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65: How to Exercise Safely When You're Injured
1k Plays1 year ago
Welcome to Episode 65 of the Movement Logic podcast! In this episode, Sarah is delving into the topic of exercising while injured. Should you? Shouldn’t you? How do you know when, how much, and what kind to do?
She takes you through a decision making strategy that will make this an easier question to tackle next time you are injured. Sarah also made a PDF Injury Decision Tree that you will receive as bonus content if you sign up for the 2024 Bone Density Course Wait List!
Caveat: This episode is not medical advice and should not be taken as such.
In this episode you will learn:
- Acute vs Chronic injuries - what’s the difference when it comes to exercise
- How different types of injury will impact your movement choices
- Your body’s mechanism of injury response at a tissue healing level
- The tissue healing timeline and what can speed it up or slow it down
- The role pain plays in injury and how it’s not a 1:1 ratio of injury to pain
- Situations where the best option actually is to rest
- What types of exercise are best depending on your level of injury
- Red flags to keep an eye out for that would require medical intervention
And more!
Sign up here to get on the Wait List for our next Bone Density Course in October 2024! It’s the only place you’ll get a discount on the course. You’ll also get the PDF Injury Decision Tree in a future email to the list.
Reference links:
Episode 1: Movement vs Exercise vs Sport
Episode 30: Mastering Physical Literacy with Dr. Chris Raynor, MD
Recommended
Transcript
Introduction to Modern Movement Tools
00:00:02
Speaker
Welcome to the Movement Logic podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist, Dr. Sarah Court. With over 30 years combined experience in the yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up-to-date and cutting-edge tools, evidence, and ideas to help you as a mover and a teacher.
00:00:37
Speaker
Welcome to the Movement Logic Podcast.
How to Exercise Safely When Injured
00:00:39
Speaker
I'm Dr. Sarah Court, physical therapist, and today we're talking about how to exercise safely when you are injured. Now, the most obvious answer to this question is just work around the injured part, and that can be a great strategy depending on the situation.
00:00:57
Speaker
However, what I'd like to do today is explore this in a little more detail because, you know, of course sometimes it's not that straightforward. So today we're going to look at types of injury.
00:01:10
Speaker
and how that will impact your movement choices, your body's mechanism of injury response, what happens when you're injured on a tissue level, the role that pain plays in injury because again, it's not a straightforward situation. When is the best option actually to rest? And when maybe is it not? And what types of exercises are the best ones to do when you are injured? I'm also going to tell you about some red flags to keep an eye out for.
00:01:40
Speaker
And I'm quite proud of this. I created a decision tree. It's kind of beautiful.
00:01:47
Speaker
in a decision tree kind of a way. And this is a decision tree to help you decide based on your specific situation and symptoms, whether or not you should exercise, what kind of exercise you should do, and all of that good stuff. And that you can get, my friends, if you sign up for the wait list for our bone density course, Lift for Longevity, we're doing it again.
00:02:11
Speaker
at the end of 2024.
Testimonial: Impact of Bone Density Course
00:02:14
Speaker
Before we get all the way into our topic today, I'm going to read a testimonial from one of our current cohort of the bone density course. They just recently finished the entire six month program and we are both so proud of them and it's been such a pleasure and an honor
00:02:32
Speaker
to watch these incredible women really work and challenge themselves and push through. And they've been so impressive on so many levels. That six months has finished, but we've now provided them with lots of options, ways to continue on their own. They can pair up with an accountability buddy, which we help them find through our private Facebook group.
00:02:57
Speaker
And we even have an option where they can rejoin our next cohort in October, 2024. And a few people are opting to do this because they're finding that they just really enjoy the course and the coaching and all of the feedback that they get on their form and things like that. The bottom line for us is that we're not just training them for a period and then disappearing forever. We know that continuing to do the work is the ultimate goal and we are providing multiple ways for our cohort to do that.
Continuing Education and Enrollment Options
00:03:27
Speaker
Overall, it's just been such an incredible experience to support this group of over 90 women as they build strength and resilience, not only in their bodies, but also in their minds. They have done the thing, no matter how many bumps in the road showed up over the past six months. And we're just so impressed with everyone that took part.
00:03:46
Speaker
So I wanted to share a message that I got from one of the participants. Her name is Elise Gibney. Elise is a clinical psychologist. Full disclosure, Elise is a friend of mine. But she decided to take this course because, like me, she has dealt with breast cancer. And there's all kinds of concerns that come up down the road with bone density.
00:04:07
Speaker
when you have taken medication that reduces the estrogen in your body. And so that is something that she's currently dealing with herself. And so she sent me a photograph of just a hotel gym weight rack. And this is what she wrote, at a hotel gym, doing heavy lifts and totally know how to use these machines because of you.
00:04:31
Speaker
So much gratitude for helping me and my bones push back against age and cancer. Getting teary writing this because I have so much gratitude. Thank you, my dear friend. I'm doing a deep dive into menopause research in order to empower my clients. And you and Laurel have created something really important.
00:04:53
Speaker
It's so nice, it's so sweet. This is just an example of the way that we wanted to empower this group of women so that, yes, we're here to support you every step of the way, but also at some point you can go to a hotel gym, look at all the machines and be like, I know how to do this and get your lifts in.
Course Waitlist and Medical Advice Disclaimer
00:05:12
Speaker
That's the ultimate goal. So it's so fantastic that it's happening. If you think that you might be interested
00:05:20
Speaker
in doing some more serious weightlifting. If you already are interested and thinking, I would love to get into using barbells, but I just feel like I don't know where to start. I don't know how to program something like this. Well, that's where our bone density course comes in. And we are offering this course again in October of 2024. The only way to get a discount on this course is to get on our weight list.
00:05:48
Speaker
So even if you're like, you know what, it's still whatever month it is right now, April. And I don't know, maybe, but it's a long way away. I would recommend that you get on the wait list anyway, because A, you never know, October might come around and you'd be like, oh, there was that discount and I missed it. And also the people who are on the wait list, every month we're sending them something cool and interesting. And so this month,
00:06:13
Speaker
the people on the waitlist are going to get the pdf decision tree that i made that goes along with this podcast episode so if that's something that you're interested in then you definitely want to sign up for our waitlist and you'll get tons of other good stuff along the way the way that you get on the waitlist is you can sign up in our show notes you can sign up
00:06:35
Speaker
from our Instagram account at movement logic tutorials. You can sign up from my personal Instagram account, Sarah Court DPT.
