• dr puisan

How to salvage (as much of) your fitness and muscle mass during periods of forced-prolonged recovery

In sports (and life!), injuries and illnesses do happen.

We as athletes try our best to prevent this from occurring (after all, who wants to take the back seat while all our training partners are out there living their best lives on social media, training for such and such Ironman/marathon/ultramarathon/whatever-event-you-were-training-for-before-shit-happened) but sometimes the inevitable does unfortunately occur.

So what can we do to prevent the inevitable reduction in our hard-earned fitness and muscle mass (at the same time, not to gain fat mass)?

First…let me backtrack and explain how this article came to be.

About 2 weeks ago on a Friday, I woke up as per usual (that would be 4.40am for me), headed to work (I have a 45 minute commute which I love at 5 in the morning while learning about the gut microbiome on an educational podcast), did my training (it was my deadlift day and I pulled an easy 3x6 of 77.5kg), started work (I didn’t schedule any patients as I had quite a bit of administrative paper work to settle) AND then realize I’m having this vague central abdominal colic.

I brushed it off as me being hungry. But the discomfort continued through long Friday lunch break and progressively intensified. By the time lunch was over, the pain was very difficult to ignore and was more localized at the suprapubic and right iliac fossa region (for the anatomically-challenged, I will insert a photo for reference sake and it is area 7 and 8).

Amazingly managed to drive home.

At the back of my mind, this was no normal abdominal pain. Something was wrong and this needed to be looked at. But also from someone who has worked in the emergency department of a large tertiary hospital in Klang Valley, I was familiar with the procedures of “getting it checked out” and I know I needed to head home, get cleaned, packed spare clothing/towel/toiletries, change into something I do not mind squirming in pain in for the next 5-10 hours (coz you never know how busy public hospitals can get on the eve of a long weekend) then (and ONLY then) called for help.

The drive to the hospital (by now I couldn’t be behind the wheels) was excruciatingly painful and torturous. I felt as if my internal organs were being ripped apart – figuratively speaking, and there were tears of pain. I rarely cry tears of physical pain. So this was extremely painful.

Fast forward 10 hours later (a lot of stuff happened in between but it is not imperative for all to know), I was being wheeled into the operating theater for, what I thought was, Laparoscopic Appendicectomy.

About 6-7 hours later, awoken and groggy from the anaesthesia, I was told that my right fallopian tube had strangulated around a cyst, gone ischaemia and became necrotic (blood supply got cut off and subsequently died) – thus they had to remove the right fallopian tube, the offending cyst, and my right ovary. Oh…and while they were at it, they removed my appendix as well.

* It may have looked similar to this

I was discharged 2 days later to rest at home for 3 weeks. This turns out to be the longest medical leave I’d ever had. The last time I broke my finger and had surgery, I was back at work within 5 days with an immobilized right hand/arm.

Knowing what I know about post-op recovery (it is after all, kinda my bread and butter), I know that I needed to move, move frequently and to nourish adequately. But despite adhering to all the above as much as I could, I was rather shocked to see the amount of loss that had taken place after 1 week: loss of weight, loss of muscle mass, loss of fitness and not to mention, loss of appetite.

So now beckons the questions… long can I rest and do absolutely nothing before my fitness and all those hard earned muscles go bye-bye? And are there anything I can do/eat/drink to make the loss less devastating?

I don’t have all the answers but let’s see what researches in this topic have to say.

Will time off affect me?

So it is not all in your head when you take a couple of weeks off and you feel less fit and probably your muscles feel a tad “softer” and “fluffier”.

The proper term used to describe the muscles being less prominent and firm due to time off from activities, is ‘Disuse Atrophy’…where atrophy means getting smaller, while disuse is self explanatory.

Common methods to counter the disuse atrophy are:

(1) many forms of mechanical loading (simplistically meaning strength training and exercise, sometimes even electrical muscle stimulation. Physiotherapy falls into this category as well).

(2) using nutrition as an adjunctive method to promote anabolic stimulation (anabolic means ‘to grow’).

How fast will the loss of muscles be?

