MODIFYING WORKOUTS FOR ATHLETES WITH PAIN

The Athlete in Pain

As coaches we tend to see a lot of athletes in pain. It’s just part of the game and it’s going to happen. Some athletes may already be in pain when they join the gym. Others may get painful while training. It isn’t your responsibility to get people out of pain but you’ll certainly be faced with working with this tricky population. The rst step to success in this area is understanding what pain is. Once we understand what’s happening with our athletes in pain this knowledge can better guide us with their training. So, what is pain?

Pain is a defense mechanism in our bodies. It is a normal and desirable process that helps to keep us safe. Imagine walking on a beach and stepping on a shard of glass. You’d feel pain, get the glass out, clean the wound and then pamper that area for the next few weeks until it was healed.

In a world without pain you may step on a shard of glass and continue walking without any type of warning. Suddenly you’d pass out catching a glimpse of the trail of red blood behind you as you hit the ground. If you had a friendly sign to let you know something was wrong, you’d have faired much better in that situation. Pain is there to help keep you safe. It is a good thing to have.

The problem is training with pain. Training with pain is not normal and the pain felt is our body trying to notify us of something. Sure, having muscular soreness after training and the discomfort of fatigue while training is normal, but don’t kid yourself. If you or one of your athletes are having pain, we need to do something about it. We can’t ignore it and hope it goes away. We’re better coaches then that.

Pain is all created by our brains. If we had no brains, we’d have no pain. We used to think that we had pain receptors in our bodies that when stimulated automatically sent a pain signal to the brain and we felt pain. Now we know that this process is a bit more complex.

In our bodies we have small receptors in all of our joints and muscles called nociceptors. The job of these nociceptors is to send potentially damaging information up to the brain. In the case of the glass in your foot, nociceptors were activated and they sent this information to the spinal cord. Once this information gets to the spinal cord it is processed again and if deemed worthy continues to pass to our brain. Our brain then processes this information again and determines if the information coming from the foot is worthy of creating pain.

Having a large shard of glass in your foot creating substantial bleeding is certainly something that is alarming to the brain. Because of this we’ll most likely experience some pain.

In our bodies we have thresholds for pain. Take sitting on a hard rock for example. If we sit on a hard rock there is surely less blood ow that gets to the muscles of the buttocks. If we sit there motionless for hours we’ll develop a pressure sore.

However, we don’t feel pain as soon as we sit down. As soon as you sit down the nociceptors are send- ing information to the brain that the buttocks are not getting blood ow. Initially this is not dangerous and our brain chooses not to produce pain. Five minutes later we continue to sit pain free on the rock. All the while these nociceptors are sending more and more information to the brain. Another 5 minutes go by and now your buttocks are starting to get sore.

You’ve reached a threshold where now the brain is concerned you’ve been sitting too long and it’s time to move. What important to understand in this situation is that there is a threshold for when pain starts.

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This doesn’t necessarily mean that you’ve caused damage to your butt muscles just yet, but if you con- tinued then there is a good chance you will. Once again, your brain is trying to protect you.

The same thing goes for too much work in the gym. Let’s say you’re doing a lot of squatting one day in the gym. At rst your knee feels ne. After a few sets the knee starts bothering you and continues to worsen as you continue working through the pain. You’ve hit a threshold and now your brain is giving you the signal that something is wrong and expects you to change your activity because of it.

Let’s continue with the above squatting example. Let’s say you continued squatting through the pain. Now your knee is irritated and for the next few days is sore with squatting, lunging and going up and down the stairs. What is happening now is that your knee is extra sensitive. After an injury your brain is attempting to protect you. It creates pain so you don’t go ahead and do anything stupid that may cause more issues in your knee. Because of this certain movements like squatting and stairs can make you more painful.

Pain in your body can be thought of as an alarm system.

Before Pain

Pain Treshold

Running

Lunges Loaded Squats

Stairs Walking

Painful Movement

Before you’ve experienced any pain in your knee (prior to your squatting incident) you’d have to do a lot of knee intensive work to ever experience any knee pain. Perhaps you’ve never experienced knee pain before despite all of the training you’ve done in the gym. This is the situation displayed above.

