Often I have cases come into my practice where they stand out as a good example of what appropriate progression can accomplish. Also, frequently I get people asking me: what do you do with people? What is your secret to helping people get pain free and strong? I thought this case might be a good example of both and allow me to share some of the principles that have brought me success with people like Chris D. While this is an extreme example of a case, it might help give you insight as to what proper progression and intention can accomplish.
Chris started working with me ten weeks ago. He came to me through a referral described as a “back problem”, which I quickly found out was a bit of a loose description. I can’t obviously share what his scans MRI revealed but needless to say they were detailed and he had a lot of spinal issues stemming from a long career as a contractor. The biggest problem with our initial assessment was a pretty glaring one:
Chris couldn’t sit down. He couldn’t sleep for more than about an hour without waking. He couldn’t work without constant pain in his neck and shoulders and legs. Even driving his car was an exercise in pain management. Due to the pain in his neck, upper back, shoulders, lower back and legs after just sitting in my office for five minutes he was uncomfortable enough to have to stand up. No matter what I tried to do in order to check movements through his upper and lower body he was in pain, and it would flare up at the slightest bit of movement or force. Even isometrics, which is usually the most minimally irritating to most people was really irritating to Chris. I’ll share later what we have found out during the course of his treatment but needless to say it was a very daunting task.
For only the second time in my training career (and you can read about the first HERE) I was faced with a situation where I wasn’t 100% sure if I could help. Chris expressed that his previous physio experience left him feeling better, but of course things came back once he stopped because he didn’t have strategies to keep helping himself after he was done. This is all too common – physio can help to an extent, but then it takes getting stronger to really complete the rehabilitation process.
Initially Chris decided to give me a two week period to see if what I was doing would help a bit. Here’s a layout of how our first movement session worked (I keep notes on everything I do with every client so this is directly out of my notes):
- Priorities: Mobilize upper neck C5/6/7, upper trap, R side shoulder blade, strengthen L side upper quadrant. Standing mobility in L side hip com/glute com/lower back, strength in R side glute/hip coms and ankle on R side. (this was all based on what I could assess)
Release therapy was done on his upper trap areas on both sides to bring blood flow into the area and expose him to self myofascial release that we could do on his own with a ball. There are varying sizes of these and we used the largest one in order to have the largest surface area and the least access to deep tissue. Chris could not stretch conventionally because any movement would cause his pain to flare.
We started with a manual two legged hip hinging movement with about 20-30 degrees of hip and knee flexion (with a base for support that was 30 inches high as a guide) for control and teaching how to use his pelvis. My initial goal was to work on getting him sitting down (to help with work and being at home), then lying down (to help with sleep). We did some R side isometric engagement (while standing) for his glute and hamstring. We did some standing brace work to teach his inner unit how to engage properly and worked on his walking gait. One major discovery we did right away was that if he flexed his L shoulder 20 degrees forward while walking his pain diminished significantly through his neck and upper back.
After 35 minutes we had to stop because Chris was getting major irritation in his shoulders and neck.
Using proper microprogression and trial and error Chris was able to sit down in his car so that he could drive to his father’s place 1 hour away for Father’s Day in June, about five weeks after we started. His sleep was still an issue and his shoulders and neck would still get irritated quite easily, but through constant self therapy and working on movement patterns we had established on his own, things started to improve. Chris started to experience periods of time without neck/shoulder pain. Through more trial and error we found that if Chris rotated his shoulder blades a certain way he experienced relief. Being mindful of all of these things kept him encouraged and improving.
His lower back and legs started to improve significantly and we introduced compound movements. After the eight week point we discovered that his thoracic spine was likely twisted and began to work on that aspect, which helped quite a bit. Chris discovered that when driving (which he could do at all previously and now could do for extended periods) if he consciously kept his shoulder blades even he could eliminate pain in his neck. By now Chris could squat (with load), split squat, flex his shoulders almost to 90 degrees and even hold his spine against rotational torque.
After ten weeks Chris could deadlift 60 pounds with perfect form. I have a video of it but Chris asked that he remain relatively anonymous.
He has been getting proper nights’ sleep and been able to do more driving for work. He has been able to do work around his home that would have caused serious problems three months ago. Here’s a layout of our most recent workout:
- Alpha Ball warmup – mobility in rotator cuffs (both sides), one legged balance and thoracic spine mobility. Blood flow increase to VL/IT Band fascial line on R side (since doing more with his legs he started to experience some weakness through this area on his R side).
