Movement Modification Before Cessation
When we have pain in a joint or in our bodies, our natural tendency (for good reason) is to rest and allow the tissues to heal themselves. Then, once we are totally out of pain, we can get back to doing the activities we love, back to working out, back to doing the yard work our significant others wish for us to do, etc… In many circumstances, this is the best option. We can often overload structures beyond their capacity, in which case they need a couple of days time to heal. But what about when we take a rest for a few days and try to return to exercise, only to find that we have the same level of pain, or worse we flare up our symptoms to the same level before resting? Do we rest more in hope of more healing and recovery to occur, then what do we do if we still have symptoms? This can be a very frustrating process, and I have unfortunately seen and heard many stories of athletes and individuals that have to stop doing activities because of the pain and discomfort it brings them.
In my experience as an athlete and in clinical practice, the biggest mistake that individuals make is from taking complete rest, and then trying to jump back into their previous activity at the same level as before. An example would be a rock climber that boulders the V6 grade. One day they are in the gym and strain their finger, take a week off, and then try their project or another V6 climb then next time they get back into the climbing gym. Another example would be a runner that tweaks their achilles during a long run, takes a couple of days off, and then hops into a high volume and intensity workout with the team. In both of these examples the athlete went from complete rest back up to regular intensity and load. Oftentimes the next error made is to take a longer rest because now their pain has flared up to even higher levels than previous. So they take 1-2 weeks completely off of any activity. The issue with this is that the more we rest completely, the more our muscles begin to atrophy due to disuse. Our tissues are not provided a stimulus high enough to create adaptation and gradually return to exercise. The process of atrophy begins very quickly, individuals that are confined to bed rest (a once common practice for individuals experiencing episodes of low back pain) for only one week experience loses in muscle size, as well as unfavorable hormonal adaptation such as decreases in systemic insulin sensitivity (Dirks et al. 2016).
So what are we supposed to do when we cannot perform our activities at full capacity? The magic word here is to modify our exercises. In this case we can alter certain variables associated with our activity such as the volume or intensity, or if it is specific movements that cause our discomfort, such as bending forward to lift an object, then we can begin by modifying that exercise to do some of the same motions, but in a way that does not cause pain and discomfort. Some variables that we should look at modifying include volume (duration or total number of repetitions), intensity (either in effort or percentage of a maximal effort), specific movement patterns, and type of load (dynamic versus slow).
Returning to some of the examples from before, if the V6 boulderer had taken 2-3 days off of climbing, and then began by having a climbing day at around 50% capacity climbing V2-V4 grades only, and then assessing their symptom response afterwards. Then they would have had a better idea of what capacity their fingers were currently able to take. If they had a favorable response i.e. no pain after the session and no pain the next day, then they would know that it is ok to progress to higher levels of climbing again. In the case of the runner, it would have been much more beneficial to perform a few runs and then maybe a percentage of the workout (50-75% for example) and then looked at the symptom response later that day, and then the next morning. It is important to assess the symptom response both immediately after, as well as later in the day and the next morning. One mistake that many athletes make is going “by feel” during a workout, and then unintentionally overloading the structure again and taking two steps backwards in the rehabilitation process. Often, going by feel can be good if our programming doesn’t match our current fitness level and can be a good indicator of when to back off. However, the issue with this is that we can often experience what is called a warm-up effect in which we begin our exercise with some pain, and then as we get into the workout the pain diminishes. We take this as a miraculous sign that we can do the entire workout, and then are unable to walk the next morning ( I have had the wonderful fortune of being able to experience this effect myself by the way). In this case we have allowed the analgesia (pain decrease) of exercise, whether it be from increased blood flow, afferent barrage of proprioception to block pain reception, increased supraspinal inhibition of pain, placebo, good vibes, the joy of running; to make us think we are totally ready to get back at 100%. This is one of the reasons it is crucial to utilize a logical progression back to where we were prior to the injury, even if it is a partial one that is not totally debilitating. The important thing is to keep being able to exercise, even if it is only a percentage or modification of where you were before.
This practice has become commonplace among professional sports teams under the name “load management.” In this case the athlete is taken out of full practice to perform a modified workout, so that they can safely stimulate adaptations without significantly risking further injury.
