By Dr. Chris Leib and the Exercise Geeks
For the past decade I have had the opportunity to work with a variety of populations experiencing a wide array of injuries. In this time, one of the most meaningful lessons I have learned is that injury, although it may have its inherent negative consequences, has great potential as a teaching tool for improved movement quality and behavioral change.
We live in a society that promotes quantity over quality and routine over mastery. This makes the average exercise enthusiast a prime candidate for overuse injury due to excessive volume of low quality movement patterns. An injury is the body’s way of telling you to stop and rethink your exercise strategies – and hopefully put increased focus towards movement quality.
In a moment, I will lay out several ways in which we can use injury as an opportunity to create safer and more effective exercise strategies. But before we get into how injury can be helpful, we first must understand common reasons why we get hurt.
Why We Get Hurt
The number one reason for overuse injury is not enough movement variability. This concept can be broken down into two factors.
- Too much inactivity
This factor isn’t difficult to comprehend. Studies show that humans sit anywhere from 7.7 to 15 hours per day. I think we can all agree that is a substantial amount. Although it is true that one can be active when sitting (check out this video and this one too for examples), it is likely that a vast majority of those hours include inactivity. The act of chair sitting promotes consistent patterns of soft tissue shortening and lengthening, as well as patterns of joint compression and tension. Furthermore, all those hours in one position do not allow for the exploration and conditioning of various other movement patterns. In effect this inactivity substantially limits our options for safe and normal movement, condemning us to accepting a life of increasingly limited function.
- Too much of the same activity
Similar to too much inactivity, too much of the same activity also stresses the same tissues repeatedly for long durations. This repetitive stress can result in similar negative effects to the body. Oftentimes athletes fall into this category due to the repetitive nature of sport coupled with the fact that in order to become skilled in many sports endeavors a basic requirement is to practice similar tasks over and over again.
Another contributor to this factor is that the general population is receiving their exercise advice from health care professionals who are frankly unknowledgeable regarding human movement. Many medical professionals would have you believe that developing a simple routine of walking or machine-based strength training is sufficient to reap the health benefits of physical activity. These professionals rarely consider the quality of a patient’s activity or the risk of overuse injury, instead they are more fixated on quantitative standards such as getting “150 minutes of aerobic activity and two days of strength training in weekly.
For all of those that have attempted to adhere to these recommendations, or for experienced professionals that actually understand movement, it is clear that these recommendations could not be more vague and are effectively useless. This type of ill-defined instruction no doubt leads many to choose an activity that seems easy to repeat over and over again, simply to meet the duration requirements set forth by their medical authority figure. This often leads to the repetitive stress problems mentioned above.
This understanding of the prevalence and dangers of movement invariability in our culture should help to set the stage for how an injury can help spark change to these flawed patterns.
Injury is an Opportunity for Improvement
What happens when you have pain? You notice it! You stop and try to figure out why it hurts. The pain is a signal to the body that something needs to be addressed.
As mentioned above, my first advice is to figure out a way to make your movement more variable. But how do you do that? In what ways can you vary your activity while being mindful not to aggravate your injuries?
Below, I present five such ways which involve varying your positions, energy systems, breathing pattern, mental affect, and movement tempo.
- Vary your positions
When assessing the forces that have led to the overuse stress causing your pain, the first thing to consider is what positions you are in most frequently. Once that question is answered, you then must ask yourself what can you do to vary these positions.
Let’s use the all-too-common example of low back pain associated with sitting in a chair. To understand what positions would be best to counteract these forces we must understand what is happening at the area of pain during chair sitting.
To understand this, let’s look at two factors:
- Weight bearing load
- Joint positions
In our chair sitting example, the spine is bearing the weight of gravity and joint positions include upper cervical (neck) extension; lower cervical, thoracic (upper back) and lumbar (lower back) flexion; scapular (shoulder blade) protraction; shoulder internal rotation; hip and knee flexion; and ankle dorsiflexion.
With all of those factors considered, the most obvious position to utilize as a counterbalance is lying on your stomach propped up on your forearms. This position checks off all the boxes in the opposite direction. It unloads the spine in relation to gravity and promotes general spine, hip, and knee extension, along with ankle plantarflexion. Some simple cueing for cervical/scapular retraction and shoulder external rotation will make this position the perfect antidote to the lower back stresses caused by the sitting position.
There are obviously countless other examples of ways to change position through the course of the day. However, don’t get too caught up in the idea of a “good position” or “bad position.” Rather, be more concerned with how frequently you are changing position. The most pain provocative position will be the one you are in for too long!
- Vary your energy systems training
This factor speaks to varying the method in which the body expends energy during physical activity. Generally speaking, we have three different energy systems:
- The ATP/creatine phosphagen (ATP-CP) system, which is involved in activities of short duration (~10 seconds) and high, near maximal intensity such as jumping, Olympic weightlifting, and sprinting.
- The anaerobic glycolytic system, which includes activities such as high intensity activities that can be sustained for a time period of about 10-45 seconds. Such activities include resistance training done for a rep scheme that takes longer than 10 seconds, 30 second sprints, or 10-45 second isometric holds.
