“Above all, do not lie to yourself. A man who lies to himself and listens to his own lie comes to a point where he does not discern any truth either in himself or anywhere around him, and thus falls towards disrespect towards himself and others. Not respecting anyone, he ceases to love, and having no love, he gives himself up to passions and course pleasures, in order to occupy and amuse himself, and in his vices reach complete bestiality, and it all comes from lying continually to others and to himself.”
~ Fyodor Dostoevsky
As previously stated, proliferation is the mort difficult stage of healing to get right. You no longer have a license for mostly rest as in the inflammatory stage. You absolutely must move to stretch and strengthen the newly laid tissue repair. The new tissue is so delicate that it is way too easy to do too much and disturb the repair process enough to set yourself back (as in literally set yourself back into inflammation). I have never, I repeat, NEVER seen anyone through a rehabilitation process where progress was perfectly linear through this phase.
This leads us to our fundamental mindset during proliferation: mistakes are not failure, they are feedback. We must not run to a doctor every time we get sore searching for answers as to what is “wrong” asking for repeat imaging, pain medications and more diagnoses. When we pause to ask ourselves “how did we get here?” we will often find that we have re-introduced an activity or increased volume or intensity of a movement. Then it would make complete sense that the newly repaired tissue is simply sore (maybe really sore depending on how big of a jump was made) and it absolutely must take time to catch up and adapt to the new stimulus. You can think of this in a very similar way to how we would make progress in fitness. I must be able to hike five miles before I would think to hike ten. The first time I did a new, longer, or steeper hike I would expect to have some soreness in the lower body. The only difference when recovering from injury is that the soreness can quite often can be more painful than bland discomfort and potentially last longer with more symptoms of inflammation.
So, the fundamental task during proliferation is to pay attention to your body and your actions. During recovery, we can be blown away by how little we can do to set ourselves back. “All I did was work a regular day!” Sure, and that probably represents a huge increase in activity for all of your parts compared to what you were doing during the inflammatory stage. Even if you were mostly sitting, that still is a way to load your body (especially your spine). When setbacks happen, as they inevitably will, the best thing to do is revert back to your plan for inflammation. Simultaneously take mental stock of what led you to that point and then use that data to inform your decisions and activities in the coming days after the soreness/inflammation has resolved. For example, were you moving and even lifting light weights below shoulder height and then started moving your shoulder overhead when pain returned? Maybe you need to re-introduce overhead shoulder motion in a modified way where you can minimize gravity. Or maybe you simply need to start with fewer repetitions. Have you been able to walk 10 minutes on your healing foot without issue but then tried walking 30 minutes and this made you sore for two days? Well, you may need to make smaller increases (maybe even five minutes at a time), or increase frequency first (three 10-minute walks per day), or change the surface you are walking on for the time being.
This is the art of the proliferation phase. It may seem easy but it’s not. This stage also takes a lot of patience and self-restraint. You are not hurting at rest and it is easy to just do something “normal” without thinking about how or if you have meticulously built yourself up to that exact thing. In my opinion, this is why physical therapy exists as a profession. Even in incredibly healthy, capable people, this stage is difficult to navigate. Get a good guide. That’s what we are for.
The perfect proliferation phase is one where a person is consciously re-introducing movement in a graded and logical way. They start with the absolute basics. At first, they are not afraid to undershoot their activity levels. They may end a physical therapy or exercise session or day feeling like “I actually could have done more” as opposed to “I am devastated, painful and sore”. When they do overshoot, they remain calm and return to their inflammation protocol. After inflammation/soreness have subsided, they resume activity slightly below where they left off. Then they plan to take a smaller next step. They wait to make that step only after spending a few days back being active and feeling great at their current level.
This stage might feel long and frustrating. Another motto that we could use here is “go slow to go fast”. The more you pay attention and adapt as necessary, the better it will go.