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After Pain

Running

Lunges Loaded Squats Pain Treshold Stairs Walking

After you’ve gotten an injury your knee will most likely feel more like this image. You might be able to go up and down the stairs and walk without pain but anything that stresses the knee in the gym hurts. Basically you can’t do much before you hit a threshold and the knee starts hurting.

So how do we address this sensitive knee?

Well, to start we need to de-sensitize the system. Pain is all generated by the brain. Your brain can be thought of similar to your boss at work. Let’s say I go to work late every day. I don’t get my work done on time, customers are complaining about my attitude and I’m not completing my work projects in a timely fashion. If my boss didn’t re me outright, he would certainly be on my case about everything. He’d regularly check my time card, double check all of my work and monitor interactions with custom- ers.

Now, what if I started doing my job properly. Let’s say I started showing up early, completing all of my projects in time and started getting rave reviews from customers. My boss would be happy with me and stop checking in on me so regularly.

Pain in the body works in a similar way. If I stop doing irritating movements that create knee pain, work to x any strength de cits or imbalances and slowly work my way back into the previously offending movements my knee pain will potentially go down. Just like at work, if you do everything correctly your pain levels should go down much like your boss will leave you alone if you’re taking all of the steps to improve.

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Our goal is to be like the stellar employee. We want to gure out what is good for the knee and what isn’t and begin down the path of getting better.

What is Pain for Our Athletes?

As we spoke about earlier, muscular soreness or discomfort that comes with fatigue while training and in the 48 hours following exercise is normal and desirable. What isn’t normal is any sort of pain that isn’t associated with normal training discomfort.

Your athletes need to know what is alright and what isn’t. Here are a few examples of situations that you shouldn’t be training through:

• Any sort of pain not associated with muscular soreness or training fatigue is not normal
• Having sore and achy knees the day following a squat workout is not normal (Some people don’texperience any pain during training but experience pain the following day instead)
• Needing 20 minutes to loosen up a “tight” shoulder joint so that you can train normally is not normal
• “Tightness” felt near a joint that isn’t felt in the right area is not normal◦ Tightness felt in the top of the shoulder during kipping or overhead press◦ Tightness felt in the front of the hip during a deep squat
• Pain or discomfort that forces you to change your technique during lifts is not normalKeep in mind that pain is very subjective and will vary greatly from person to person. You’ll most likely see individuals that call their muscular soreness (delayed onset muscle soreness) extreme pain and then on the other side of the spectrum those that don’t call anything pain unless it is greater than 7/10 on a pain scale. For some of these individuals you’ll have to dig a bit deeper to see if they’re really ex- periencing something they shouldn’t be pushing through.Another interesting phenomena is that some people feel no pain in their bodies while training. They feel it more that night or in the following day or two. These individuals need to take note of the movements performed the day prior and use a bit of detective work to determine offending movements.How Do We Get Out of Pain?

  First of all, if you or any of your athletes are ever concerned they are experiencing pain, it is always a smart idea to refer out to a healthcare practitioner trained to help these people. Pain is complex and there are people out there that have devoted their entire career to helping these people out. Developing a network of healthcare professionals to treat your athletes in need is helpful for a variety of reasons:

  • It shows you care about athletes enough to point them in the correct direction
  • Athletes get better faster (or they get better when previously making no progress or worsening)
  • They get peace of mind that nothing more serious is occurring in their bodies (And if there is thenthey’ll know it and the proper steps can be taken)
    After you’re working with a knowledgeable provider, our goals are to:

• Take away offending movements

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• Reduce the alarm system and allow tissues to heal (Remember the boss example from above) • Re-build capacity slowly and progressively

Over time things heal if the problem is not exacerbated, the offending issue is dealt with and the brain doesn’t perceive a threat anymore.

At the most basic level we’re trying to calm things down and then build them up afterwards.

What is the Doctor’s Role?

A pretty universal piece of advice for people in pain is to see a quali ed healthcare professional. Coaches need to recommend their athletes go through this step. It’s a no brainer and should be done. However, it can be a frustrating process. Often times a physician’s advice will be to stop performing the activity that created the injury in the rst place, often blaming the activity for the problem. The physician can also blame the coach and the training program which creates distrust between the athlete and their coach.

