Disclaimer: this information is to serve as a guide and provide general information. It is not meant to give specific medical advice. If you need help with your specific situation, contact me for consultation via email: caleb@retrainbarbell.com, or consult a healthcare provider
We often think that when we become injured that we have to stop activity such as weight training and that rehab is a completely separate thing.
“Strength and conditioning is traditionally thought to exist only in the training of the healthy athlete, while rehabilitation is for the athlete who has been injured.” (2)
Complete rest is likely counterproductive to healing compared to loading the injury itself or at least moving and loading around the injury until it is ready to be directly worked. There is no reason to avoid lifting after an injury unless there are serious medical concerns/emergencies or the area is so sensitive it does not allow for any tolerable movement. There is no exact time you have to wait until you can touch a barbell after an injury and you potentially can do so right away, possibly without interruption of your normal routine.
“Rehab is Training in the Presence of Injury” - Phil Glasgow
Here are some key recommendations when pain or injury occurs:
“Let the dust settle” and avoid catastrophizing
When an injury occurs, there is going to be an immediate reaction of pain and panic. Try to avoid making any snap judgements and decisions and particularly work to avoid thinking worst case scenarios of what the pain/injury may mean right after it happens.
Things may seem bad initially but you will often get a clearer idea of what is going on over the subsequent days as things start to settle. Although the pain may be severe initially, it may improve to a tolerable level sooner than you think and you may be able to keep training in a relatively normal fashion without having to make any drastic changes, thus rash judgements and decisions need to be avoided.
2. Assess the nature of the pain and what movements you can tolerate vs what you can’t
Continue as normal as possible with unaffected movements and movements that are uncomfortable yet tolerable, figure out how to modify movements that are painful and problematic
If you can reasonably tolerate normal training, then you may be able to continue and pain will likely improve without any necessary changes
You don’t have to stop everything and do a specific “rehab” routine as this is likely overreacting and excessively conservative. Continuing to train with appropriate and needed modifications is going to be the best way forward to get back to normal training
Keep as much “normalcy” as you can as this will feel like you can still train and progress. Rehab can simply be training with an injury
Loading the injury may actually help improve the pain
“sensitive tissues respond well to physical load (as seen in, eg, the management of knee and hip osteoarthritis). This is likely due to the involvement of endogenous pain inhibitory systems” (1)
3. Avoid adding in a bunch of “rehab” exercises
When you become injured, the area and potentially your overall stress tolerance can be less. Thus if you start adding in more exercises you may potentially overstress the injury
The rehabilitating athlete may need to be considered similar to the untrained category initially with respect to the injured body part. (2)
Pain simply is not solely due to mechanical dysfunction, tissue damage, faulty mechanics, and other biomechanical causes. Thus trying to arbitrarily “fix” these supposed causes likely will not actually improve the issue.
The one caveat where more isolated and specific exercises that are typically associated with rehab can be helpful is when they are used to directly target and build up capacity of the injured area when tolerated. However, they are in addition to weight training to supplement improving the local capacity of the injured area, not the main focus or in place of training.
4. Do not put timelines on improving pain and getting back to normal training.
You can’t make it happen any faster but you can prolong it if you push to much, or stop being active and training all together. There are no specific or exact timelines as these are going to be highly variable and individual. Focus on getting each session in with some tolerable and productive movement and training.
5. Work with the pain and the ups and downs of rehab
Pain is going to vary day to day. Work through pain that is tolerable and set boundaries around more intense pain. Have your training plan and assume you are going to complete it as planned no matter how you are feeling when you show up, but be adaptable to changing things if the pain tells you it’s warranted once you start moving.
6. Trust that you are going to get better and that how you feel today is not how it is going to be forever
You will heal, you will get back to normal training, and you will get stronger
A case for continuing to train compound movements that involve the injured area to help it heal:
Performing large muscle mass, multi-joint exercises early in the workout has been shown to produce significant elevations in anabolic hormones. This type of an anabolic response may potentially expose smaller muscles (such as those in the affected area) to a greater anabolic response than that resulting from only performing small muscle exercises. (2)
Sometimes the compound movements can move and use the injured area with less direct stress compared to isolation movements. This can allow for moving and working the area in a tolerable fashion compared to direct work as the physical stress can be distributed over more muscles and joints (larger area).
