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The previous chapter extensively covered general information about injuries and how to deal with them. The focus of this chapter is programming around certain injury conditions while we continue to rehabilitate them on the side. Also, we will talk about how to program when coming back from an injury.
Working around injuries presents some difficulty since we never want to exercise through pain. We have to plan our workouts extensively to avoid certain injured muscles, connective tissues, and/or joints. However, the most important thing is that we continue to rehabilitate injuries even as we work around them
Intra-limb and opposite limb exercise are tools for keeping strength specific to the joint that has been injured while continuing exercise with the unaffected limbs and other areas. This will help promote circulation to facilitate healing and retain the habit of continuing to workout.
A right side shoulder injury will be the model used here to help demonstrate some of the approaches available. We will assume moving it too much hurts or we have doctor’s orders to rest and avoid exercise on this injured body par.
The number one reason our muscles start to atrophy is immobility. Atrophy duc to immobility occurs very rapidly, even as soon as a week or two after having to restrict a joint due to injury. For instance, anyone with a cast for a broken bone has seen how quickly the atrophy starts to set in.
As such, the first thing we want to look at i if we can use the rest of the arm for exercise. We can counteract some of the effects of atrophy with exercise distal to the injury site. In this right shoulder case, we would want to start utilizing isolation exercises for the elbows, wrists, and fingers.
If doctor’s orders have been given, it would be a good idea to talk to him or her and ask if arm or forearm exercise is contraindicated during the period of immobility for the shoulder. If the exercise is cleared, it is time to get busy.
This is a great time to use specific isolation exercises for the arms such as biceps curls or triceps extensions. Forearm exercises would also be a great idea to work with to keep up strength in that arm while the shoulder is immobile. Some of the exercises do utilize a bit of shoulder muscles for stabilization, soif that aggravates the site of injury then avoid them. Grip work is often a good choice as well
Additionally, the use of the arm and forearm muscles sends neurological output to the arm as a whole. This is important because of the radiating effect of neuromuscular impulses will stave off atrophy. Activity from the motor neurons themselves are very important to the health of the muscle. In fact, if one were to cut through a motor nerve or sever the spinal cord, related muscles will start atrophying within a couple days.
If light exercise or mobility work (non-painful of course) is indicated for the affected joint, we should to do as much as possible without aggravating the area. It will stimulate additional blood flow to speed healing and prevent muscle atrophy while maintaining the very important range of motion.
There are almost always ways to continue training the injured limbs in question without compromising the injury. If, however, nearly al types of movements hurt at an injured joint then that is a big red flag. Get checked out by a medical professional.
Do note that essentially any exercises you can do without pain are fine to do. A common example is a stark difference from pushes to pulls. Pushups (or another pushing exercise) may cause very intense pain while rows (or another pulling exercise) do not bother you at all. Avoid the painful pushing but continue with the pulling.
If you are cleared by a physical therapist or doctor to do rehabilitation work but it is painful ask them. There are select instances where working through pain is useful. For example, if you had an ankle sprain, we definitely want to begin stretching out the ankle to prevent less of range of motion while the ankle is still in the inflammatory phase. It depends how bad the swelling is as to when begin stretching protocol. However, generally speaking we will start stretching even if it is painful.
In these specific cases, we may prescribe stretching or mobility work and tell you to do as much as possible if and only if the pain does not get worse. Like using cardiovaseular activities for recovery, we always want to end feeling better than when we started or at least as good. This should make logical sense given how easy it is to make an injury condition worse.
Referring again to the proposed right shoulder injury, one of the things that helps retain strength in the injured arm is doing strength work with the uninjured arm.
The nervous system is very adaptive. One of ts interesting adaptations is the phenomena of cross education. Cross education occurs when a unilaterally trained a skill or strength movement with the opposite limb, some strength benefit is conferred to the opposing limb even if the opposite imb has not
practiced the skill or performed any strength work at all. Therefore, if we do unilateral work with the left arm during this time, there are some conferred benefits to the right arm.