Types of Exercises for Injured Individuals
00:06:43
Speaker
You can sign up from Laurel's personal Instagram account, Laurel Beaversdorf. There are so many ways we are throwing options in your face. There's basically no way that you will not be able to find the link. It is everywhere.
00:06:59
Speaker
Okay, well, let's get into today's episode topic. Now, before we start talking about whether or not you should exercise with an injury, I have to state one huge caveat, which is this. This episode and what I say in this episode is not intended as medical advice and should not be taken as such.
00:07:19
Speaker
This is a broad stroke explanation of what happens in your body when tissues are injured so that you can make informed choices around what to do. If you already have specific advice from a doctor such as, you should not weight bear on this leg for the next six weeks, you should 100% do what they're telling you to do.
00:07:41
Speaker
In my discussion of this topic, what I'm really talking about are situations where it's not totally clear, where it's something where the pain is not that intense or you think you might be able to course correct around it. I am not talking about something like a broken femur or a concussion. Please consult a medical professional in person if you are unsure what to do.
00:08:07
Speaker
Okay, well that's my cover your ass taken care of. So for the purpose of this episode, we need to define what we mean by exercise, not in a general like what is exercise, which is actually a conversation that Laurel and I had in the very first episode of this podcast, believe it or not.
00:08:26
Speaker
But I'm defining exercise in sort of three categories so that you can think about not only should I exercise but what kind of exercise should I do. And so those three categories are external load, meaning a weight or a thera-band or something on the outside of you.
00:08:43
Speaker
Moderate to vigorous cardiovascular exercise, which is moderate is you can talk, but you can't sing. And vigorous is you cannot talk or sing while you're doing it. And the third category is using the body part that is injured.
Acute vs. Chronic Injuries
00:09:03
Speaker
So when I say exercise, I want you to think about it in terms of those three things. Load, heart rate, and using the injured area.
00:09:13
Speaker
For the most part, walking is always okay when you're injured. And if you're immediately thinking like, well, what if I have a sprained ankle? Obviously, some circumstances you might want to use an assistive device, a cane, a crutch or something like that, or you might be told to, or wear a boot or something. But it might be the best choice of movement, especially in the very early days of an acute injury.
00:09:39
Speaker
where maybe you've got a broken arm and you're going crazy and you're like, you know what? I just, I need to just walk and get some exercise. With that said, you could still do what I did when I got a grade two ankle sprain a few years ago. I got that ankle sprain by dropping my motorcycle on my ankle, which I don't recommend. And I got very mad at the poor timing of this accident and I walked and hiked on the ankle because I was mad.
00:10:08
Speaker
and I temporarily made it worse. So yes, walking is generally safest early on with an acute injury, but don't overdo it if your injury is somewhere on your leg or legs. Okay, so now we know what we're talking about when we're talking about exercise. Now we're going to get down into a little bit more of the nitty-gritty of different types of injury. So in terms of thinking about injuries as far as
00:10:35
Speaker
getting back to exercise, I'm going to separate them into two basic categories. Acute injuries and chronic injuries. The difference between acute and chronic is going to really give you some information about what to do because the definition in this case, the way I'm talking about it, is one of time. Meaning, how recently did this injury first occur?
Body's Response to Injury
00:11:02
Speaker
Acute injuries are ones that just happened recently. Let's say you missed a step going down the stairs and you sprained your ankle, or you caught your little toe on the edge of a table and you broke it, or you fell out of a window, caught hold of a nearby tree branch on the way down, dislocated your shoulder and then broke your leg when you landed.
00:11:25
Speaker
Sorry, I know that was kind of dramatic, but the first two that I gave you were little milk toast. Those are all examples of acute injuries. So the acuteness doesn't have as much to do with the severity of the injury as much as it has to do with how recently it happened. However,
00:11:43
Speaker
That's not to say that the severity doesn't matter because it absolutely does when it comes to any decisions you're going to make about whether it's a good idea to exercise. A splinter in your finger might not be a reason to not work out, but a major laceration that needs stitches might be a cause to rest or refrain from anything high intensity.
00:12:06
Speaker
So chronic injury now is something that's been going on for a long time, often as something repetitive. It's usually something where a particular movement or a particular position that you do repetitively is irritating your body in some way. So they are usually called repetitive overuse injuries. And it could be something like, I sit in one posture in front of my computer all day without changing position. And at the end of the day, I have neck and shoulder pain.
00:12:33
Speaker
or it could be something like, my shoulder generally feels fine, but every time I do my tennis serve, it hurts. So these are the cases where there may not be one single huge moment of trauma that caused the injury, but instead multiple small iterations over time. So I like to use the rope analogy for it. So if you imagine a rope and it's made up of say like 500 strands, an acute injury would be like taking knife and cutting through a chunk of the rope
00:13:03
Speaker
or possibly all of the rope, a significant enough amount that your body goes into injury response mode in a big way, five alarm fire.
Stages of Injury Healing
00:13:13
Speaker
Whereas a repetitive overuse injury might ping one strand each time you do it. For a while, the injury response is at a very low level and you might not even feel pain. Your brain might not notice it enough to decide that it's pain, but eventually,
00:13:31
Speaker
enough strands are broken that your brain sees it as pain and you experience it as such.
00:13:38
Speaker
Or another way you can have a chronic repetitive overuse irritation is you might have an old acute injury that healed, like a hamstring strain, let's say. But every time you go for a run now, you feel it again. Not as severely as the initial injury, but it keeps happening over and over. So while the original injury healed, it didn't heal to the level of being able to handle the higher demand of running.