This is a very hard question to answer. But different muscles seem to atrophy at different rates. The quadriceps (front of thigh muscles) decline in size by 3.5% and showed a reduction in strength of 9% within 5 days of immobilization (not moving). The figures jumped to 8% and 23% respectively by 14 days (Wall et al., 2013). If numbers mean nothing to you, imagine losing a quarter of your baseline strength within 2 weeks – getting dropped climbing up Genting Peres after 2 weeks of not cycling, is not just all in your head. You are NOT as strong as you were by a significant amount, compared to 2 weeks ago.

How about you taking 2 weeks off, then return to cycling and are ecstatic that your bib shorts fit you a bit looser now? Did you lose weight miraculously?

Most likely not (but I like the optimism). In fact, most likely your muscles have shrunk in size and circumference causing you to delusionally think that you lost weight (or fat). Suetta et al. showed that there is a reduction is cross section of muscles by 10% within 4 days (!) of immobilization which declined up to 20% at 2 weeks. Imagine that….1/5th loss in your thigh circumference after 2 weeks of immobilization.

How about if I just don’t cycle hills and only do Zone 2 steady state cycling? I’m sure I won’t get dropped…I hope!

Fair point. So far I had discussed about muscle size and strength. You are probably thinking the endurance bit will stay intact a bit longer. So let’s look into muscle fibre types. As you know, Type I fibres are the endurance type – they are not employed during explosive, speed-required movements, and they do not fatigue easily. You need these for steady state, very long duration activities such as a marathon, ultramarathon, the Ironman etc. On the other end of the spectrum, there is Type II fibres…for speed and explosiveness, for weight lifting and box jumps, for the sprint to the finishing line…they are powerful but fatigue easily.

* Side note: There are also other types of Type II fibres and there are differences between them but for the purpose of this article we will stick to Type I and II only, and leave it at that.

There is evidence to suggest that Type I muscle fibre atrophy is greater than Type II after 1 month of being sedentary, and this research showed it over the Vastus Lateralis (the outer part of your quadriceps). Your endurance bit of your muscles fibres seem to go AWOL first. So…that kinda sucks.

Is there anything I can eat/drink/take that can counter the muscle atrophy?

To counter the disuse atrophy, you have to take into consideration of the balance between ‘Muscle Protein Synthesis’ (MPS) and ‘Muscle Protein Breakdown’ (MPB). As much as I think MPS vs MPB concept are self explanatory, let’s run through the terms as basic as possible to aid in your own understanding. When talking about MPS, we are talking about GROWING the muscles, in many cases this is ideal and is what we aim towards…whereas MPB is regarding the breaking down of muscles, which is what we want to avoid.

Certain nutrients and certain hormones (which can be attenuated with said nutrients) can tip the balance between MPS and MPB.

There are plenty of evidence that points to the Essential Amino Acids (EAAs) of protein that promotes MPS and that this anabolic effect of protein is dose dependent up to a point. Cuthbertson et al. showed that there is drastic increment in MPS of up to 200-300% from baseline for a period of about 2 hours after ingesting about 20-30g of protein.

Having said that, it was previously thought that insulin (the hormone that clears blood sugar and most people think about when discussing about diabetes) promotes MPS however of recent years, research suggests that insulin is more likely to suppress MPB. This anti-catabolic effect (prevents breaking down) of insulin aids as an agonist to protein’s effect on MPS. In layman terms, protein BUILDS muscles while insulin prevents BREAKDOWN of muscles. This does not mean you are can gorge and binge on doughnuts, pizzas, breads and rice….because despite popular believe, carbohydrates are not the only things that leads to insulin secretion. A less known fact is this: protein, especially some of the EAAs also lead to insulin secretion!

So does that mean I can drink protein shakes all day and not have to worry about disuse atrophy?

Not so fast. Yes, protein intake helps. However physical inactivity sometimes can triumph despite your careful dietary manipulations. Many studies have looked into MPS and inactivity/immobilization and have concluded that the longer you stop being physically active, the harder it is to stimulate MPS and the harder it is to get the same rate of MPS as an active person. According to Kortebein et al., after just 10 days of bed rest, there is up to 30% reduction in post meal MPS (yup…you can drown yourself in protein shakes, eat all the steaks and roast chicken but it is still going to be 30% less MPS than when you are active and training). This number goes up to 50% reduction in MPS after just 2 weeks of bed rest/inactivity!