An example of this for skill work would be throwing a ball or dribbling with a basketball with the left am. Then we would practice throwing or dribbling a basketball with the right arm. To conclude the experiment we would retest the left arm and you should be able to dribble better or throw a ball farther without having practice with that arm at al.
The studies show that the transfer of strength from cross education is somewhere around 5-10% to the opposite limb. While this is not much, it is sill very beneficial especially if our injury sets us back for any Tonger than two weeks because of the potential atrophy and rapid decrease in neurological strength we tend to see during periods of prolonged rest. Retaining strength and stability is vastly important because weakness prolong injury recovery as well. The more intact the system stays, the quicker the recovery will be.
We do have to take care that we do not develop any imbalances between the uninjured and injured Timb 0 we will tend to keep the volume of the work on the lower side but the intensity fairly high, much like typical strength work
After utilizing all options we have with the injured limb and its opposite, we still need to continue work with the rest of the body.
Some types of exercises that utilize the full body such as squats and deadlifts may interfere with proper healing or involve the injured side in a way that would be detrimental to recovery . Therefore, we are going to want to avoid those for the time being.
This is also a great chance to work on specific weaknesses. For example, if you know you have tight hamstrings or a tight back, use the injury recovery time as a chance to work on these mobility limitations. Once recovery is finished, an even more complete athicte has been developed. This is especially important if flexibility and mobility are lagging behind in certain skills such as press handstands or V-sit/manna type work,
For the legs it may be better to focus more on light intensity exercises to help get the heart rate up and speed blood flow which will accelerate healing. Likewise, it may not be a bad idea to pursue balance and agility type work alongside everything clse.
Really take advantage of this time; whatever we can identify as a weakness in regions other than the injury should be focused on as long as it does not impede the injury recovery process.
In a similar vein, it is also possible to work more strength oriented work, again assuming it does not affect recovery. For instance, injuries in the lower body may allow us to focus a lot of work on handstands or rings strength work
The possibilities are limitless. You just have to identify weaknesses or goals that you want to work on while recovering and then be creative with your exercises. Sometimes that is when you have the most fun
too — when you think outside the box. Do not let injuries get you down. Use them as a learning experience and to work on your weaknesses so you can come back stronger and better than ever.
NOTE: Consult your physician or physical therapist before doing any specific rehabilitation on yourself.
The exercise(s) chosen is/are dependent on the particular injury condition and the physiological parameters that we are trying to affect. However, any exercise must fulfill two conditions.
The first and most important parameter is that any exercise chosen must not be painful. Again, pain is the body's way of telling us that something detrimental is occurring in our bodies. Thus, we are not ready to execute that particular exercise. Exceptions may apply to strengthening or range of motion exercises that may cause pain to rehabilitate certain conditions (usually this occurs as a result of rehabilitation from a catastrophic injury), but this should only be preseribed by a qualified medical professional.
Note that the "pain" from stretching is generally acceptable as that discomfort is inherent in completely healthy stretching. Encouraging the maintenance of range of motion is extremely important but be sure the pain is not from a true injury. It can be very hard for some people to differentiate the types of pain or discomfort. All in all, the best option in that casc is to consult a medical professional about your particular issue.
The second condition that we look for is that the exercises themselves are performed with a full range of motion and controlled with good form. While this should always be reinforced, now more than ever is the time to be absolutely sure there is no deviation from accurate technique and control.
Rehabilitation is not useful if the wrong structures are being rehabilitated. Additionally, strengthening anarea in a limited range of motion is not conducive to regaining full operating capacity of the structures we are working to heal.
During the concentric phase of the movements we are looking for a smooth, well-controlled motion. Therefore, do not worry about acceleration through the movement like most regular strength training. Our biggest focus will be on a slow ccceniric phase of the movements as it is the most important factor in rehabilitation exercise
More intense injuries like tendonitis and muscle strains tend to respond exceptionally well from properly used slow eccentric exercises during rehabilitation. Even semi-injury conditions such as chronically sore muscles or injuries where there may be control, balance, to proprioceptive issues also tend to respond well to the use of negatives.