00:14:06
Speaker
And so it's getting pinged each time you run. And again, just like acute injuries, chronic injuries have a severity level and that should also come into your decision making here. So if you're playing pickleball and every time you do an overhead shot, your shoulder hurts and it's getting worse each time, you might want to do another activity or refrain from overhead movements. And in the meantime, go to physical therapy, get it checked out, see if you can solve what's going on.
00:14:35
Speaker
Versus something like, let's say you plan on going for a run and you wake up that morning and your back is like a little bit stiff and it's kind of a little bit stiff every morning. You walk around, you stretch, you drink your coffee, you get ready, you put your shoes on, you start to warm up and the stiffness goes away. That would be a situation where, in my opinion, it's fine to run.
00:14:56
Speaker
And you may still want to see if you can do something about that back stiffness, if it comes up a lot, but you're not going to make it worse in the moment by exercising. So hopefully that makes sense. We've got these acute injuries that just recently happened.
00:15:11
Speaker
and we're looking at how long has it been since the injury and how severe it is. And then we also have this kind of chronic overuse, repetitive, you might not even think of it as an injury anymore. You might think of it like, oh, it's a bit irritating, but it keeps coming up over and over each time you do an activity, whether it's an old injury that just never fully healed all the way, or it's a new irritation that is just happening each time you do a certain movement.
00:15:38
Speaker
So in either case, your body has a injury response at a tissue level. And so now we're going to delve into that response mechanism.
00:15:49
Speaker
And like everything else, this is going to vary based on the severity of your injury in terms of the size, the volume of the response. Which means if you got a paper cut, you would not see your entire hand swell up. And if you did, that would be a really good sign to go see a medical professional because something is very wrong. So the size of the response on a tissue level should fit the severity of the injury.
00:16:17
Speaker
But as we will see, there are conditions and situations where the response is either outsized from the start or for some reason lasts longer than it should. So this healing timeline will also help you make your decisions around when to return to exercise as you can compare what your body is doing to the average response and see if you're at least in proximity.
00:16:39
Speaker
because there are also a lot of external factors that are going to play into your injury response time, your healing time. One of them is the older we are, the slower our response time becomes. You may have noticed this already yourself with simple cuts and bruises just taking a bit longer than it used to.
00:16:56
Speaker
And then there are things like nutrition, right? Is your body getting what it needs to be able to heal quickly and well? There are certain co-conditions like diabetes that play into slower wound healing. There's also things like premature physical activity, like super stubborn Sarah going hiking on a sprained ankle.
00:17:18
Speaker
Also, just to be clear, we're gonna talk about pain separately in a moment because that is not a, because your pain response is not something where it automatically fits the severity of the injury. But so here, we're just talking about the tissue response. Okay, so we can break it into three basic stages. So your injury response mechanism has a acute stage,
00:17:44
Speaker
a proliferative or repair stage and a remodeling stage. If everything is going as it should, your body will cycle through these stages appropriately. However, sometimes the healing process can get stuck in a chronic version of that last remodeling stage, or it can get stuck earlier in the healing process, either because of a co-condition
00:18:08
Speaker
or because of a circumstance, or because you're not allowing it to heal, or for some reason it gets stuck in one part of the cycle.
Pain's Role in Healing
00:18:15
Speaker
So we will address that as well. It's also really important to note that this timeline, it's averaged, meaning there's going to be individual variation from person to person. Okay, so stage one is our acute inflammatory stage. And that's usually the first like three to four days following the injury.
00:18:38
Speaker
And so what's happening here is inflammation. And one of the reasons inflammation is happening is because it's going to stabilize the area. In particular, it's going to stop you from immediately using the area too much and damaging tissue further. And so you're going to see swelling, redness, heat, and most likely pain. Although sometimes the pain doesn't show up until the inflammation has gone down.
00:19:06
Speaker
and the damaged tissues are more exposed. So what's happening in this inflammatory stage is your capillaries start to, that are damaged by this injury, they start to leak fluids and that causes some of the inflammation. And there's a specific kind of white blood cell that's called macrophage. And the macrophages go around, oh, this word is so hard, phagocytizing.
00:19:32
Speaker
And the macrophages go around basically eating up the damaged tissues and the waste products that come from the damaged tissues. And then these macrophages also produce enzymes that attract fibroblasts, which are the kinds of cells that build collagen. And they also produce a type of chemical called regrowth factor, and that supports tissue repair.
00:19:56
Speaker
So the worse the injury, the greater acute inflammatory response your body will have. But like I said earlier, the amount of pain you experience is not a one-to-one ratio of this much injury equals this much pain. And we're gonna talk about pain later because it does need its own category for conversation.
00:20:14
Speaker
So that's the acute initial phase that you're going through. The area swells up. It is hot because there's a lot of blood that's gone to the area to try to help with the healing process. It is red for the same reason and it is painful to some amount.
00:20:31
Speaker
So then we get to the next stage, which is called the proliferative or sometimes just the repair stage. And that is roughly three days to about six months following the initial injury. So during this phase, we see the initial collagen formation taking place that makes a connective tissue matrix. It's like if you were
00:20:55
Speaker
going to make a dress. And I don't make dresses, but if you ever watched Project Runway, you make a pattern first, right? And so that pattern is eventually going to turn into the finished product. But first you sort of lay out your plans, right? It's like a blueprint first. And then over time, during this period and the next period, that collagen
00:21:16
Speaker
And that connective tissue matrix hardens and becomes more consolidated and that's when we start to get things like scar tissue. So the tissues are breaking down and regrowing because they're reorganizing themselves into a cohesive shape before they get stiffer. But there's more growing going on than there is breaking down.
00:21:37
Speaker
And this is where external loads and forces in the shape of exercise, whether it's mobilizations, stretching, or some weight bearing, things like that, it's going to help the repair process.
00:21:49
Speaker
organize the tissues because the tissues are going to line up to meet the demands at that joint. For example, let's say I just keep going back to spraining your ankle because it's a pretty common thing, but let's say you sprained your ankle and then you stuck a boot on it and you didn't move it for three months. This is, by the way, not advised. I'm not saying that that's the right thing to do. It's definitely not the right thing to do. After three months, you take the boot off, your foot is going to feel very stiff and it's going to be unwilling to move.