Example:
Issue:
patellar (knee cap) pain that limits ability to perform regular squatting such as high bar squats
Direct/isolation that is too stressful and not tolerable:
leg extensions or any direct quad loading in which force is directed right at the patellar region of the knee
Compound movement that is more tolerable and able to be trained:
low bar box squatting (involves more forward trunk lean and sitting back) which moves and works the knee but stress is spread over more of the legs and towards the hips vs directed right at the knee
With the squatting variation, you are still able to move, load, and work your knee while keeping pain tolerable where as the direct work is too sensitized and not tolerable.
It helps to think of training in this way when rehabbing an injury: letting things calm down, if they are sensitive enough to warrant this, then building it back up by improving tolerance and capacity through loading and training.
The clinical framework of calm tissue down, build tissue up, improve work capacity is the integration of a concept introduced by Greg Lehman, a physiotherapist and chiropractor.(3)
Using the 4 phases described by Reiman and Lorenz in their article: Integration of Strength and Conditioning Principles into a Rehabilitation Program, below will demonstrate how barbell training can be modified and implemented for the purpose of rehabilitation. The example will involve using the squat after a back injury with 4 scenarios that are progressed through each phase:
1) Normal squat still tolerated but not at normal weights
2) Normal squat pattern not tolerated in full ROM, but can tolerate modified ROM or can tolerate another loaded variation
3) Squat pattern only tolerated unloaded (no weight)
4) Squat pattern not tolerated (cannot squat at all)
For Simplicity, the normal training will be 3x5@70% for 3x/week prior to injury
Modifications that can be used to adjust the affected movement: reduce weight, reduce volume, adjust ROM, adjust tempo, adjust positioning/grip, change to another lift variation, or substitute a different movement pattern
These modifications are not necessarily used in isolation. You may need to utilize more than one:
Changing bar position or lift variation and modified ROM
Slower tempo with higher reps
Lower intensity with lower reps and different lift variation
General guidelines to determine if stress is appropriate or if training need modification:
Pain should be tolerable, roughly 3-5/10 or less
If pain too high, then movement pattern and/or load are not appropriate right now
Pain that is elevated post training should return to baseline within 24 hours
If pain elevated more than 24 hours, then volume likely needs to be reduced some
Phase I, Immediate rehabilitation: Characterized by tissue and/or joint inflammation and pain, disuse, detraining, loss of muscle performance, potential immobilization (dependent on injury), and initiation of tissue repair and/or regeneration… Protection of the integrity of the involved tissue, restoration of range-of-motion (ROM) within restrictions; diminishment of pain and inflammation, and prevention of muscular inhibition.(2)
Immediate post injury and the few days following. General idea here is to find out what is still tolerable involving the injured area. It can be thought of a spectrum of minimal adjustment and relatively normal training all the way to avoiding the movement pattern and getting some light, tolerable movement with other variations that may not directly use the injured area.
Barbell Training Adjustments:
Loaded normal squat pattern can be tolerated, but not at normal weights:
Reduce load: 3 sets of 5 at 50-60% vs 75%
Reduce volume: 3 sets of 3 or 1 set of 5 vs 3 sets of 5
Use a slower tempo: 3 sets of 5 with 3 second eccentric, 2 second pause, and 3 second concentric
Increase volume (at much lower intensity): 2-3 sets of 10 at much lighter weight vs 3 sets of 5
Example:
Day 1: normal squat 3 sets of 3 at 50%
Day 2: normal squat with 3-2-3 tempo for 3 sets of 5 at RPE 7
Day 3: normal squat with 3-0-3 tempo for 2 sets of 10 at RPE 8
Normal squat pattern not tolerated in full ROM, but can tolerate modified ROM or can tolerate another loaded variation:
Low bar squat adjusting ROM to tolerance: partial ROM squat, can use pins or a box to keep modified ROM consistent or feel out ROM each rep. Can be similar sets and reps or adjustments in intensity and/or volume as needed
Front squat or high bar squat instead of low bar squat at same planned sets and reps or also adjust using load, volume, or tempo examples above
Example:
Day 1: normal squat with pins set to lowest tolerable ROM 3x5@60%
Day 2: Front squat 3x3@70%
Day 3: High Bar Squat 3x5@70%
Squat pattern only tolerated unloaded:
Bodyweight squats at sets and reps that are tolerated, potentially supplementing other leg training that does not directly load or affect the back.