- Dead Lifts starting at 50 lbs and increasing to 60 (he holds the bar in external rotation because his shoulder is able to maintain in that position) for up to 9 repetitions.
- Lying position shoulder flexion with 3 lbs load on both sides maintaining position above 20 degrees from floor (through various positions we found that he is able to use front delt/pec/serratus in this position)
- Single Legged Leg press at 90 lbs of load (does not affect his lower back or hip complex any more)
- Eccentric loaded row in an incline position (I would have to take a picture of this for you to understand but think about lowering through a chest press focusing on the negative portion only)
Chris had made phenomenal progress over his time so far seeing me for only two hours per week. He also does a lot of work on his own, which is what I expect from my clients. He is aware of what he needs to do (and not do) and every time he comes in we have some new insight into a movement pattern that he experienced and we are able to build on that. One thing I constantly express to him is how I love the fact that he wants to understand what is going on and focuses constantly on moving properly. Chris has invested in his recovery, which is vital to any progress you want to make physically. It doesn’t happen slowly, it happens with careful application and time.
So here’s a good example of how a properly progressed strength program can help someone that has been in chronic pain for a long period of time. Many people walk around in situations that can easily be diminished or resolved through a properly progressed program with lots of intention and appropriateness. I’m hoping that Chris will continue to improve. One of our major goals was achieved last week when he actually slept properly, something he couldn’t remember doing for a very long time. These little things can make a huge difference to someone’s quality of life.
If you have any comments or questions about what I have been doing/have done with Chris please simply ask and I will share it (with his permission of course). Also, if you have any people who you think could benefit from the type of treatment Chris has gone through feel free to let me know.
Until next time – keep moving!
Every spring brings with it clear roads, nice lush trails and always an explosion of new or reborn runners outside. The year seems bright and shiny and new goals get set, sometimes held over from the year previous. That ½ marathon that didn’t get done last year – this is the one! I’m going to finish my first 10k race in under an hour! I’m going to set a new personal best in May! After coaching endurance athletes for over a decade I’ve pretty much heard all of them before. This applies to those of you who ran regularly last year and haven’t consistently since November (when you finished your last race) too. So I thought I might list off some of the biggest mistakes that I see new or renewed runners make early in season and hopefully it will make sure that a lot of those injuries I end up fixing in the fall don’t happen – at least to you.
1) Start as easy as you need to.
Many beginners start out with a walk/run protocol until they can run continuously for 20 minutes – and you should too. One mistake many beginners make is thinking that they can instantly hop out of their door and run forever without walking. They get 1 kilometer down the road, are gasping for air and their muscles are screaming, limp home and never go out again. I wonder why? This applies to reborn runners as well – sometimes those first few runs are hard on the body and it needs time to adjust and get used to the movement again. Try walk 1 minute, then JOG (not run) 1 minute and repeat for about 10 cycles – this is 20 minutes total, 10 minutes of jogging. This is a good starting point. Start with 3 times a week on non-consecutive days. You will know you are improving when things get easier and then you can progress to 2/1, up to 10/1 and then try for a long continuous run.
Also, it has been proven that aerobic conditioning is incredibly important. The majority of running at the starting stages should be at aerobic pace (meaning at least conversational). This can be very difficult for beginners, so watch your perceived exertion levels!
2) Warm up and Cool Down properly
Just putting your shoes on and going full speed right away is something even experienced runners shouldn’t do. My athletes all start out with mobility movements and drills before starting, then slowly ramp up to their workouts. High level athletes sometimes warm up for over an hour before their main workout starts! This is important for blood flow, getting your brain into movement and making sure all is okay before you start pounding on your joints. At the end of a workout, take some time to walk, evaluate how you feel and don’t just plop yourself down and stop moving right away. Don’t necessarily just stretch, either – often your muscles are too taxed and you are potentially doing yourself more harm than good by stretching immediately afterwards anyway. Treat every workout seriously, because if you want to perform well over time this is an essential habit to have right away.
Historically my athletes all tell me that if they had a crappy run it was because they didn’t warm up or do any movement before they went into their workout. It also significantly increases injury risk.
3) Progress yourself slower than you think you need to.