As of this book’s writing, the theories as to why this happens are not very well hashed out, Thus, T willtry (0 discuss them here as thoroughly as possible as to give you the reasoning behind utilzing eccentrics or emphasizing the eccentric phase during rehabilitation exer
The primary component of exercise-induced muscle damage comes from the eccentric phase. When under load, the myosin heads that bind to the actin have to release in controlled fashion to keep tension on the muscle as it lengthens. In concentric exercise the myosin heads only need to grab and pull depending on the force load.
The popping sarcomere theory attempts to explain the damage that a muscle undergoes during eccentric exercise. As the muscles tire, the myosin cannot release in controlled fashion. Multiple bands of actin and myosin are in a single sarcomere, the smallest unit of a muscle. Thus, as control of myosin detachment in a sarcomere decreases, the sarcomeres themselves will eventually distend and pop causing microdamage to the musculature at this level. This type of microtrauma causes delayed onset muscle soreness via the inflammation and repair to the muscles. The inflammation also heightens of the sensitivity of C and Ad pain fibers from the inflammatory processes.
To counteract this, the muscles then undergo some adaptive changes.
Firstly, when the body senses that there is a lot of eccentric damage it starts adding sarcomeres to the muscle to help try to mitigate that damage. This way, if the exercise is performed again it will have more available units to fire as the muscle fatigues so less popping occurs. Basically, the same amount of work will be distributed over more nits and will decrease workload per unit. This will avoid significant damage to the muscle. Athletes who take a break off exercise for a while who push themselves when they come back can have wicked DOMS for 7-10 days or even develop rhabdomyolysis. This is what the body wants to avoid. The addition of sarcomeres is especially useful for rehabilitation of strains because it increases resistance to damage, especially the macrodamage to the muscles when a strain occurs.
Secondly, the eceentric motion requires the most control. When this control system starts to become compromised due to pain or injury, we find that when performing a negative there is an interrupted, jerking-type motion instead of a smooth movement.
The jerky movements leads to unstable movements, especially when repeated a lot, and thus may represent a significant factor in the development of some injury conditions like tendonitis. As you know, creasing the jerking of a movement increases the impulse forces on a muscle, tendon, or other body tissues which can lead to more damage. Thus, restoring the smooth movement through controlled eccentric training will help take the strain off of the jerking movements. This will allow better and faster healing to occur.
In particular, pain is a big inhibitor of muscle function. If you punch someone in the arm and then make them try to lift weights even if you did not do any significant damage to the muscle they will still be able to lift less. Why? When the body senses a noxious stimulus, it will feedback to the motor cortex to inhibit force production. The body knows that if large forces are used in a painful area, the more likely it s to receive additional damage. Thus, it inhibits motor drive. The body already has natural inhibiters on the
muscle via golgi tendon organs. I am not particularly sure if the body is suppressing cortical drive through the golgi tendon organs or at the level of the brain or spinal cord —all I know is that it occurs.
A third factor is the standard adaptive muscular changes from strength and hypertrophy work. Time under tension, fast twitch activation and fatigue, acelusion, ecceniric damage, and metabolite accumulation all driven by progressive overload will produce strength and growth. Fighting the inherent atrophy from injuries is critical.
To top all of that off, there is also plenty of benefit from simply improved circulation and encouragement of blood flow from the high repetitions and the consequent nutrient avalability, prevalence of healing factors, and clearing of waste.
The culmination of all of these factors will help speed the recovery and performance maintenance processes, but understand that there are still physiological limitations of time when it comes to healing.
If you have suffered a catastrophic injury, the amount of time that it takes to recover can be estimated by the number of letters in the name of the tissue that is injured. This is fairly easy to remember and gives a good approximation. For example, a torn ligament that has been repaired will take approximately eight months (ligament = § letters) to rehabilitate properly. The other tissues are cartilage (9), bone (4), muscle (6), and tendon (6). Since these figures are used for catastrophic injuries, understand that strengthening the tissues to properly rehabilitate enough to workout again for most any other type of injury will take fraction of that time,
In my opinion, if after one week of pain that does not start improving, i i professional to get a diagnosis. If the injury relapses a second or third time then you should immediately see a medical professional. Injuries that are non-catastrophic will generally not take longer than 3 months to rehabilitate. Therefore, if you are struggling with injuries longer than a month to heal up completely it is simply a waste of your training time and health to be dealing with these when you can likely have them resolved much quicker with professional help.