Example:
Day 1: bodyweight slow tempo squats 2-3x5
Leg press 3x6@ RPE 7
Day 2: lunges 3x8@ RPE 7
Day 3: bodyweight slow tempo squats 2-3x5
Leg extensions 3x12@ RPE 8
Squat pattern not tolerated:
Replace with other leg based training that does not affect the back such as lunges, step ups, leg extensions, leg press.
Perform at sets and reps that provide some stimulus to the legs if back pain allows
Example:
Day 1: Step ups 3x12-20 @ RPE 6
Day 2: sled drags and/or pushes 3-5 trips at moderate effort
Day 3: bodyweight lunges 3x12-20 @ RPE 6
Phase II, Intermediate rehabilitation: Characterized by continuation of tissue repair and/or regeneration, increased use of involved body part or region, decreased inflammation, and improved muscle performance… Continued protection of involved tissue(s) or structures and restoration of function of the involved body part or region. (2)
Acute pain has subsided significantly and the injured area can now tolerate some movement and direct work, but not at full capacity
Barbell Training Adjustments:
Loaded normal squat pattern was still tolerated in Phase 1:
Start incrementally increasing intensity as tolerated, possibly at longer intervals such as weekly vs session to session. May have 1-2 days of the planned progression at higher intensity and the other 1-2 days lighter
Example:
Day 1: 3x5 at 60%
Day 2: 3x5 at 50%
Day 3: 3x5 at 60%
Normal squat pattern was not tolerated in full ROM, but loaded variants tolerated in Phase 1:
Start to incorporate the normal squat pattern, likely at lower intensities than normal training as tolerated. Keep other loaded variation in 1-2x/week and substitute one of the sessions with normal squat pattern 1x/week.
Example:
Day 1: normal squat 3x5@50%
Day 2: high bar squat 3x5@70%
Day 3: normal squat 3x3@50% or front squat 3x5@60%
Squat pattern was only tolerated unloaded in Phase 1:
Begin to load the normal squat pattern or other squat variant if normal not tolerated. Start at lower intensity where pain is tolerable or pain free if possible. May start with some slow tempo to keep the internal intensity (how hard it feels) high but will force you to stay light, thus keeping external intensity (weight on the bar) low.
Continue with other supplemental leg training to continue to stimulate and train legs
Example:
Day 1: normal squat or tolerable variation 2-3x10 with 3-2-3 tempo A RPE 6
Day 2: lunges 3x12 @ RPE 7
Day 3: leg press 3x10 @ RPE 7
Squat pattern was not tolerated in Phase 1:
Start to incorporate the squat pattern with bodyweight squats in stance, trunk position, ROM, and tempo that allows tolerable movement. May perform this for 2-3 sets of 3-5 reps each lifting session to get some low volume exposure and help desensitize and habituate to the movement. Continue the other leg based training you had incorporated in phase 1.
Example:
Day 1: bodyweight slow tempo squats 2-3x5
Leg press 2-3x10@ RPE 7
Day 2: lunges 3x8-12@ RPE 7
Day 3: bodyweight slow tempo squats 2-3x5
Leg extensions 3x10-12@ RPE 8
Phase III, Advanced rehabilitation: Characterized by restoring normal joint kinematics, ROM, and continued improvement of muscle performance… Restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/ balance/proprioception. (2)
Continued progression of training from phases 1&2. Tolerating more squatting frequency and load than previous phases.
Barbell Training Adjustments:
Loaded normal squat pattern was still tolerated in Phase 1&2:
Continued progression of intensity similar to normal training. May be back to normal intervals of progression of intensity compared to more spaced out in phase 2, using less light days or no lighter days
Planned, heavier intensity 3 days/week from 2 heavy and 1 light
Planned, heavier intensity 2 days/week from 1 heavy and 2 light
Example:
Day 1: 3x5@70%
Day 2: 3x5@60-70%
Day 3: 3x5@70%
Normal squat pattern was not tolerated in full ROM but loaded variants were tolerated in phase 1, normal squat pattern re-introduced in phase 2:
Increase frequency of normal squat per week, gradually increase intensity at longer intervals such as every week or every 2 weeks or have a heavier and lighter intensity day with normal squat.