But….I’m still healthy, right? I just lost a bit of muscle, strength and endurance. It is not like I’m now at an increase risk of getting diabetes and what-nots. I have been training all these while!!!

I see your point there. I do not want to get anecdotal on this but what I can show you are evidences from multiple researches done on similar and related topics.

In our bodies, when we take carbohydrates, it gets broken down into glucose (sugar) and the body clears the glucose by means of insulin secretion. Insulin allows the glucose to enter your muscles and liver to be stored as precious glycogen (for everyone who has “hit-the-wall” after the 30km mark in a marathon will know how precious this glycogen is!) or used as energy. You can have abundance of glucose in your blood stream but as long as there is no insulin, the glucose cannot be utilized properly.

So in the early parts of diabetes, what you will typically see is a condition known as ‘Insulin Resistance’. Which means, the muscles and liver are not sensitive enough to the insulin released in the body that allows for the glucose to enter both muscles and liver. So only partial amount of glucose is taken up and utilized. When insulin resistance state is not corrected (by means of lifestyle changes, dietary control, weight loss and increment in physical activities), it will likely progress to Type II Diabetes Mellitus where enough muscles and liver cells are absolutely NOT SENSITIVE to insulin secretion, thus only minimal (or none) glucose is taken up and remains lingering in our blood stream causing havoc.

Dirks et al., revealed that within 1 week of bed rest, there is 1.4kg of muscle loss and up to 29% reduction in insulin sensitivity, especially at the level of muscle uptake. This translates to being 1/3rd more insulin resistance 1 week after starting bed rest. In fact, declines in muscle mass is inversely proportionate to HbA1c readings (this looks at blood glucose control over 3 months – you want this to be low).

So lets conclude the information in this article before I give my anecdotal evidence:

(1) You need to move and stay active. Regardless what the nature of injury that cause your immobility (or in my case, the surgery), it is imperative to stay active to as much a degree that is possible in your situation. Which is why post injury/illness/surgery, your doctor should responsibly advice you on staying active and to try to walk more. If you are of the low motivation sort, perhaps getting a referral to the physiotherapist and having frequent sessions may be helpful in the first few weeks of recovery.

(2) You need to get back to being pre-morbidly active (your activity level before you got injured or fell ill) as soon as possible. If you were not active before, now is always a good time to start. Having said this, you also need clearance from your doctor to return to pre-morbid levels of activity as it isn’t cool to be re-injured again due to impatience or just sheer stupidity.

(3) You need to continue to “fuel” your body even in times of injury/illness. Protein (with all essential amino acids intact) is your best bet. In fact I suggest to increase your protein intake if you have yet to do so but do keep in mind that energy balance still rules the day. Just because I recommend for higher protein intake, it does not mean you can eat everything under the sky. You do not want unnecessary weight/fat gain. Vegetarian sources of protein is also recommended as long as it provides all the EAAs. The recommended intake per day ranges between 1.5-2.0g/kg/day (it can go higher is muscle loss is of an extreme concern to you).

So how did I do in the past 2 weeks post abdominal/pelvic surgeries?

Again, I had my (1) appendix…and (2) right fallopian tube and ovary removed. Thus the abdominal and pelvic surgeries.

The moment they told me the exact diagnoses that killed my long weekend plans, I knew the following:

(1) I knew that the soft tissues that can injured from the surgery itself will take 6 weeks to heal (so no HEAVY lifting for 6 weeks, or at least until I can properly brace my core – but the caveat is HEAVY is a relative term).

(2) I knew that pelvic surgeries have an increased risk of deep vein thrombosis (DVTs).

(3) I knew that being on a course of antibiotics (I was on 2 – 1 from the surgical team, 1 from the gynae team) will cause me to have gastrointestinal upset which will either destroy my appetite, affect my absorption of nutrition and/or cause runny diarrhea. Also will be bidding my gut microbiome farewell.

(4) I knew there will be pain which will impede my daily movements and I will experience muscle atrophy which to a degree is unavoidable.

(5) I will not be partaking in GCE Duathlon :(

So I needed a self-care plan that will reduce and eliminate the risks associated with the points above.