00:22:18
Speaker
You're gonna have to go about a very consistent program to get the range of motion and mobility back into the ankle, right? so in that instance the framework of the collagen has started to solidify not completely but has started to solidify in a shape that has no Movement to it. So then suddenly when you take the boot off and you're like, oh actually I'd like you to do this ankle and
00:22:43
Speaker
The tissue is like, what are you talking about? We haven't seen that before. We've just been holding this one place. That's what you told us to do. Oh my God. Now we have to reorganize a different way. Right? So that's what can happen. Um, if you don't do enough exercise, but the flip of it is if you start overloading it or progressing it too quickly,
00:23:02
Speaker
During this phase you might reinjure it or you might lengthen the overall healing time because you're not giving it enough chance to spend time building the matrix building the the skeleton as it were in The way that it needs to like you're you're telling it. Okay, it has to do this It has to be able to move in this direction and support this kind of load, but it's like you're loading up The tissue paper version instead of the actual strong version and so it just keeps breaking
00:23:33
Speaker
So then over and over and over again, you're irritating it and it's never getting a chance to actually form correctly. That's if you overload too much, progress too soon, too quickly. So hopefully that makes sense. After this initial phase of the acute injury, once we get into this proliferative repair phase, there are negative consequences from not moving it and there's potential negative consequences from moving it too much.
00:24:00
Speaker
So it's always a little bit of a tightrope that you're trying to walk here where you have to figure out how much is enough, how much is too much. And my decision tree, just to plug my decision tree, that's going to help you actually with this figuring out the choices just based on things like what part of the timeline are we in and how severe is the injury and what's it looking like and what's it feeling like.
00:24:24
Speaker
So now, so we've had our first stage, that acute inflammatory stage, that sort of first three to four days, we have our proliferative or our repair phase, which is from that after that first three to four days to about six months post-injury. And now we get into our remodeling phase. Now the remodeling phase actually overlaps with the repair phase.
00:24:48
Speaker
And so the remodeling phase starts from about three weeks and it could potentially last all the way up to a year following your injury. Not that you're necessarily noticing it a year later, but it's still remodeling. It's still laying down. So essentially during this time, your body is trying to reorganize the soft tissue of the injury to make it as similar to the original tissue as possible. So the goal is for your body to have the least amount of disruption after this injury.
Chronic Conditions and Medical Intervention
00:25:18
Speaker
But because there is some damage that has taken place, there's going to be some amount of change that occurs that is unavoidable. So depending on the severity of the injury, this permanent change, it might lead to future issues down the line. For example, if you have a ligament that has been stretched beyond its capability,
00:25:41
Speaker
it has a permanent plastic change, meaning it no longer is able to stabilize as effectively as it used to be able to. And then that lack of stability can lead to some joint degeneration and arthritic changes in the joint. It might also lead to a joint that is easier to re-injure. So to give yourself a picture, a broad picture, we've got that initial injury phase.
00:26:09
Speaker
And then starting around day three, day four, your body is starting to rebuild the tissues, right? It's going in, it's cleaning things up, it's starting to lay down a framework for
00:26:21
Speaker
how it's going to most effectively heal as close as possible to the original tissue. And then depending on the appropriate forces, stretches, mobility, loading, all of those things, it's being encouraged to be as strong as possible in the way that the joint is being used or that the joint is used for your movements and for your activities. That's why we see that sometimes
00:26:50
Speaker
Exercising too much too early is not the right choice because it might just interrupt this process so much that it can never actually lay down a really clean framework. And then the flip of it is sometimes if you aren't doing enough exercise, that also means that your healing timeline is going to get extended because it's going to take longer now for the mobility to come back, for the range of motion and the strength to come back.
00:27:18
Speaker
if you have been immobilizing the joint for too long. Now, sometimes people like to point out that injuries heal without intervention after about a year, and this is true, they do. But that doesn't mean that in the case of a moderate or severe injury that you should just leave it alone and go about your business. You want massage, you want exercise, you want load, you want all of these categories,
00:27:43
Speaker
because that's going to get you the best possible results, which is hopefully what you want. If you just leave it alone, sure, it will heal, but it might never be quite right again, right? You might be like, oh God, it always clicks. Or when I go to do this sort of movement, I'm always worried that it's going to kind of give out. It doesn't feel very stable or it feels too stiff, any of those things, right? So we do want
00:28:06
Speaker
to have some sort of intervention but we just have to kind of make sure that we are timing it really nicely and you don't want
00:28:15
Speaker
to have an acute injury turn into a chronic repetitive injury either because you didn't bother to work on it during the healing process and so it healed in a suboptimal manner and then you repetitively re-injure it like the example of the hamstring strain that I gave earlier. Now, sometimes this healing process goes wrong and there's some very specific reasons or ways that it might go wrong. If it's delayed, for example, if the healing process is delayed for any reason,
00:28:43
Speaker
whether it's too much physical activity too early or too little physical activity at the appropriate time, we can get stuck in this chronic inflammation where the inflammatory response is just caught in a loop and it's just stuck there and it can't get out of that phase. Now, if we return to appropriate movement and exercise for the stage we are in, typically the process is able to return to normal, it goes through the whole phase and you heal the tissue.
00:29:13
Speaker
But there are times when an acute injury can actually bring on a more chronic condition. For example, sometimes shoulder injuries or shoulder surgeries can lead to adhesive capsulitis, which is frozen shoulder. It's sort of an outsized response from your brain. Oh no, something is happening to the shoulder. We better lock it down and so we're just going to freeze it.
00:29:35
Speaker
And then that's a whole new problem that you have to deal with less frequently, but it does occur. We see a condition called CRPS, which stands for complex regional pain syndrome. And that can develop in a limb or in a body part following a trauma or surgery. And this is a condition where the response, including the pain is outsized compared to the actual injury.
00:30:01
Speaker
So this is a situation where your your brain and your body are just really overreacting to the severity of the injury.
Biopsychosocial Model of Pain
00:30:10
Speaker
So you'll see things like temperature changes. This the area can be really hot or really cold. The skin will change color.