What if we injure or feel symptoms in a specific tissue? These kinds of instances may require altering the variable of load that is placed on a structure, not just the overall load or size of load but the type of load can be a crucial factor. The best example of this is in the realm of tendinopathy or tendon pain (some people still call this tendinitis but the reason this is not necessarily correct will probably be discussed in a later post). Tendinopathy more often occurs as a result of too much dynamic loading of a certain tendon. This is why we see more cases of tendinopathy in the achilles of runners, or the patellar tendon of jumpers as opposed to the tendons of strength athletes. In these cases we often cannot simply change the volume of the activity, because the injured tissue simply cannot tolerate that type of load in any capacity. This is evidenced in the cases of jumper's knee in which the athlete can walk around all day with little to no knee pain and then their first jump of practice spikes their knee pain to an amount that makes it difficult to walk afterwards. In this case the athlete’s tissues cannot tolerate the dynamic type of load that was placed on it. The best treatment for this bar none is to impart slow and heavy loads onto the patellar tendon in the form of either heavy isometric (same joint angle) or slow isotonic (exercise performed with constant weight through a range of motion). In some cases, changing the stimulus to different kinds of load can potentially decrease pain and allow the athlete to withstand higher levels of dynamic load (Rio et al. 2015; Baar 2019). However, different individuals and different tissues have different responses to these types of interventions and the analgesia producing effect of isometrics in particular has been called into question recently (van der Vlist et al. 2020; Gravare Silbernagel et al. 2019; Vang and Niznik 2020).
The bottom line when we experience an injury or a “tweak” is that it is important we first try to modify our exercises before stopping all together. Are we able to change some of the biomechanics of the exercise we are performing in order to make it pain free or less painful? Can we alter the sets and reps of the workout and thus change the workout. If movement is painful then can we perform an isometric or isotonic exercise in which we change the type of load we are using.
Things to try:
Modifying the exercise to one that is similar, yet changes some of the load distribution on the body
Ex: Changing load distribution:
If the high bar back squat is provoking pain and symptoms in the back, does a front squat provoke the symptoms to the same degree? Here we tweak the load and biomechanics of the movement, yet are still able to provide a great stimulus for the structures of the legs and hips
Ex:Movement modification:
If there is closing angle hip pain at full depth, can we rotate the hip outwards to reduce the pain, or is it still the same. If rotating the hip outwards decreases some of the pain, then you may have a condition called femoroacetabular impingement which you can read more about HERE
Ex: Movement modification:
If bending forwards, aka spinal flexion, causes you pain, then try going on all fours and performing a cat camel exercise. In this case we perform the same action i.e. spinal flexion, but we are using different muscles and a different load distribution. Over time modification like this will allow us to accommodate higher loads in spinal flexion.
Ex: Volume modification:
if you are a runner that has pain with running for more that 20 minutes, can you run 15 minutes pain free? Then can you run another 15 minutes later in the day? This way you do not overload the specific tissues because of a single bout of exercise, but are able to get a higher amount of volume and stimuli with lower amounts of pain.
Ex: load type modification:
If you are a climber experiencing shoulder pain after making large dynamic movements while bouldering, do you have the same amount of pain with holding the two positions? If you don’t, then it is likely the type of load that is affecting your symptom level. It would be best to begin your rehab with isometric exercises at multiple joint angles, then slow isotonic movements (think of climbing like Fred Nicole), and then progressing to easy dynamic movements before performing limit boulder problems requiring large dynamic moves.
All of these modifications are able to get some of the same stressors to connective tissue structures and may not be painful or as painful. If all of these are painful or symptomatic, then it is a great idea to get an evaluation by a qualified medical practitioner. This could be a sports chiropractor, a physical therapist, an athletic trainer, or a great personal trainer. These may sound like simple modifications but oftentimes it takes an outside perspective on your condition to perform a proper evaluation and help you with the correct modifications to help you get back to your previous level of activity. Some adjunctive care such as manipulation, soft tissue therapy, and other forms of treatment can help speed up the process of recovery. In the case of long standing pain and symptoms it may be wise to get an evaluation from a sports chiropractor or physical therapist to rule out serious pathological conditions.