I can’t stress enough that the majority of overuse injuries I see are caused by their name – overuse. Some days are going to be a lot better than others for running, so ramping up mileage needs to be done weekly with a deload week once in a while (meaning just drop your total mileage by about 20%). There are lots of good plans out there and if the plan calls for 3 miles, don’t suddenly do 5 just because you are feeling great that day. My marathon runners spend months increasing weekly mileage from 50km per week to 70 and many more to 100 – you have to give the body time to adapt to stress under load. I often explain it to people that if you walked into the gym after hardly bench pressing 100 pounds and suddenly tried for 150, likely it wouldn’t go very well and you could easily hurt yourself, right? Running (and any other form of muscular stress) is the same thing. Start with alternating days, then add in a day once you feel capable. 4 days a week is generally plenty for most runners unless you are trying for a very fast time, especially when you add in other components, like…
4) Strength train. Both with resistance and while running.
Huh? How can you strength train while running, you ask? Well, the funny thing is that the body adapts to stress under load. Especially for beginners, getting into the weight room and lifting weights (properly) has been proven to be better for your running efficiency, allow you to recover from workouts faster and severely reduce your risk of injury. Now, this doesn’t necessarily mean bench presses – the strength movements should be tailored to the muscles that you need to be better at running. A good strength coach (and I happen to know an excellent one!) can be your guide here. Strength training while running can be done with things like hill workouts, hard track workouts and even simple drills you can do at the end of a good run. Again, like anything else care has to be taken to do things properly at the start. There are lots of good beginner strength programs out there for endurance athletes.
It also doesn’t require a gym membership. I can outfit a decent home gym for less than $100, so if you need any guidance there or even if you don’t have a lot of space it can definitely be done. In fact, you can get a lot of strength from bodyweight movements alone.
5) Be realistic.
If a person comes to me having never run consistently and tells me they want to run a marathon, I tell them it will take 2 years to do properly and injury free. They usually walk out at that point. So many of us want that big goal without giving our body the time to adapt and get stronger while doing it. If you want to do a ½ marathon (without walking) be prepared to be running up to 50-60km per week. For a 10k it should be at least 30-40 – which requires time, commitment and preparation. Don’t be afraid to downgrade your goal if you find you haven’t put in the training time, you are better off to do that then do the race you set and possibly set yourself back for the future as a result. There are races pretty much every weekend during the summer – they will always be there. Would you rather have a bad experience or a good one? The road is long and if you take your time and do things right the first time, you can enjoy running for years without any issues.
All of this being said, a good coach is invaluable and will give you some perspective. Just please make sure you don’t come to them with a list of goals – pick a top one and have a secondary one, but don’t expect that you will lose 30 pounds while also running a ½ marathon. They are separate things and should be treated as such. If you are interested in exploring either your first race or your twenty-first and are going for a personal best feel free to contact me. I have helped dozens of runners get to that target goal they have been waiting for, whether you are just getting off of the couch or heading towards the Boston Marathon. Feel free to comment, subscribe and follow me on Facebook!
Something I have rarely done is talk in detail about my methods, even though for many years I have had some pretty good success with many conditions where people were frustrated and had reached the end of their rope. The story I’m going to tell you today is about one of my people. Her name has been changed for obvious reasons but the story is really what is important. It is a bit long, but hopefully when you’re done you will gain a new appreciation for what proper progressed and appropriate exercise can potentially do for someone who had given up on ever improving herself physically.
Just over two years ago a woman walked into the local chain gym where I worked and asked to be set up with a trainer who had dealt with special populations. She had decided to try exercise as a way to help her with various physical problems. I was referred from the trainer she was initially set up with who basically told me “I have no idea how to deal with her”. Maureen was instantly suspicious when she sat down with me because she was used to promises. In a nutshell, her story was simple. Thirty years ago she had been hit by a tractor trailer in her car, almost killing both her and her husband. She had broken her back and sustained a lot of trauma to much of her body, mostly in her hips and spine. Because of their circumstances she had never really had proper care beyond some brief physical therapy after they both got out of the hospital and had basically lived the way she was for that time. She wasn’t overweight, she just had massive physical restrictions. Here’s a short list of what she dealt with:
- She walked with a constant limp in her left leg, dragging it for most steps
- Any force on her back or hips (stepping off of a bus, for example) could cause a migraine headache and make her feel nauseous
- She couldn’t rest her head on the head rest in her car without pain. She couldn’t turn to check her blind spot without a problem.
- Constant ringing in her ears that would become worse with any sharp noise
- Since her body was so bound up, she had IBS whenever she changed anything in her diet
- Sleeping was tough because her back was constantly sore and she would get nauseous and spasm whenever she tried to turn over
She had seen physios, chiros, osteopaths, doctors and many other professionals over the recent years because she was at the end of her rope. She tried many practitioners and did not see any improvement. One massage therapist actually refused to treat her and doctors tried to give her pills constantly. She also dealt with all of this while taking care of her husband who had his own set of physical limitations. Her life was very, very hard and she was sick and tired of it.