00:30:18
Speaker
It'll be like very red and purple. The swelling will be quite severe. The pain is usually quite severe, although sometimes this shows up without pain, which is another weird one. So this clearly is a condition that requires medical intervention and is not something that you should try to deal with on your own or exercise on. And I hope that's obvious.
00:30:40
Speaker
There are other non-typical responses that we can talk about, but that's going a little bit outside the scope of this episode. So I'm going to leave it there for now and just assume that we're talking about a body and a body part that is going through a pretty standard healing response, pretty standard timeline. Nothing is going awry. There's no outsized response. Everything's just going along as it should.
00:31:08
Speaker
We're going to leave this for now and we're going to switch focus because I want to talk about the role that pain plays in your injuries. This might sound like a weird sentence, but one of my favorite conversations I've ever had about pain was with Dr. Chris Rayner in Season 2 of this podcast, Episode 30, Lincoln Show Notes. He calls pain a low-level language that is telling you where to spend more time.
00:31:37
Speaker
I've also heard pain defined as your body's request for change, which I've seen attributed to Kelly Starrett, but I don't know if there is someone else who originally coined that phrase. And I think those are both great descriptions. What I really like about Dr. Rayner's definition is that he calls it a low-level language.
00:31:56
Speaker
Which in my mind gives us a sense of what kind of attention to give it and what I mean by that is By sort of lowering it on the validity scale We are in essence saying that when we feel pain our response should not be my body is requesting change Everyone stop what you're doing. It's a catastrophe ah
00:32:18
Speaker
which is, you know, sometimes how people respond when they feel some sort of pain in their body. But instead, in my opinion, our response should be more like, hmm, something's up.
00:32:28
Speaker
I need to take a look at this and see if I can figure out how and what I should change. And if I can't figure it out, then I'm going to seek some outside help. His point with this is that sometimes people think that they should never experience pain in their body, and it's just not true. I think we've sort of created a society where we're very afraid of pain.
00:32:50
Speaker
even sort of small, low-level aches and pains, we're pretty quick to think that something's desperately wrong and we're pretty quick to seek out, I don't want to be mean, but it does seem like for a lot of people, we're quick to seek out the fastest way to get the pain to go away, which is a different thing than actually working on healing whatever's going on, right?
00:33:09
Speaker
The reason why this is important, as I mentioned before, one of the really well-researched aspects, what we know about pain is that it is not a one-to-one ratio of this much tissue injury equals this much pain. This is because your experience of pain is completely subjective and it is not simply about the current damage to tissue that has happened, but it has a lot of inputs from a lot of different areas. This is called the biopsychosocial model of pain.
00:33:38
Speaker
which means there is a biological input, right? Any tissue damage that's going on. There is a psychological input. How is your brain explaining or reacting to what you're feeling? And there's a sociological input. What is around you? What is your support network? Things like that. So you may have heard Laurel and I talking about this in our recent episode about Dr. Stu McGill, which is episode 62, because he does not believe
00:34:08
Speaker
I just can't, the reason I start laughing is I find it unbelievable. He does not believe that something called non-specific low back pain exists, which is the kind of pain where there is no immediately obvious tissue damage. He does not believe in any back pain or I would imagine pain of any kind that does not have a
00:34:29
Speaker
Really strong mechanism of injury so he is all bio and really none of the psychosocial and if you're like what are you talking about go back and take a listen to the episode because
00:34:41
Speaker
I think we explain it pretty clearly. So let's give ourselves an example of this, you know, pain to injury ratio and what might be all of the inputs going on. You know, I keep coming back to the sprained ankle because it's pretty common. And it's also a pretty common injury to have more than once. So let's say in this example, this is the third time.
00:35:01
Speaker
you sprained your same ankle while you were running. Let's say you stepped on a surface that you did not navigate properly and your ankle rolled and you sprained it. So physically your body is going to have the tissue mechanism response that we talked about earlier. It's going to go through all three stages. Mentally, however, psychologically, there's all kinds of things that your brain and the rest of your nervous system will get up to. So as part of the determination of how painful is this currently,
00:35:31
Speaker
your brain is going to start comparing it to previous times that something like this happened and how painful was that and what emotions came up then. And it's also going to start storing all of this sensory information for future comparisons. Your amygdala in your brain will get pinged by it, which is your fear and anxiety center.
00:35:53
Speaker
And you might start thinking, oh God, this is always going to happen when I run. I should stop running. I can't stop getting injured. Am I going to be able to do that 10 K that I signed up for that's next month? Right. You're having a response where you're comparing it to previous responses and calibrating, let's say, how much pain you're feeling based on that, because the more stressed out and anxious and fearful you are,
00:36:16
Speaker
the more you feel your pain. And this has been researched. And there's also the psychological component of your memories, like how was pain dealt with in your family growing up, right? Was it something that you were told to just kind of, you know, brush off, suck it up? Was it calamitized?
00:36:35
Speaker
I don't think that's a word. In an outsized way, whenever anyone hurt themselves, was it a big deal? Was your family like Patrick Swayze in the movie Roadhouse, where he tells the very beautiful doctor in the local small town ER that pain don't hurt? Or was your family more like everything hurts and I'm dying? That's the psychological part of the pain experience that is inputting into this current injury and
Exercise Decisions for Acute Injuries
00:37:05
Speaker
helping you determine, or maybe it doesn't feel like it's helping, but it's making you determine how bad this feels. And then the sociological part has to do with the people around you. Do you have good emotional support? Do you have friends, family, community?
00:37:21
Speaker
someone to help out now that you can't walk the dog, things like that. And if not, you might start to experience more stress if your injury means that, for example, you can't do your regular day-to-day activities or you're going to have to now hire a dog walker and that's going to cost money, right? That kind of thing. All of these elements will play into your experience of pain.
00:37:42
Speaker
and potentially make it feel worse or better, depending what your brain concludes about the event and how it's impacting your life. And, you know, there's ways to intervene, as it were, to kind of talk back to your brain and find more objectivity if your pain experience is really oversized.