- The oxidative/aerobic system, which includes activities that generally take 2 minutes or longer. Obvious examples are running, cycling and swimming at a pace that can be maintained for at least 2 minutes.
With most activity there is a blending of all three systems working together with one system being dominant, but for the sake of understanding methods for varying physical activity it is important to distinguish the differences.
In conjunction with varying the energy systems you train, three important factors will also change: breathing patterns, mental affect, and movement tempo.
- Vary your breathing patterns
How you breathe directly affects the duration of activity that you’re able to withstand, as well as the amount of tension that you can create in your muscles. The simple act of changing which energy system you train will vary the breathing pattern best suited for the activity being undertaken.
With explosive power movements done when training the ATP-CP system, breathing should include a sharp inhale that fills the abdomen followed by a sharp exhale that tenses the abdominals and hip musculature.
Which hip muscle contractions are enhanced will be based on the direction of the movement being performed. With hip extension movements, the gluteus maximus will be the prime muscle to be stimulated by a forceful exhale, while with hip flexion movements, the psoas major will be stimulated. With rotational movements the hip internal and external rotators with need to fire in a reciprocal fashion and in combination with the psoas or gluteus maximus depending on flexion (psoas) or extension (glute max) bias. The abdominals and other spinal stabilizers need to activate in order to stabilize the spine and pelvis. By doing this the abdominals create a fixed point for the hips to move around in order to allow for more explosive motion (think of a swimmer pushing off of a solid wall versus a rubber wall).
With strength-based movements utilized when training the anaerobic glycolytic system, the breath will be released in a slow, highly pressurized fashion throughout the entire movement.
This breathing pattern allows for the individual performing the movement to create the maximal amount of tension in the muscles at various points of the range of motion, while at the same time making the exercise last long enough to move through the ATP-CP process and into glycolysis. This intensive breathing pattern should also promote a high level of activation in the central muscles of the abdomen and hips, but due to the slowness of the release of the breath, a “body scan” of increased muscle tension to the peripheral muscles of the upper and lower extremities can be created as the exhale is extended out (see video below). Basically this means that the slow intense exhale allows you to tense as many muscles in your body as you possibly can.
For training the aerobic system, breathing should be as relaxed as possible without losing midline control.
This means that the goal of breathing with endurance-based activities is to find a way to maintain the lowest rate of breathing for as long as possible without losing your desired pace or position. A common example would be to hold a prone plank for longer than 2 minutes. In order to do this you need to first set a standard for the plank position you want to maintain and then use the minimum amount of muscle tension to maintain that position. In order to maintain a minimal amount of muscle tension, a light, almost conversational breath strictly through the nose should be applied. Any excessive increase in the rate of breathing will set in motion of variety of body processes that include increased muscle tension which is coupled with hastened muscle fatigue. This increased muscle tension and fatigue will frequently result in an inability to maintain position for the allotted time.
More traditional aerobic endeavors such as running, cycling and swimming also fall into this category of breathing. However, changes of speed and effort in these activities will force an individual to change breathing tempo and intensity.
- Vary your mental affect
More and more research is demonstrating that exercise has benefits effects on cognition and emotions. However, specific programming for mental changes are not often discussed. When tapping into the energy stores of the various movement systems discussed above, it’s important to recognize that there may also be a subsequent change in mood.
Power and strength training involved in stimulating the ATP-CP and glycolytic systems promotes acute increases in the anabolic hormones testosterone and human growth hormone (HGH). The increase in these particular hormones has been demonstrated to promote improvement in confidence and assertiveness. However, along with testosterone and HGH, the stress hormone cortisol is also promoted during these type of activities. In the short term, cortisol has positive effects on metabolism and inflammation, but increased levels over a longer duration have been demonstrated to cause increased fat storage around the abdomen, bone density loss, poor wound healing, and electrolyte imbalancehttps.
Beyond the effects that the hormones stimulated elicit on mood, the physical act of partaking in both power and strength-based activities inherently calls for a more aggressive demeanor. To many this may seem undesirable, but when performed for short durations, displaying an aggressive manner can actually counter feelings of malaise and low energy.
With aerobic activity, a near opposite manner to power and strength training is the goal. In order to be able to sustain a level of activity for longer durations, the mind and body must remain calm so that unnecessary energy is not utilized that might lead to premature fatigue.
Unfortunately, it is often the case where individuals will view aerobic activity as a grind to reach a certain distance in the fastest time possible. This is often accomplished by ignoring the body’s distress signals and pushing one’s self to the limit of exhaustion repeatedly. I strongly recommend that a majority of aerobic exercise be performed using a calm, relaxed nasal breath as the guide for what pace should be kept. In this way, aerobic activity will be likely to decrease activity of the sympathetic nervous system (fight or flight system) resulting in relative relaxation. This effectively counterbalances the more aggressive mental effects of power and strength training. If the intensity of the aerobic exercise is too great for long periods, these positive nervous system effects may not be realized, and overstimulation of the SNS will result. This will inevitably lead to increased physical and emotional stress.