• “Oh, you were doing kettlebell swings? Of course that’s why your back hurts”.
• “You lifted how much? No wonder your knees hurt. You guys really help us stay in business”.Another common situation is having a physician with little to no experience treating athletes that enjoy engaging in intense weight training and tness. Sometimes this leads to poor advice coming from the physician and poor patient progress.

• “Now I don’t want you to go back to the gym and doing any clean and snatches.”
• “Now when you go back don’t lift anything heavier than 25 pounds”These recommendations obviously are not helpful but it happens frequently. This leads to more distrust between coaches and healthcare practitioners as well as equally confused and frustrated patients. Finding a quali ed professional who understands the athlete’s sport, trusts the referring coach and is willing to work toward the patient’s goals is a must. You’ll de nitely have to search around for good doc- tors, but when you nd one it will all be worth it.So What Can a Physician Do for Your Athletes?1

  One of the most important things these professionals can do is to get athletes out of pain. The goal
  is to drive down the alarm systems in the body so athletes can get back to what they want to. These practitioners are experts in techniques to speed the rehabilitation process up and provide short term relief. Common treatments may consist of soft tissue work like massage, instrument assisted soft tissue mobilization, dry needling, pin and stretch, joint mobilizations, manipulations and stretching. These techniques seek to reduce sensitivity and can be a pivotal piece of rehabilitation.

Get Athletes Out of Pain

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A good practitioner serves as a coach for the athlete in pain. They determine which movements are good to perform in which amounts and what frequencies. They know when to push their athletes and when to back them off. They’ll know the right modi cations to use and how to progressively return to previously painful movements.

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Bodyparts don’t start hurting for no reason. These practitioners serve as detectives in the process of guring out the root cause of an athlete’s pain problem. A savvy practitioner can accurately determine the area involved in the injury, the mechanism of injury (how the injury occurred), the reasons why the athlete got injured and come up with a plan of care to return the athlete back to training.

Therapists and chiropractors are experts at evaluating movement and identifying causative factors for the injury. Maybe this is a strength issue or imbalance? Perhaps the athlete has not build enough tissue capacity for the amount of training they’re currently attempting? With this information they can provide a treatment program to get the athlete out of pain and keep them that way with training.

What is the Coach’s Role?

Now that we’ve referred out and found help for our athletes we can get to the juicy stuff. What can we do as coaches? Well, we’ve already started on the path. The rst step is simple, we just need to under- stand what pain is. We’ve already covered this in depth in the chapters prior. For a refresher head back to those sections.

Next we need to determine who’s actually having pain. This may sound silly, but it’s often unclear from a coaching perspective. At the start of each class I coach I like to ask if anyone is hurting today or if any of the movements in the workout look like they’ll cause any pain.

This may seem pretty straight forward but often times athletes in pain won’t speak up. Some people ex- pect to have pain while training and accept it as normal. Some athletes are intimidated by the coaches and don’t want to admit pain. Others just don’t want to inconvenience the coach with their issues.

As a therapist I listen to a lot of histories of how these injuries start. There is generally a period of time where these injuries are developing and communication between the coach and athlete is lacking. Over time the pain gets bad enough where it’s not a simple x anymore and they’ll speak up to someone. You might have to dig a bit deeper to nd these athletes and develop a culture in the gym that is sensi- tive toward handling athletes in pain.

Another useful tool for the coach is learning what an athlete in pain looks like. A wincing face could be a sign of fatigue or a sign of pain. Other athletes will rub a sore joint after an aggravating movement. Some athletes will perform extra “warm-up” for a “tight” joint throughout the session.

Pain also changes movement. If you see an athlete shifting their weight to the right when squatting

Evaluate the Athlete

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perhaps the left knee hurts and they’re of oading the painful side during the movement. Some athletes might short the backswing of a kip not because they’re stiff but because that extra movement causes pain. Maybe the lacking depth in a squat is due to pain in the hole and not a lazy athlete. The rst thing to do in this case is to ask if pain is creating this problem. If pain isn’t a player then we know we’ve got to correct their technique, give a regression or prescribe some mobility depending on the situation. If we treat a pain problem like a mobility problem then we aren’t being effective coaches. We may even be making the situation worse.