00:38:04
Speaker
But some amount is appropriate, depending on what you've done to yourself. And that's okay. That's to be expected. Now, the way that pain impacts a person's return to exercise means that some people will undervalue
00:38:19
Speaker
the amount of pain that they're experiencing and they will exercise more intensely than appropriate or earlier than is appropriate. Other people will fear the possibility of making things worse and will rest for excessive amounts of time. I see examples of both of these in the clinic.
00:38:35
Speaker
And this is not a scientific analysis, but my experience has generally been that people who put off exercise or stretching or physical therapy tend to make things worse for longer than people who accidentally exercise too early, push a little too hard and then regret it.
00:38:52
Speaker
Now, I'm not talking about something like Carrie Strug. Some of you may remember this, the gymnast who was in the Olympics and basically did, I think it was a vault on, I believe, a broken ankle. That is an extreme athlete example. Probably must have ended her gymnastics career or close to it. So when I say accidentally exercised too early, I mean like went for a walk that was a bit too long or
00:39:19
Speaker
started lifting weights and discovered that that made it feel worse, something like that, where it's like you tried something a little bit too much, discovered it was too hard, maybe made things feel worse for a while, but the amount of time that that is adding to the healing process, this is not a scientific analysis, so please do not take it as such, but my experience has been that those people don't disrupt the timeline quite so much as the people who maybe show up three months after an injury happened,
00:39:48
Speaker
and haven't done anything at all in that time. Now, we're seeing this switch of valuing movement versus valuing rest a lot in the medical field. We're seeing it in post-surgical protocols in hospitals.
00:40:05
Speaker
Patients often were previously told to rest a lot after surgery, and nowadays, depending on the surgery, some doctors will have patients up and moving, potentially walking, the same day that they had their surgery. When I had my hip replacement in 2012, they had me walking the same day.
00:40:25
Speaker
They actually gave me the option to leave the same day, but I decided to stay because hospital food is amazing. No, it was because I thought that, you know, on the off chance that something went funky the very first night after surgery, I didn't want to not be close to a hospital. So now if we're considering this, should I rest or should I exercise question, we have to consider it against some of these criteria that we've discussed. So let's begin.
00:40:53
Speaker
by talking about your decision making with an acute injury because it's going to be a little bit different than your decision making with a chronic injury. So if you are in the first three to four days following a pretty severe injury, not hospital requiring, but acute, something big happened, a sprain, a strain,
00:41:15
Speaker
a fall where you bruised really badly, essentially anything where we're seeing visible swelling, bruising or redness and pain, then you should rest in that first three to four day period and actually really rest. Maybe take a little bit of a walk here and there, but your body in that acute period, it needs to be sending a lot of blood and energy and materials to that injured area.
00:41:43
Speaker
The exercise we do is going to use up some of that energy available. But as I was saying, this might be a great time to just walk because bodies do crave movement. And if you are sitting around all day with a sprained wrist and not exercising at all, you're going to start to have aches and pains in other parts of your body from disuse. So walking is a great option here or some other low level
00:42:06
Speaker
cardiovascular exercise. If we're talking about our three exercise options, we talked about load, we talked about cardio, and we talked about direct use of the affected area. In this instance, we're not going to use the area. We're not going to load because that's going to require too much energy getting shunted away from the healing process.
00:42:27
Speaker
And so would any moderate or vigorous cardiovascular exercise. So in the first few days, you're keeping it very gentle. You're moving enough that you don't feel aches and pains in other parts of your body, but you're not using up the energy that your body needs to start the healing process well. So here's our first potential decision in the decision tree.
00:42:48
Speaker
So we're going to say during the acute phase of an acute injury, gentle movement of the unaffected parts, that's our plan. Now, if we continue with our healing timeline, let's say we are in that second phase, the proliferation or repair phase of our acute injury. It's been over a week.
00:43:08
Speaker
the swelling and the redness mostly have gone away great now we can start to use the affected area now you're probably depending on the severity but most likely you're going to want to start with no weight or body weight only for the affected area specifically
00:43:25
Speaker
But for the rest of your body, you can start to reintroduce things like load and cardio in ways that don't use the area. So a week following a pretty severely sprained ankle, you're not going to load up your deadlift to, you know, your one RM, but you might start to do body weight exercise. You might start to do your deadlift shape, but unweighted or
Exercising Through Healing Phases
00:43:51
Speaker
you might increase your cardio in a way that doesn't put more load through the ankle, like a stationary bike or a rowing machine instead of switching from walking to jogging. That's if we had a lower body injury. If you had an upper body injury, you might reverse it. So you would pick some sort of cardio that didn't bother your arm, right? So then you might
00:44:13
Speaker
depending, you might feel like you could go for a jog and you might even do some weights for your lower body, probably something like a machine at the gym where you don't have to involve your arm, right? A deadlift might not feel great at this point with a barbell. You might be able to tolerate a back squat using a rack and you might figure out some simple either body weight work or less than body weight work like a plank on the wall for the affected upper body injury.
00:44:42
Speaker
This is where, in this second phase, this is where we start to consider our three options and figure out ways to make it work with the body part itself. We will start to introduce movement into the body part but not load, possibly body weight, depending on how severe it is, but possibly not even body weight. We are going to introduce more cardiovascular exercise to the rest of your body in a way that's not going to irritate
00:45:08
Speaker
the injury and we're potentially introducing more load into the rest of the body, but also not in a way that's going to irritate the injury. So hopefully that makes sense. Now, obviously, and I hope this is obvious.
00:45:22
Speaker
If you start during this phase trying something a little more vigorous and you have an immediate spike in your pain or sharp pain when you're doing it, you should stop. If you have a bit of a dull ache afterwards, that is to be expected and not something to worry about. And on the pain scale, the pain scale is such a tough tool. If you're not familiar with the pain scale, it's a scale from zero to 10.
00:45:47
Speaker
of how much pain you're having, 0 being no pain at all, 10 being the equivalent of somebody sticking a rusty knife in your eye. It's not great for comparing people to other people, but it is useful for comparing yourself to yourself. And so a dull ache is something that I would call under a 4 out of 10 on the pain scale. Now, that's just kind of my specific number. You might think of it as a 3.