When I sat there with her and heard her story, I didn’t know if I could help her, but all I told her was that I was willing to try and she would be under the best of care. I asked her to commit for six months and we would see how things went, but if things weren’t working out then she could walk away any time. She agreed and decided to place her faith in that I was at least willing to try. Doctors had turned her away telling her that they couldn’t do anything for her. The saddest thing is (and she told me this only after we had worked together for a year) she was actually planning suicide if she couldn’t be helped because she was so tired of her life and how she felt every day.
Let that sink in and then imagine the massive responsibility that I carried when working with this woman. Here’s the first few exercises we ever did together:
- Modified squatting movement at 140 degrees of knee flexion (she could not go further than this – I used a bar behind her to guide her movement).
- Stepping up had to be modified to only five inches of height, otherwise it caused a headache and nerve pain right away. We focused on movement and coordination.
- She could pull things, so we sat her down and did some one armed shoulder and back work, focusing on moving her shoulder blade properly.
- She was unable to bend, twisting was out of the question and even simple movements with her hips caused her a problem, so traditional “core” work was out of the question. For example, having her able to lie on her back on a mat without pain was a first accomplishment.
- For movement her walking started at 2 miles per hour – and she could only do that for about five minutes before being exhausted and having to sit down. And she was not overweight.
Often other trainers would wonder what I was doing and my only answer was “being careful”. Often during a workout she would get nauseous and experience pain in various places, but this could be used to find out what movements she was capable of, and with what degree of force her body could tolerate. An additional inch of movement or five more degrees of angle was an accomplishment. Loads were increased incrementally workout by workout.
Six months into her regime she fell off of the bus and broke her foot. The good news I took from that is not only did she not want to stop exercising; she was encouraged by the fact that she caught herself without falling to the ground. We continued to work on her back and upper body. Her headaches were lessening in frequency and movements were becoming easier. We were able to expand ranges, add some load and introduce new patterns to her brain, which had previously guarded against them. A year in she picked up 80 pounds (half her bodyweight) with good form. She didn’t limp any more when she walked in. By now I had learned what movements might trigger things and what signs to look for when she was trying to hide that she was extremely tired so that we didn’t do too much to her.
About fourteen months in she was doing quite well so we introduced mild jogging for 15 seconds. She had not jogged for over 30 years and was ecstatic even though it was very hard for her. She could lift things off of the floor, squat, bend and push things over her head at this point. Twisting was still an issue for her spine (likely due to scar tissue build up) and I told her it might always be. She could get down on the floor and get up again with minimal assistance more than once. However, some weeks we would push things just a bit too hard and have to scale back and gently nudge things forward again carefully. There was a constant process of progression in small increments.
Today I’m happy to report that Maureen can pick up 50 pounds several times without an issue, can squat with a (small) back load but load her front no problem, can jog for 60 seconds and can twist without nerve impingement. She can do a full plank for 30 seconds. She can do movement without having to anticipate a problem. More importantly, her headaches are non-existent, she can sleep at night without pain, she doesn’t have to worry about falling off of the bus and she can check her blind spot while driving without a problem. Just the other day she reported to me that she rolled over in bed without thinking about it and was fine – for the first time since her accident. For some of us this is a simple thing, but for her it is huge and means she can sleep through the night without getting woken up. She is stronger – and therefore her body is more able to deal with the forces it encounters every day and not manifest them in pain or nausea.
I use this as an example to many people about the power of proper exercise and application of force. With a lot of work, careful application and monitoring and a big investment in time and effort her life has been completely transformed in a positive way. It has taken two years for us to achieve these things, but if you ever talk to her, she will tell you that it has been life changing for her. The thing is, this is possible for just about anybody because she is not the only example I have from my career of being able to do some amazing things with people given the right time, care and application.
All the time we think of exercise as a way to look better. We can also think of exercise as a way to feel and perform better on a daily basis and carry a better quality of life forward through the years. To me this is the most powerful thing about exercise. It can make things possible that you previously thought weren’t possible. Maureen invested her time and effort into getting stronger and better and trusted in the process. If you’re looking for results over time, this is really what you need to do. I hope that you spread this story around and let anyone in your life know that anything can be improved given the right application. It just takes time, effort, and proper progression. If you have any comments or questions, feel free to let me know. I’m also happy to put you in contact with Maureen if you would like to hear her story directly.
