a sports doctor) to discuss the situation and carry out a series of medical and physical tests.  This to determine whether there are any medical conditions that are causing the problem. A doctor will assess the need for additional tests (blood tests, breathing tests, EKG, and possibly other tests).  If medical causes are identified, these must always be addressed first.

  2. The coach and athlete must together evaluate the training and previous tests to determine when the problems began and whether there are obvious causes that may have led to the "non-functioning state".  Athletes who have increased their training volume and/or intensity significantly may often be at risk.  We often see that "good" training periods are followed by longer breaks in training due to injury or illness (leading to a lack of continuity) and that the load over time has been too great or monotonous.  Lack of periodization (easy, medium and hard periods) are also typical causes (periods, weeks and days become too similar and without time for adequate rest and recovery which prevents adaptation and desired response to the training).

  3. See a nutritionist.  Even if you think your own nutrition is adequate, we think it's a good idea to get a professional assessment of your nutrition. If everything is fine, you don't need to change anything.  Map out your current nutritional status and develop a strategy for optimal nutrition before, during and after training/competition.

  4. The mental aspect must also be analyzed and optimized.  Many people are a little reluctant to visit a specialist in psychology/mental optimalization, but we believe that the mental aspect is hugely important for getting through a difficult time and reaching your athletic potential. The truth is that having a mental supporter/expert on your side does not make you worse, hence the risk is zero.   Seek out an expert to optimize your mental state. This can be crucial for getting through a challenging situation faster, but also positive for future development.

  5. An interdisciplinary team (several experts from different fields) is important to uncover the cause(s) and find solutions. It is important that this group acts as a unit/team and is well coordinated.  One person should coordinate all expert opinions and strategies to facilitate an effective and efficient process.

  6. There is no standard recipe for how to recover from a "non-functioning condition".  Experience suggests that, over a longer period, you need to reduce stress (including the training load), sleep more/better, focus on recovery and optimal nutrition.  Remember that you must change something to get better! In other words, if you do the same thing, the result will remain the same (unless everyone else changes in a negative direction).  Change is difficult and can be scary, but it's often necessary.  Set goals for what needs to be done and don't force a solution.  This is going to take time!

    1. Rest/reduce your training load drastically for 2-3 weeks.  Walking and fresh air/sun is better than just lying on the couch!

    2. Eliminate intensive sessions from your training plan.

    3. When you feel fit/well (no symptoms of illness), a lactate profile should be performed to obtain a physical status.  The test should be repeated every 3-4 weeks to see if the body is in balance and responding well to exercise, as well as to ensure that the plan leads to positive development.

    4. The amount of training, form of movement and intensity are controlled by what you see on the tests and how the athlete feels.  If the test results develop in a negative direction, the training load must be reduced; if the test is okay, the training load can be increased gradually.  In our experience, it is best to increase the amount of easy volume with a focus on good technique before introducing more intensity into the training.  The gradual adaptation to training can take months.  When the athlete tolerates and responds well to easy training, you can carefully increase the training intensity.  Example: The athlete has gradually increased the training and has completed 10 hours of easy training per week for 3-4 weeks and the tests (and feeling) show a positive development. The next step is to try a light periodization of the training (depends on how long the athlete has been training and what is "normal" training for the athlete) - try a week with 13 hours (medium week), if the response is positive, try a week with 16 hours (hard week).  If the response from the body is negative, reduce the volume to an acceptable and safe level and wait before you again try to increase training volume gradually again.  If all signs are positive during this period, one can try the same number of hours in a 3-week cycle with 1 intensive session per week (level 2/3 intensity), if this works, one can keep the same number of hours and increase to 2 intensive sessions per week (level 2/3 intensity).  If the tests show a positive development and the athlete feels good, you can increase the volume gradually BUT continue to check the test results and feelings of the athlete.  The goal is to ensure continuity and that the athlete can tolerate normal training over time.  Don't underestimate the importance of rest days and easy weeks even if the body starts to function again! Too many people want to make up for lost time too quickly!

  7. How you organize your training is important.  Our experience suggests that periodization is important.  The simplest (not always easy to implement) is to organize the weeks (or periods of 10 days) into: easy, medium and hard weeks/periods - for example, easy 10 hours/week, medium 15 hours/week and hard 20 hours/week, or for those who train a lot: easy 15 hours/week, medium 25 hours/week and hard 30 hours/week.  Again, it's important not to underestimate the importance of an easy week!  In a training week, it may make sense to concentrate the "hard" elements on a few days, so that the other days consist of only easy training.  For example: Monday: easy with speed, Tuesday: intensity and strength, Wednesday and Thursday: easy, Friday: easy with speed, Saturday: intensity and strength, Sunday: easy.  