00:46:12
Speaker
or you might think of it as a one or a five. Whatever to you feels like, ah, yeah, a little bit more than just post-exercise soreness. It's a little achy, might feel a little throbbing, right? That's just your blood going to the area. This is to be expected and this is not something to worry about.
00:46:29
Speaker
A little bit of an increase in a generalized, dull way of your pain post-exercise, or maybe even during the exercise, is okay. Returning to exercise from an injury is not going to be a totally pain-free experience, but the type
00:46:45
Speaker
and the timing of the pain matters. Sharp pain at the time of the exercise suggests that there's some kind of tissue that is getting aggravated or there's just something about it that your body's not liking and that's an instance where you should stop and say, okay, I'm trying a little bit too much too soon. A generalized dull ache either during or directly afterwards or maybe even the next day is totally okay.
00:47:08
Speaker
And it suggests that yes, the area was working, but the amount of work, the amount of load, the type of work, the type of load was tolerable. So then continuing our timeline.
00:47:20
Speaker
Now we are going to get into the remodeling phase. It's been over three weeks since the acute injury. Swelling and redness are gone or mostly gone. Pain is mostly gone. Now we can start to rebuild in a more concentrated way. And you can think of this time as going back to what you were doing previously, but with regressions that you will then build back up from.
00:47:45
Speaker
So let's say previously you were running five miles three times a week and then you sprained your ankle but at this three week mark it wasn't such a bad sprain. You feel like maybe you could start moving it again. You might start with 20 minutes of light jogging or alternating walking and jogging and build back from there.
00:48:07
Speaker
If you were weightlifting and you were squatting 100 pounds previously, you might try 50 pounds or 25 pounds and build back from there. It's all going to depend on exactly how severe the injury was and how well it's healing. And that might be something that you end up having a little bit of trial and error with. You might decide, OK, I'm going to try a little 20 minute jog. And at minute eight, you're like, you know what? I think I'm done. And then that's where you stop. Right.
00:48:36
Speaker
So it's important during this phase not to decide ahead of time what your body is going to be able to handle, but have an objective, have a plan of what you're going to do and be ready to totally
Addressing Chronic Injuries
00:48:48
Speaker
scrap it. If it turns out it's a bit too much too soon. And then, you know, at this three week point, if you don't know how to progress properly, if this is not something you've done a lot of work on yourself, or if you feel like you just kind of want some expert advice or another set of eyes on you,
00:49:04
Speaker
might I recommend that you seek out a physical therapist because we do this for a living and if you're nice to them they might massage you as well which makes everything better. In all seriousness though prior to the three-week mark of an acute injury you can still go to PT but they're not going to be able to do very much because they're also working off this same healing timeline and know that their interventions
00:49:27
Speaker
prior to that three-week mark need to be on the gentler side. So it may be something like very gentle range of motion or massage or things like that. With that said, if you feel that this particular injury is too much or too complicated to try to deal with on your own, go to a physical therapist. We're here to help you. So now, what if it's a repeat of a chronic injury?
00:49:53
Speaker
that nagging hamstring strain that you've had forever that just keeps coming up with certain types or certain amounts of exercise. Well this is going to require a different approach because now we're getting stuck somewhere in that remodeling phase where it never fully rebuilt the capacity to tolerate a certain amount of stress and load and every time you go over that line you have pain.
00:50:18
Speaker
So here, since we're not dealing with the acute injury issues of swelling, redness, pain over 5 out of 10 level tissue damage, we can go after figuring out why this continues to happen pretty quickly.
00:50:33
Speaker
And I want to say as well, if you are having swelling and redness and pain over five out of 10, you should seek out medical attention. I'm not talking about that. I'm talking about what people describe as feeling activated, which to be honest is not a word I totally understand in this context, but I know that they know what they mean. Or I have one patient who says their piriformis is barking at them.
00:50:56
Speaker
So you're feeling it, no doubt, but this isn't the first time you felt it, nor is it the most extreme. You may need to rest a bit or take a break from the specific activity or intensity level that lights it up, but here we're going to be doing a little bit more sleuthing because unlike an acute injury where we can really clearly see and state what happened, I rolled my ankle, I injured it, right? With a chronic injury, we need to figure out why it keeps getting irritated.
00:51:25
Speaker
One common possibility is that there is some kind of compensatory pattern going on in your movement that is causing this part of your body to overwork again and again during this particular exercise, and getting it to feel better will require figuring out what area
00:51:42
Speaker
is not doing the work it's supposed to do. Sometimes it's as easy as trying a movement on one leg versus the other and seeing what happens. Something like a single leg bridge can be very revealing where the unaffected side is actually weaker than the painful side. I see this all the time in the clinic and it often blows people's minds that their painful side is actually the stronger one.
00:52:08
Speaker
And the reason it's happening is that the painful side is doing double the work that it's supposed to because the weaker side is not keeping up. And as a result, the stronger side hurts. If you can figure out a way to use one side versus the other to compare something, sometimes that's enough to uncover the cause. And that's a pretty easy fix because then you just focus on strengthening the weaker area or areas. Or perhaps there's pain because for whatever reason, there's some reduced mobility in the area.
00:52:37
Speaker
you may not have as much flexibility on that side as you do on the other because it's an old injury and that old injury brought with it some limited range of motion. You might try a certain stretch on one side versus the other and then that shows you something interesting to work on. I'll have people do a figure four stretch and it is eye-opening. How many people have a very different experience on one hip versus
Decision-making and Seeking Medical Advice
00:53:03
Speaker
the other.
00:53:03
Speaker
Now another possibility is that your body is not able to keep up with the exercise specific demands of your activity and is just defaulting into this one area of your body and continuing to light it up. So for example, if you've recently started running and you're getting hamstring pain,
00:53:22
Speaker
maybe you need stronger lateral hip muscles or you need to work on your calf strength or try more single leg workouts those are all sort of classic things you might work on for running so this is a great time to look for resources online for training for particular types of exercise and there is tons and tons of stuff out there you can literally go to youtube and type in
00:53:44
Speaker
training for kite surfing or whatever your thing is that you like to do. And you will get back a lot of, maybe not so many for kite surfing, I don't know, but you'll get back a lot of results and then you can compare and see, okay, well, what exercises are coming up in all of these different tutorials? Speaking of tutorials, Movement Logic has six tutorials that might help you with your pain in your body. I didn't do that on purpose, that was an accident, but I'm gonna leave that in.