Again, each athlete is an individual. Some athletes will only report anything over a 9 out of 10 as pain. Everything else is tightness. For others, sore muscles from training are extremely “painful”. You’ll have to read the athlete and give the right advice. This is certainly an art.

Also remember that joint pain the day following a training session is not normal. For example, some individuals with knee pain won’t feel any pain during a training session but will have sore knees the following day with stairs and deep squats. Athletes need to be educated that this is not a normal or favorable thing.

Athletes also need to be educated about where they should feel stretches and strength training move- ments. It sounds silly but some athletes will think pain is the “stretch or stress” sensation they’re looking for. Some examples:

• A pinching sensation on the top of the shoulder during “lat” stretches
• Tightness in the front of the hip during deep squats
• Tightness behind the knee cap during deep squats and lungesIf you nd an athlete with issues as explained above, it’s probably time to refer out to a physician.After we’ve referred out, what’s next? For one, open up a conversation with the treating professional. It’s going to be a bene cial conversation for all parties involved. The therapist gets valuable information about the athlete from you. The therapist can give you their opinion, what to focus on and what to avoid for the time being. Having a coach as well as a therapist pushing the athlete to perform their home ther- apy exercises helps to improve compliance. The athlete feels cared for and is excited that they’ve got an entire “team” working on their injury and goals. Ultimately this communication sets the athlete, coach and treating professional up for successful rehabilitation.Next our job is to allow things to settle. We’re looking to decrease the alarm system. One of my favor- ite sayings comes from my mentor and physical therapist Mike Reinold. We’re looking for “addition by subtraction.” Basically what that means is that by taking away offensive exercises and lifestyle activities we allow things to settle and make progress. Particular movements or habits (think sitting for low back pain) can keep an area sensitive. If we remove them we progress by the virtue of elimination.

  If kipping pullups create your shoulder pain and we continue pushing through them your risk of hurting yourself further increases. If we take them out of the program temporarily, we start slowly feeling better. Just keep in mind that simply taking offending exercises out of the program for some time and them injecting them back in later at the same intensity and volume doesn’t always work. You’ll need to slowly introduce the movements back in, often times at a lower level of dif culty.

  Potentially your technique is also off or you have another restriction that is leading to continued pain. Make sure you work closely with the athlete and therapist when attempting to return athletes back to training to ensure you’re checking off every box to ensure the athletes returns safely.

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Keep your clients moving and not afraid. Our goal is to keep our clients healthy and progressing to- wards their goals. What we don’t want to do is stop training completely (However, most will need to modify). Fear of training can be healthy in that it can keep athletes from performing things that further irritates and potentially damages the injured area. Excessive fear can do the opposite. Fear and anxiety that keeps athletes from moving altogether and creates false beliefs about their injury is a bad thing. Keep them moving and make the modi cations to continue training pain free.

Slowly rebuild tissue capacity. Tissue capacity is a term popularized by respected tendon researcher Jill Cook. Essentially, the structures in our bodies need to be prepared adequately for the demands of our sports. Think of the amount of hamstring strain injuries that occur in weekend warriors that attempt to go out and sprint for the rst time in 15 years. They haven’t adequately built the tissue capacity required to sprint without injuring their hamstring.

Coming back from an injury is no different. We have to rebuild tissue capacity. If it’s been some time since your athlete has performed a given movement then chances are we’ll have to start with easier movements at a lower intensity and slowly build back to where we were before with our training. We can’t expect to take extended time away from a particular movement and then randomly throw it back into your training at the same capacity at some point just because you’re feeling better. Often times this leads to a recurrence of the same pain and more frustration from the athlete. Our goal instead should be to slowly reload the injured area slowly and cautiously. This will require careful attention to program- ming with speci c modi cation. In the modi cation sections below we’ll talk about additional examples to accomplish progressive return of athletes to training.

As a last piece of advice we also want to gure out what the root cause of the problem is. This could come from programming errors such as throwing too much at the athlete all at once or from poor technique in a given movement. We’ll have to become detectives to determine the causes and correct them.