As briefly discussed earlier, high repetitions tend to be good because of the increased blood flow and other physiological parameters that are increased that will help speed up the healing process. Start off with the 20-30 range and if there is any doubt, err on the side of 25-30 repetitions.
All repetitions are performed with a constant speed concentric taking about 1-3 seconds on average with a slow, controlled eccentric phase taking anywhere from 3-10 seconds. The length of the eccentric: phase typically depends on how poor the control of the limb is: the poorer the control, the longer we want to take for the eccentric phase,
Generally, you would start with 1-2 sets and then bump up to 2-4 sets as you improve. This depends on the actual amount of exercises that you are doing for rehab as well. Overall volume for rehab depends
on alot of various factors such as how the injury is responding to exercise, how fast it is recovering, and how it is feeling specifically that day.
For tendon specific injuries the repetitions will increase to 30-50 repetitions for around 100-200 repetitions total at about 40% 1 RM. For cartilage type injuries you will actually want a 20% 1 RM load for thousands of repetitions if possible. For example, this is why you will see athletes coming off of knee surgery (in the NFL) riding the cycle on the sideline for long periods of time. Injured cartilage takes a relatively long time to heal, and thus we want to use very low intensity at very high repetitions to increase blood flow and nutrients to that area.
If there is any pain during any part of the rehabilitation process that is generally a reason to back down the weight or volume. When in doubt, stop the session completely. "No pain, no gain" is a poor motto in rehabilitation.
Choose isolation work if compounds are too painful, but if not then work with low intensity compound exercises. If the injury is catastrophic then default to isolation exercises because the weights and forces can be modulated to suit the injury much better than compound exercises. It is always favorable to be conservative and start on the low end.
The goal i to get back to the exercises from the original workout plan, so add them in after the injuries start showing some sign of improvement. The next goal is to work back up to full intensity with those exercises with the following approach.
Start with 40% of the volume previously used and add about 20% a week until returned to the original full workout load. This sets the stage to take about four weeks before working with full intensity again which gives time for the injured issues to be strengthened without the possibility of us overusing it again If there is a relapse, drop the volume 20-40% depending on how the injury takes it and come back by adding about 10-15% per week instead.
Taking a month to get back into full workload is going to be typical of a fairly minimal to moderate injury which would be around a grade I strain or have had tendonitis for 2-3 months. This would also correspond to having had some other type of overuse or pain for about a month. The month of decrease in volume and allowing proper recovery will help calm the tissues down from being aggravated. Scale from there accordingly.
For low grade injuries, it will take a quarter to a half of the time that the injury has been around. So if the injury has lasted for four months it will likely take about four to cight weeks to get it back to full health depending on your individual recovery factors (diet, sleep, stress, ability to rehab without pain, how your body is responding, etc.).
This is an extremely conservative protocol, but it is much wiser to spend a little extra time now rather than have a continually re-occurring injury. When in doubt it is always best to start conservative and then increase the volume if need be. If you start with too much and reinjure yourself it will take that much Tonger to rehab and you will be even more prone to injury. It is just not worth it. Take things slow and consult a trained medical professional if possible.
In this chapter we learned about how to effectively and safely program around injuries using the various methods of intra-limb exercises, opposite limb exercises, and working out in unaffected areas. Intra-limb exercises that avoid the injury help to keep up the strength/mobility of the uninjured tissues, opposite limb exercises help out by the theory of cross education, and other affected areas will also help with blood flow and overall well being.
Likewise, we learned the physiology on certain programming protocols for general rehabilitation of injuries. We learned that typically light, controlled, eccentric exercises work the best for most types of injury conditions. We also identified why higher repetitions tend to work the best.
The most important thing we learned though is that we should always be doing rehabilitation for our specific injuries and not just try to skirt around them by programming other types of exercises to compensate.
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