00:54:13
Speaker
so you can try out some of these these tutorial movements and if you get that kind of a wow i had no idea that my calf muscles were so weak or so tight or so different from side to side you'll know that you're on the right track anything that gives you sort of a whoa i had no idea that's generally a good sign that that's your missing link
00:54:34
Speaker
And if none of these strategies show you what you need to work on, or you don't feel comfortable going through a little trial and error, you should go to a PT and they will know how to uncover what's really going on. Even PTs go to other PTs because we know a lot, but we can't always see what we're doing that needs adjustment.
00:54:54
Speaker
My physical therapist, who's actually a friend of mine from school and a work colleague, calls my body a Rubik's Cube because there are so many different things going on and influencing my movement. It's a real head scratcher sometimes. You too might be a Rubik's Cube, especially if you try out some of these ideas to work it out on your own.
00:55:14
Speaker
and you don't really get anywhere or you don't uncover anything that feels easy enough to work on. That is our decision-making process for acute and chronic injuries, and this is available as a flowchart if you like visual guides. Just make sure that you sign up for the bone density course wait list and you will get it in a future email that is going to the wait list only. Now, I also have to mention some situations where you should take yourself immediately to a medical professional.
00:55:43
Speaker
This is not supposed to freak you out, but I would not be doing my job if I didn't educate you about these. So the first category is nerve involvement. This would feel like electricity, zinging, tingling, sometimes pain, sometimes numbness. It might be a constant feeling or it might happen with a particular movement or position. This is telling us that a nerve is getting pinched somewhere and it would be a good idea to rule out
00:56:10
Speaker
something like a disc herniation or a stenosis. In particular, if you're feeling these sensations on both legs or both arms, that is a definite go see a doctor situation. Nerve involvement can also look like sudden muscle weakness. And I mean sudden, not like I haven't worked out as much and I'm not feeling as strong as I did a month ago. I had a patient recently who just woke up one day with a lot of leg pain and couldn't walk properly.
00:56:37
Speaker
And when I tested their muscle strength in certain positions, it was extremely low. I recommended they go to a spine doctor as all the signs pointed towards some sort of disc herniation that was pressing on a nerve and causing their extreme pain and extreme weakness. That's a bit of an extreme example, but it can happen with nerve involvement. And of course, it's different than that sort of, oh, I just overdid it where you wake up and you're sore and stiff. This was very sort of sudden and out of the blue. Another situation
00:57:06
Speaker
where you are going to want to take yourself to a doctor is if the pain is constant, getting worse and or bad enough to wake you up in the middle of the night. So sometimes when people are having pain and you try to help them figure out if it's if the pain is constant sometimes it seems like it is but when they sort of you know consider it a little bit more and they realize it's not the constant same level it'll like go up and down it'll go up if I do this kind of activity it'll go back down if I
00:57:34
Speaker
don't do that activity or if I rest. There's also like, is the pain waking you up in the middle of the night or are you shifting position and that shift in position irritates something and that wakes you up, not just without even moving, you're waking up because you're having pain. These point to a possibility of some diseases that affect visceral organs that then their pain masquerades as musculoskeletal pain
00:58:02
Speaker
but there is no actual musculoskeletal source. It's a completely different source. Another situation would be if you have been in a car accident or some other kind of vehicular accident where you were in the vehicle or you were a pedestrian or someone on a bicycle, any sort of vehicle related accident, I would recommend going to a doctor, especially if you go through any kind of whiplash
00:58:25
Speaker
or if you were not in the car but you were a pedestrian or on a bike or something like that because there's a checklist of things to go through to make sure that you didn't get a concussion or any kind of other brain or spinal cord injury and in my opinion it's always worth getting it all clear rather than just hoping it wasn't too bad.
00:58:44
Speaker
Okay, that's the end of my dramatic interlude. And again, I'm not trying to freak you out, but as much as I am in favor of empowering people to make decisions about their bodies, I have also seen, sometimes doing your own research is not a good idea.
00:59:01
Speaker
Okay, if you've listened to this whole episode and you're thinking, you know what, all of this makes sense, but I would rather go see someone to help me with this, then you absolutely should. There is no pressure for you to figure this out on your own, especially when there are lots and lots of professionals out there who can help you. Or maybe all of this makes sense and I can follow along, but there's something weird about this particular situation and I can't put my finger on it, then you should absolutely go see a doctor.
00:59:28
Speaker
The TLDR of this whole episode is, if in doubt, go see a doctor. Personally, I would rather go see someone and have it turn out to be nothing than to not see someone and have it turn out to be something.
00:59:42
Speaker
I know that there are certain people, certain personalities for whom that is not the case or they feel like they don't want to waste their doctor's time or they'd be embarrassed if they went to the doctor and they were like, no, that's not a tumor. That's your elbow. I mean, I don't know. My feeling is like stuff can happen. I'd rather have a professional tell me, no, it's nothing.
Closing Remarks and Audience Appreciation
01:00:02
Speaker
All right, friends, I hope you enjoyed this episode and that even though injuries can be frustrating, there is always a pathway for your healing, and I hope that feels a little more clear now. You can check out our show notes for links to all of the references I mentioned in this podcast, including
01:00:21
Speaker
the link to sign up for the waitlist for the 2024 cohort of our bone density course. And it's the only place that you can get a discount on the course. And it's the only place that you can get the beautiful decision tree that I made that I am quite proud of. And I want lots of you to see it.
01:00:39
Speaker
So go ahead and sign up and you'll get the decision tree and you'll also get other freebies along the way. It's totally worth it. Thank you so much for listening. And finally, it helps us out a ton. If you like this episode, please subscribe and rate and review it. So as the kids say, smash that subscribe button. I don't think the kids say that. You know how to get in touch with us. We love hearing from you. So keep in touch. Can you tell that I never really know how to finish? We will see you in two weeks.