Injury Prevention and Keeping Athletes Safe

Recent research from Tim Gabbett is illuminating a few key concepts about keeping our athletes safe and reducing risk of injury. The rst key principle is to reduce spikes in training volume. What this means is avoiding large increases in volume or training load at any point during training. Tim’s research shows that increases in training workload resulted in increases in risk for injury. This can easily be ap- plied to our population. We’ll want to avoid spikes in total training volume as well as joint speci c train- ing volume. Here are some examples to be aware of:

1. Any particular spike in total volume of training or introduction of new unfamiliar skills
   a. Beginning an olympic lifting program (especially on top of a normal training schedule)
   b. Increasing squat volumes (Smolov and Hatch programs)
   c. Hero WODs and chippers (any workout containing more total volume then what your populationis used to)
   d. New members (especially those with no history of recent tness experience)
2. Old members returning after a break in training
   a. These members may want to pick up exactly where they left off but chances are they’ve lost

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some tissue capacity in their time off b. Athletes returning from long vacations

3. Members who come infrequently
   a. Encourage regular training
   b. Modify movements that athletes are incompetent in
   c. Modify set / rep schemes and volume for movements athletes are prepared for
4. Spikes in Joint Speci c Work
   1. Increasing handstand pushup frequency to improve skill and strength○ Extra strength work is great but ramp slowly and be mindful of total work in their normal program
   2. “Randy”, “Karen”, “Murph”
      ○ Members may not be ready for the large increases in volume over a single workout

With this concept in mind it becomes incredibly important to introduce new movements and volume slowly and progressively over time. Hero workouts and chippers are not bad workouts. Hatch and Smolov are not bad programs. They should just be slowly introduced into your programming.

The second concept Tim Gabbett has illuminated is that maintaining a high volume of training can be protective against injury. If athletes are not thoroughly prepared for what’s being thrown at them on a regular basis then the risk of getting injured when tough workouts or competitions pop up increases. It makes sense, prepare the body adequately for the demands of our sports and activities and we’ll be more resilient.

Just keep in mind that our bodies can handle a nite amount of work and even elite athletes will be prone to overuse injuries with too much total work. This amount will be different for each individual and unfortunately we often won’t know how much work an athlete will be able to handle until they start breaking down (pain and injury).

Periodization

Another key to athletic success and injury reduction is periodization. Now, entire texts have been writ- ten about periodization and this book is not made to help you understand how to periodize for athletic success. However, several aspects of periodization can help us improve over time and decrease injury risk.

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Programming time off for your athletes after a competitive season provides much needed psychological and physical rest. This helps to restore the endocrine and immune system while improving emotional and psychological well being. This time off is also great to help unload joints and muscles. Just ensure your return to training after time off is slow and progressive in nature. Remember our talk about avoid- ing spikes in training volume earlier.

Get Athletes Out of Pain

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2 Varied Yearly Training Periods

Doing the same thing day in and day out in the gym is no recipe for success. Our bodies require time to adapt to a given stimulus (muscle growth, strength and endurance improvements) but if there is not enough variation we stop making progress. This is known as accommodation (reference). Because of this we want to vary our training throughout the course of the year.

The other reason to provide variety in training is to help prevent overuse injury. Certain sports produce speci c stresses on the body. For example, distal clavicle osteolysis is an AC joint (joint in the shoulder girdle) dysfunction seen very commonly in powerlifters. It occurs because of the very speci c stress-
es on the shoulder during bench press. It stands to reason that if we do too much bench pressing we can irritate our AC joints. Tommy John surgery is very speci c toward baseball athletes because of the unique stress on the ulnar collateral ligament from throwing. Because of the speci c stresses that occur in a sport certain areas are prone to increased stress and damage.

One way to mitigate this stress is to vary the exercise stimulus throughout the year. Let’s use the pow- erlifter as an example. Throughout the training year we can have times where we avoid barbell bench for periods of time. We can consistently change the main pressing movement by using different types of bars, different width grips and different pressing angles. We can alter the sets and reps as well as the bar speed. All of these things serve to vary the stress on the shoulder enough to avoid overuse and avoid accommodation. We want to apply the same idea to our training program.

One of the easiest ways to do this is to split your training up over the course of the year and determine what are the most important aspects to focus on at each portion of the year. We’ll use the goal of pre- paring for the Cross t Open as a goal for the training year.