(1) I may not be able to lift heavy, but I can do functional strength training like sit to stand (chair squats). This helps me to get out of bed and from a chair, recruit lower body muscle fibres, reduces the risk of DVTs, and hopefully reduce the amount of atrophy that will take place. I achieved 3 sets of 15 reps chair squats within 12 hours. Uncomfortable but it has to be done, unfortunately.

(2) I needed to not always lie down. Complete bed rest is the bane of all post surgery care. I got up and walked to the toilet (to look at myself in the mirror) within 5 hours. Not the most pleasant of experience, let me assure you.

(3) I needed to eat. To be honest this was the hardest to achieve. But force feeding was necessary. I drank within 5 hours, and ate within 8 hours. I hated the IV drip with a vengeance.

(4) I wore the TED stockings to prevent DVTs (mostly I just wanted the staffs there to stop asking me about the stockings despite hating it).

(5) I would not stop fidgeting. Any movement helps. Ankle pumps, isometric strengthening of quads and calves, leg raises, flexion and extension of knees etc.

Anyway I went home 35 hours after being pushed into the operating theater.

But by doing everything (almost) right, I still lost weight, my muscles became soft, always tired and I'm so sick of downing protein shakes. Also I've started by rebuilding endurance by getting on the trainer and strength by body weight strength training.

Most of all....I can attest that the drop in endurance, fitness and strength within 1 week is REAL, FAST and definitely very FURIOUS!!!


1. Kortebein, P., Ferrando, A., Lombeida, J., Wolfe, R., and Evans, W. J. (2007). Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA 297, 1772–1774. doi: 10.1001/jama.297.16.1772-b

2. Dirks, M. L., Wall, B. T., van de Valk, B., Holloway, T. M., Holloway, G. P., Chabowski, A., et al. (2016). One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulation. Diabetes. doi: 10.2337/db15-1661

3. Dirks, M. L., Wall, B. T., Snijders, T., Ottenbros, C. L., Verdijk, L. B., and van Loon, L. J. (2014). Neuromuscular electrical stimulation prevents muscle disuse atrophy during leg immobilization in humans. Acta Physiol. 210, 628–641. doi: 10.1111/apha.12200

4. Park, S. W., Goodpaster, B. H., Strotmeyer, E. S., Kuller, L. H., Broudeau, R., Kammerer, C., et al. (2007). Accelerated loss of skeletal muscle strength in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes Care 30, 1507–1512. doi: 10.2337/dc06-2537

5. Suetta, C., Frandsen, U., Jensen, L., Jensen, M. M., Jespersen, J. G., Hvid, L. G., et al. (2012). Aging affects the transcriptional regulation of human skeletal muscle disuse atrophy. PLoS ONE 7:e51238. doi: 10.1371/journal.pone. 0051238

6. Suetta, C., Frandsen, U., Mackey, A. L., Jensen, L., Hvid, L. G., Bayer, M. L., et al. (2013). Ageing is associated with diminished muscle re-growth and myogenic precursor cell expansion early after immobility-induced atrophy in human skeletal muscle. J. Physiol. 591, 3789–3804. doi: 10.1113/jphysiol.2013. 257121

7. Trappe, S., Creer, A., Minchev, K., Slivka, D., Louis, E., Luden, N., et al. (2008). Human soleus single muscle fiber function with exercise or nutrition countermeasures during 60 days of bed rest. Am. J. Physiol. 294, R939–R947. doi: 10.1152/ajpregu.00761.2007

8. Wall, B. T., Snijders, T., Senden, J. M., Ottenbros, C. L., Gijsen, A. P., Verdijk, L. B., et al. (2013). Disuse impairs the muscle protein synthetic response to protein ingestion in healthy men. J. Clin. Endocrinol. Metab. 98, 4872–4881. doi: 10.1210/jc.2013-2098

9. Rudrappa SS, Wilkinson DJ, Greenhaff PL, Smith K, Idris I, Atherton PJ. 2016. Human skeletal muscle disuse atrophy: Effects on muscle protein synthesis, breakdown, and insulin resistance—A qualitative review. Front Physiol 7: 361.

10. Cuthbertson, D., Smith, K., Babraj, J., Leese, G., Waddell, T., Atherton, P., et al. (2005). Anabolic signaling deficits underlie amino acid resistance of wasting, aging muscle. FASEB J. 19, 422–424. doi: 10.1096/fj.04-2640fje

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