Take care of yourself and your body and never take anything for granted. Your life can change in an instant, but you can also make it better if you choose to.
Often when I’m dealing with clients (or even other trainers) and start talking about things like moment arms and force angles or resistance profiles I get a blank stare. I understand that because I’m a geek and like to learn about things like this, just like I would give someone a blank stare if they started telling me about their ’68 Ford and how they replaced the carburetor. Different strokes for different folks.
So when I’m working with clients and start adjusting things often I get asked why I’m doing it. Something as simple as changing an angle during a movement can provide a totally different exercise experience not only for the person involved, but more importantly for the muscles and what you are trying to do to them. A change as insignificant as 10 degrees in the knee during a knee extension depending on the position of the person’s hips can change the amount that a muscle is getting stimulated in ways that you might not think. I’m not going to get into details, but if you want to take a look at THIS study go ahead as an example of what I’m talking about. If you’re really keen I can direct you to about a few dozen more covering similar topics. Another example when dealing with shoulders is that at a certain angle of shoulder abduction (like a lateral raise) the deltoid isn’t working as the primary mover, and then all of a sudden it is.
For our purposes we can call an angle as the measure of a rotation (or an amount of rotation) around a fixed surface – that being your knee, elbow, or finger joint. In the strength work we take this to mean what angle one joint is achieving most often. For example, “going to parallel” generally means that the angle of the thigh relative to the floor is parallel, but some people also take this as achieving 90 degrees in the knee joint.
So here’s the major question that most people are asking right now – why the heck does this matter in my exercise program?
I have clients ask me all of the time how they can change up their workouts, and this is one of the simplest ways to change a fundamental movement pattern and make it do something just a little bit different to the joints in question. In RTS we call this “rotating the tires”. For example, doing a flat bench press, or a 45 degree incline press stimulate the shoulder joint (and a few others) in different ways. A pull down from straight above is different than a pull from in front of you. All of the muscles that cross the joints are still moving and being stressed – just in different ways.
Angle also can contribute a lot into how much force is required to move an object. Example – bicep curl. When a curl is at 90 degrees the force in question on the bicep muscle is potentially twice as much as it is when the elbow is at 30 degrees (towards the end of the movement). This also has to do with how far the weight is away from the joint in question like I discussed in my previous article about distance. Suddenly a ten pound weight is now a twenty pound weight and can start to cause a problem for the person moving it or put more force into their joint than it can handle, causing tendon and ligament damage.
With something as complex as a back loaded squat, there are many angles in question. The ankle, knee and hip joint all have to move together along with achieving a certain angle in the back, the feet and legs in order to provide not only safety but the ability to provide force along a chain that makes sure the muscles are being used to their maximum capacity. The ability to maintain an even hip and knee angle is essential for deep squatting, and then if the whole chain is limited by the ankle joint it will throw everything off and you won’t be able to go as deep, therefore not providing as much stimulation or even tracking into injury. There is a reason that people who have heavy loads on their back often do quarter range squats – because they simply can’t create the force to move the weight if they are at a certain angle. Here’s an illustration:
Simple things like achieving a larger range of motion during a movement can actually alter your exercise in a very significant way. One of the reasons that I’m all over my clients during workouts is because there is simple intention behind every exercise, and if it is performed differently, or with sloppy form then we can’t accomplish the goal for that particular exercise in the way it has been designed. This simple squat illustration can also show us where a person might be restricted due to something else and allow us to alter the current workout to help, not hinder progress. Imagine in each diagram what the different forces might be on the ankle, knee, hip and spinal joints.
A person’s physical structure can also have a lot to do with this. A person with longer levers like a basketball player would have a totally different movement path than someone a foot shorter and much wider like a powerlifter. If my femur is longer then the whole movement changes again and I may not be able to achieve the perfect angle. There is nothing wrong with that, but it does need to be considered when designing an exercise program. Would an exercise like a squat be as “good” for someone who can’t achieve the depth they need to get to in order to stimulate what you are trying to stimulate? Or would something else maybe be safer and more effective?
So here’s an idea – during your next workout, change a couple of angles of movement (while reducing load in order to be safe) and see if it doesn’t stimulate your body in an entirely different way. I can almost guarantee that your body will thank you for the rotation of the tires you are giving it, and your experience will be much more fulfilling. Feel free to report back to me and let me know how it went.