Early Off-season (April and May)

1. Emphasis on deloading overused movements a. squats

b. overhead press
3. Emphasis on strict movements

a. Strict Pull-ups and Dips

b. Romanian Deadlifts
3. Implementing more variety in training

a. Novel movements (Sandbags, carries, crawling, climbing, throwing, jumping) b. Working on multiple planes (Front and Transverse)

I. Rotary throws
II. Lateral Lunges
III. Shuf ing, change of direction drills

c. Hypertrophy and tempo work
I. 3 sets of 8-12
II. 2-3 second lowering phase III. Paused reps

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Mid to Late Off-season (June – October)

1. Re-introduce dynamic movements a. olympic lifts
   b. dynamic gymnastics (kipping)
2. Focus on maximal strength a. Bench, squat, deadlift
3. Skill Work
   a. Strict Muscle-ups b. Handstands

c. Handstand Walking

Pre-season (November – January)

1. Speci city of training
   1. More speci c met-con workI. Similar energy system
      II. Similar time of workout
      III. Similar exercises (couplet / triplets)1. Overhead Squat and Pull-up2. Rowing and Thrusters
   2. Bring skills into conditioning environmentI. Kipping Muscle-ups + Wall Balls + Double Unders
2. Volume build up – Get the body prepared for the amount of volume seen in competition

a. Slow ramp up to: I. Chippers

II. High volume wallballs

III. High volume pull-ups
3. Tapering – gentle reduction in training volume in order to peak for competition

In-season (February – March)

1. Maintenance – to keep progress made over training year without affecting ability to perform during competition

In the above outline you can clearly see where we are purposely either pushing or avoiding certain movements. This is ok. We aren’t supposed to be able to peak at any given time throughout the year. In this case we want to peak for the open. It means that during parts of the year our conditioning may be lacking. It may also mean that during parts of the year you’ll be stronger than others. Ultimately I be- lieve this style of training will maximize your ability to peak while also reducing your risk of injury.

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It’s also important to understand that people are individuals and because of this training must be differ- ent from one individual to the next and modi cations will have to occur. One of my favorite lessons to tell my patients is some advice I gleaned from Paul Buono. Paul was captain of Cross t Milford in 2015. Cross t Milford was the #2 team place winner at the cross t games in 2015. He’s also an old co-work- ers and good friend. Paul once told me that he modi es almost every single workout that his coaches write for him. This is because he understands his body. He knows when to push and when to back off. He works around injuries. He has a smart approach to his training. If Paul modi es something almost every training session then we should probably be modifying also.

What one athlete can tolerate and is optimal may be totally different than what another athlete can. This goes for both performance and avoiding injury. One athlete may make the most progress training 5 days per week while another may make the most progress with 3 days per week. The same athlete who progresses at 3 days per week may start to break down and get injured on a 5 day per week pro- gram.

Tolerance to exercise is also joint speci c. One athlete may be able to handle squatting 3 days per week and another may only be able to handle 1-2 days per week or else their knees will start hurting. For another athlete maybe their low back is the limiting factor in how frequently they can squat. For others maybe deadlifting is the limiting factor and not the squat. It changes for every person and every exercise. For most people it is a learning process that will be ne tuned over time as long as we listen and learn from what our body is telling us. Keep in mind that generally the volume we can tolerate will improve over time as long as we periodize and progress properly.

Some individual considerations to take into account when developing a training program:

• Goals
• Prior training experience
• Age
• Injury history (old shoulder injuries, low back pain etc..)
• Nutrition
• Stress
• Sleep
• Work / life balanceLearn From Your MistakesInevitably, people are going to get hurt in the gym. Obviously we don’t want this to happen but like any other mistake in life, it’s a great time to learn. Did someone rupture an achilles performing high rep box jumps? Maybe you should have programmed more reactive jumping earlier in their off-season. Maybe they have no ambitions of being competitive. Perhaps they should have never been performing higher rep rebounding box jumps.Having trouble with people pulling hamstrings during sprints? Potentially add in several weeks of build up runs before attempting maximal running with your athletes. Maybe add in more hamstring strength- ening into the accessory work of your program.

Individualization

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