- Vary your movement tempo
Training the various energy systems incorporates an inherent changing of the pace of the movements being performed. In order to perform efficiently and not limit ourselves with activities of daily living, we all have to move at various speeds. The vast majority of everyday tasks are longer duration and relatively slow-paced, which is associated with utilizing energy from our aerobic system.
However, to be a full-functioning human we also need to be able to move heavy objects from point A to point B, which calls for a generation of high muscular tension. Depending on the load that needs to be lifted, a decision needs to be made whether moving in a slow and controlled manner or a fast, explosive manner better suits the task at hand.
The heaviest loads will not be able to be moved at a high velocity, but instead will require a consistent high level of tension throughout the duration of the task. Moderate or bodyweight loads are often best moved at a more rapid, explosive pace so as not to waste energy and prevent unnecessary physical stress that would be inherent to moving an object slowly.
As a physical therapist, it is common to see acute injury resulting from an individual moving at a pace in which they are not accustomed. Examples of this are the weekend softball player that tears an Achilles tendon sprinting for a fly ball in the outfield after spending the previous six days of his or her life sitting in front of a computer.
Another serious, and often overlooked, example is an older adult falling when getting up from a low seat because they don’t have the ability to move with the power necessary to move their body to an upright position. In this example, slowness of movement leads to the individual staying in front of the line of gravity for too long and eventually either losing balance and toppling forward or collapsing back down into the seat in an uncontrolled manner. Too often slow controlled movements with light resistance are often prescribed as a form of a “safe” exercise routine. However, there is nothing safe about not being prepared for the demands of daily life.
Pain as Feedback
The final, and likely most important, factor to be considered in understanding how injury can be an opportunity, lies in the understanding of the very nature of pain. Pain above all else is a “danger” signal. It is a sign that the body deems a certain movement unsafe. This signaling can be one of the most powerful tools for teaching individuals the errors of their prior movement patterns while at the same time show them how to move more efficiently.
In order to be able to do this, we need to have system in which we sequence our movements so that we can feel an initial onset of pain or any other symptom. This means that when working on movements that are likely to cause pain, we need to move at a deliberate and controlled pace to note the exact point in the range of motion where pain occurs. With this knowledge, we can now use the symptoms as a baseline in which to assess change that might occur from other non-painful movements.
For example, suppose there is knee pain at 60° of knee flexion during squatting and we see a subsequent inward movement of the knees around that point. We can re-assess if the same squat is less painful or pain-free after an adjustment is made to the inward knee position. If the pain is eliminated, it is a much more powerful lesson to the client than any coach’s cue would be to for a non-injured client.
This factor is absolutely crucial for individuals to get a better understanding of the concepts of stability at various regions of the body. As any physiotherapist or coach is aware, it can be quite difficult to get clients to understand how to get into a “stable” position in areas like the lumbopelvic and scapular regions. However, when pain is present, the most stable position is often the one in which the pain is the least. This feedback is extremely valuable for the motor learning experience of the client, making the process of stability training in these crucial regions much more effective.
Developing a Plan
Now that we understand how to vary our activity and use pain as feedback in order to work around injury, let’s look at the assessment process needed to develop a plan for which movements are best for both limiting stress to injured tissues and allowing injured individuals to safely train areas often neglected.
First we must answering the following questions through both subjective questioning as well as objective movement assessment:
- What was the mechanism of injury? (How did the individual get hurt?)
- What movements are currently the most pain-provoking?
- What movements are currently the most pain-relieving?
- What activities or inactivities does the individual most frequently undertake?
Once we answer all of these questions, we want to break down which body positions and which energy systems are most biased during the movements that are (1) responsible for the initial injury, (2) most pain-provoking, (3) most pain-relieving, and (4) encountered most frequently.
Once we have this knowledge, it should go without saying that we want to program movements that promote the body positions and energy system that bias the pain-relieving activities and limit the types of movements that are provocative and already frequently performed.
Please note that issues involving injury are best assessed by a licensed medical professional such as a physician or physiotherapist. These professionals are trained in ruling out sinister pathologies (i.e. cancer, spinal cord injury, visceral or vascular conditions) that need imminent medical attention and cannot be worked around. Moreover, these professionals are the ones who actually work directly on your symptoms, not just around them.
With this being said, in the absence of sinister pathology, the ability to maintain a high level of symptom-free activity in the face of injury is a major part of the recovery process and is, unfortunately, overlooked by many medical professionals. Therefore, make sure you are an advocate for staying active throughout your recovery process and seek out professionals that understand both injury and strength and conditioning principles.
In conclusion, of course nobody wants to get hurt. However, developing exercise programs that “play it safe” in regards to minimizing complexity and variability of movement is short-sighted and ultimately about as unwise as having no exercise practice at all. Fear of injury is one of the most limiting factors in recovery from injury. If we are able to develop a better relationship with pain via the methods discussed above, not only will our injuries be less debilitating but they can also be a great opportunity to enhance our physical performance.