Normal squat 2-3x/week, other variant 1x/week if normal squat only 2x/week
Example:
Day 1: normal squat 3x5@65%,
Day 2: high bar squat 3x5@70%
Day 3: normal squat 3x5@50%
Squat pattern was only tolerated unloaded in Phase 1, began to load in Phase 2:
Progress back to normal sets and reps to increase intensity a bit and reduce volume some, but still keeping intensity lower than normal (50-60% vs 70+%)
Example: phase 2 – 2x10 slow tempo squat-> 2-3x5 normal tempo squat at 50%
If tolerated, incorporate other loaded variations that can be loaded heavier, similar to normal training:
Example: high bar pin squat, pins set to for right at parallel depth, 3x5 @ 70%
Example:
Day 1: normal squat 2-3x5@55%
Day 2: lunges 3x10 at RPE 8
Day 3: high bar pin squat 3x5@70%
Squat pattern was not tolerated in Phase 1, was introduced unloaded in Phase 2:
Begin to load the squat pattern in normal squat and/or other variant if normal not tolerated. Start to substitute loaded squatting into leg training incorporated in phases 1&2:
Example:
Day 1: normal squat or tolerable variant 3-2-3 tempo 2-3x10 @ RPE 7
Day 2: lunges 3x10 @ RPE 8
Day 3: leg press 3x8 @ RPE 7
Phase IV: Return to function: Characterized by activities that focus on returning the athlete to full function… Successful return to previous functional level in the athlete's preferred activity, and prevention of re-injury. (2)
Progressing back to normal training and continuing with normal training thereafter.
Barbell Training Adjustments:
Loaded normal squat pattern was still tolerated in Phase 1&2, progressed closer to normal or back to normal:
Fully resumed normal training for normal squatting without any modifications
Example:
Day 1: normal squat 3x5@70%,
Day 2: normal squat 3x5@70%
Day 3: normal squat 3x5@70%
Normal squat pattern was not tolerated in full ROM but loaded variants were tolerated in phase 1, normal squat pattern re-introduced in phase 2, normal squat frequency and intensity progressed in phase 3:
Intensity further progressed closer to normal training, possibly with still some fluctuation between heavier and lighter intensity if needed
Example:
Day 1: normal squat 3x5@70%,
Day 2: normal squat 3x5@60-70%
Day 3: normal squat 3x5@70%
Squat pattern was only tolerated unloaded in Phase 1, began to load in Phase 2, and progressed in frequency and intensity in phase 3:
Increase frequency of normal squat with fluctuations in intensity, possibly 1 variant
Example:
Day 1: normal squat 3x5@60%
Day 2: high bar squat 3x5@70%
Day 3: normal squat 3x5@65%
Squat pattern was not tolerated in Phase 1, was introduced unloaded in Phase 2, began loading in phase 3:
Progress intensity with normal squat, increase frequency of squatting with use of tolerable variations
Example:
Day 1: normal squat 2-3x5@55%
Day 2: lunges 3x10 at RPE 8
Day 3: high bar pin squat 3x5@60-70%
Scenarios 2, 3, and 4 in this last phase should be progressed, when indicated using the pain guidelines list above to guide, to the preceding scenario until you are back to normal training.
Example: scenario 4 progresses to 3 when able, then 2, then 1.
Concluding thoughts:
A significant factor I want to point out is that these phases are not distinctly separate and do not necessarily flow and progress in a smooth, linear pattern. The progression of these phases is going to depend on how things are responding. You do not need to wait and stay a certain amount of time in a phase if you are ready to progress, nor do you need to force and rush progression to the next phase if you are not ready. Timelines are going to be highly individualized and situationally dependent. Also, the process may not follow exactly as the examples above. For instance, you may need to make significant modifications to training initially, but may be able to progress back to normal training sooner without having to go systematically through all the steps/phases if things respond more quickly than anticipated. Rehab is not a straight and linear path. It is messy and not always predictable. You need to start where you are at, progress as you can, modify as needed, be willing to regress when indicated, and ultimately work with what you are given each and every training session. Focus on the process, not the performance, and the end goal will eventually be obtained.
References:
1. Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M, Moloney N, Vaegter HB, Bagg MK, Travers M. Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Phys Ther. 2019 Nov 25;99(11):1511-1519. doi: 10.1093/ptj/pzz108. PMID: 31355883.
2. Reiman MP, Lorenz DS. Integration of strength and conditioning principles into a rehabilitation program. Int J Sports Phys Ther. 2011 Sep;6(3):241-53. PMID: 21904701; PMCID: PMC3164002.
3. Washmuth NB, McAfee AD, Bickel CS. Lifting Techniques: Why Are We Not Using Evidence To Optimize Movement? Int J Sports Phys Ther. 2022 Jan 1;17(1):104-110. doi: 10.26603/001c.30023. PMID: 35024210; PMCID: PMC8720246.