  8. Athletes who have struggled for a long period of time often bring with them many negative experiences and emotions from competitions and hard sessions.  It is important to distinguish between physical fitness, mental fitness, and competition fitness.  When physical fitness returns, it doesn't mean that things automatically work as they should right away in competitions.  Again, you must be patient!

 

Regardless of whether your problems are of short or long duration, or whether the causes are clear or not, it is important that you take the time to solve the underlying problems as soon as you notice that something is wrong.  If you listen to your body when it quietly whispers that problems are arising, the road back to a "normal" and healthy state will often be significantly shorter than if you ignore all signals and wait until your body is screaming for rest. If in doubt - rest! It doesn't mean you're lazy, it means you're smart!

 

How does Team Aker Dæhlie do this in practice?

Team Aker Dæhlie has an experienced general practitioner/sports doctor in Erlend Haugstad who follows the athletes closely. We have simple, but clear guidelines in the event of sickness. A fast and direct dialogue with a doctor is important to clarify conditions and find an appropriate treatment as quickly as possible. It is also important that the coach, athlete, and doctor agree about the athlete's condition and required measures.

Infection control, cohorts and the names of various viruses and other microorganisms with difficult names have become commonplace in recent years. There is a long tradition in sport of taking infection control seriously. The "10 Commandments" below were presented by former Olympic surgeon, and Ski Association doctor Ola Rønsen before the 1997 World Championships in Trondheim: The “rules of engagement”, might be old, but they have in our opinion withstood the test of time.

 

"The 10 health commandments" (Ola Rønsen)

  1. Limit unnecessary contact with people outside the team where you live, train, eat and stay. This also applies to managers and support staff dealings with people outside our own squad.

  2. Keep a safe distance (1 m) from all persons outside the team when meeting outsiders, including external service people, sponsors, family, and friends

  3. Minimize shaking hands, hugging or other close contact with strangers

  4. Wash or disinfect hands before every meal, after shaking hands or after direct contact with objects touched by many other people, and otherwise as often as possible

  5. Be particularly observant in the dining room when it comes to contact with shared cutlery etc.

  6. Limit your own hand-to-mouth and nose contact, as this is the most common route of transmission for respiratory infections

  7. Do not cough or sneeze into your own hands and use disposable tissues to blow your nose

  8. Keep your own room and common areas tidy so that daily hotel cleaning can be carried out

  9. Avoid contact with sick persons completely and report to the doctor if sick people are not following the rules of engagement. 

  10. If you notice any symptoms of illness, report it quickly to your doctor. Do not hesitate!

 

Taking responsibility for yourself and your teammates' health is necessary to facilitate good performance. If "one link fails", you can risk taking an entire team out of action in, for example, a major championship. The same sense of solidarity should also be present in your training group, even if there is no race or championship. If you don't want your teammate to show up sick at training with the risk of infecting you, then you shouldn't do it yourself.

 

"Return to play" after sickness.

In the early stages of illness, you shouldn't exercise. You don't know what is about to happen. Fever is an absolute "no" to exercise, as this is a sure sign of a systemic impact of the disease. You should not start training until you have fully recovered, possibly after an extra safety day off. Return to training must be gradual. Sometimes there are residual symptoms from the nose and sinuses. As long as these are local symptoms, sufficient time has passed and there are no general symptoms, you can probably exercise lightly. Start short and easy. It is a prerequisite that you get gradually better (less stuffy and get the snot out). Contact and dialog between athlete-coach-doctor is very important. No two courses of illness are identical, and the individual adaptation is often decisive for how successful the return to normal activity will be. The challenge often lies in the ability to conduct training lightly and slowly enough, as it is easy to often start training at too high a level (everyone wants to make up for lost training).

 

Important checkpoints during training:

* Record heart rate during training.  If you measure your heart rate, you MUST also face the consequences of when the heart rate is not normal.

* Record resting heart rate and possibly HRV in the morning.

* Record the perceived load of the session from light to heavy (1-10)

* Record any fatigue experienced during the session, as well as in the afternoon/evening and possibly the next day.

All training should feel normal, i.e. you should not feel abnormally tired during and after training. This in turn means that training must be adapted/adjusted.

It's important to not engage in too hard intensity sessions or rush to get back to competitions.

If you are in doubt - you are not in doubt. Rest and contact your team doctor/coach.

Written by Team AKER Dæhlie/Trond Nystad, Knut Nystad, Jostein Vinjerui, Hans Kristian Stadheim, Chris Jespersen og Kari Vikhagen Gjeitnes.

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