Ask a Physio

Training Injuries
21

That’s all good mate!

In that case, it’s more likely you do have a muscular and/or neural contribution to your symptoms

To get started, I would keep points 1, 3 and 4 from above, and add a small volume of long-length rectus femoris exercises 2-3 times weekly.

For example, you could do 2 x 6 reverse Nordics superset with Bulgarian split squats 2 x 12, starting at a low intensity “loaded mobility” focus, and then progressing to heavier loads

This combined with 1, 3 and 4 above should help build the specific tolerance of your anterior hip muscles to load and length. Further improvements will require a good hip and lumbar spine assessment in my opinion

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22

This is great.

Any chance you can advise on the following issue i have:

Rear ankle (achilles area) - pain when flexing toes down and up towards sky. Pain in rear ankle when foot pushes off to run.
Pain in rear ankle when rotating foot with toes pointed down in circular anti clockwise motion.

Mechanism of injury was following shadow boxing rounds and or skipping straight after.

Is it achillies tendonitis? Am grateful for any advice.

23

Hey mate - this sounds like my ankle!

How long ago did the symptoms start?
Are the symptoms improving at all?
What have you tried so far?
What makes the ankle feel better?
How does it feel when cold vs warmed-up?
How does it feel when walking, jogging and running?
Is the pain directly on the achilles, the back of the heel bone or somewhere else?

24

Hi mate thanks for the reply. Well ive had this since late august and did it shadow boxing.

But get this. I did my first short walk, jog, run the other day nothing to bad and it was painful but managable. I have been tsking injectable bpc 157 and tb500 for last two weeks. Ive been over the last 3 -4 days using a tens machine on effected area…i woke up today and its massively better…about 90% and 10% pain. I ran on treadmill today and again a little painful but not as bad. I swear the peptides must be doing something now. Will report back as i pushed it a bit today and i might be in pain when i wake up. Am gonna ice and tens in a bit.

25

Very much appreciate your launching this thread. I’m in a “understanding my existing diagnosis” mode after getting an MRI on my shoulder on Friday.

The shoulder has been a mild issue for years, but got much worse in August after a pair of unplanned, sudden lateral raise/Y-raise motions about a week apart (was unable to lift my arm more than 30 degrees for 4-5 days).

I’ve been doing PT for the past few weeks (six sessions). And I think it’s helped, though there’s still a decent amount clicking and popping with certain movements.

At any rate, I would love to hear any thoughts you feel comfortable sharing about what I may be dealing with. I can provide the report but, for now, just to give you an idea, here’s a chatGPT-generated summary of that otherwise impenetrable medical language.

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Thanks!

26

Sounds like a decent plan mate

IMO - with any sort of calf/achilles/ankle pain, sort of fracture, you can’t go wrong spamming heavy calf raises

5 x 5 @ 5050 is money for the tendon (if that’s the issue), but won’t irritate ligaments or joint capsule (if they’re the issue)

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27

Hey mate! By reading that ChatGPT summary, it sounds like you’ve got a cracker of a supraspinatus tear. The supraspinatus’ friend and co-conspirator, the infraspinatus, is affected as well but to a lesser degree.

These are two of the most often injured muscles of the rotator cuff, and their actions are as follows:

  • Supraspinatus: lifts the arms up, particularly for the first 30 degrees of motion
  • Infraspinatus: externally rotates the shoulder, resists forward “sliding” (anterior shear) of the shoulder

Functionally, these muscles coordinate with all the other big and small muscles between the elbow and ribcage to help your shoulder move smooth and strong. The supraspinatus is particularly active whenever the shoulder is moving upwards and/or internally rotated. The infraspinatus is particularly active during pressing motions.

Regarding the injury itself:

You have a fairly large tear through the tendon of the supraspinatus that also affects the infraspinatus tendon. This is made possible through the unique anatomy of the rotator cuff. Unlike other muscles like the hamstrings, quads and pecs, the cuff muscles don’t really have distinct tendons. Instead, the tendons of all the rotator cuff muscles sort of fuse together into a “sock” which wraps around the entirety of the “ball” of the shoulder. This is how your supraspinatus tendon tear is also an infraspinatus tendon tear.

The “retraction” that report mentions can also be explained by the sock analogy. Once you put a hole in a sock, the tension through the fabric will start to widen the hole. A similar thing happens to the rotator cuff, particularly with older tears.

Regarding outcomes:

Because the structure of the rotator cuff tendons are very complex, expected recovery varies a lot, somewhat regardless to the size of the tear itself. For example, location of the tear relative to a structure called the “rotator cable” can be a predictive factor of recovery. Other considerations are the size of the tear (yours is large, but by no means the largest), the presence of retraction, your age, previous activity, current strength, occupational demands.

On a population level, outcomes between rehab and surgery are similar for rotator cuff tears. However, the problem with population data is that multiple people with different tears, anatomy, strength and demands all get lumped together. Unfortunately, without more information (and time) it can be pretty tricky to know whether or not you’re a surgical or non-surgical candidate.

Your best bet will be to follow the advice of your physio exactly, raise any and all questions with them wherever possible, and give conservative management an honest go for at least 3 months.

Hope that helps!

EDIT: Regarding clicking and popping - these symptoms (called “crepitus” in medical jargon) are expected with your style of injury. They don’t necessarily indicate worse injuries or outcomes, and are unlikely to get much better for a while (if at all, to be honest). The crepitus usually improves as the strength and control in your shoulders improve, but may “lag behind” improvements in strength and pain

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28

That was incredible. 1000 thanks!

29

Thank you for the detailed response!

That sort of stuff does seem to help. I periodically rotate through Kelly Starret/Donny Thompson stuff, but I’m never clear on how to program it. How many exercises would you begin with, for how often, and how long?

Usually, Im pretty haphazard about rehab, get a bit better, then ignore the advice below:

and get banged up again

What you wrote about TOS is interesting. No one ever diagnosed me with TOS–the symptoms kinda fit what I’ve been experiencing…based on a random YouTube video I watched. Then again, the shoulder pre/rehab stuff I’ve always done seems to make it better.

30

You’ll notice all the exercises I listed are “regular” strength exercises, and I’ll program them as such: 2-4 sets of 6-12 reps with 0-2 RIR.

For a “regular” person I’ll usually choose 1-2 of those per session, and program them with specific KPIs in mind. For myself, I really benefit from consistent training of the posterior shoulder, especially in stretch positions. Therefore, I’ll finish most workouts with one of:

  • Sidelying reverse fly
  • Deep range dumbbell external rotation
  • Behind-back cable lateral raise

For a more hardcore example, here is the gym program I’ve written for a client who’s dislocated both shoulders repeatedly. We want to improve his confidence under load at end-range positions of the shoulder, whilst still ticking off our strength & hypertrophy goals. He’s getting to the end stages now, so the training is close to the sketchiest feasible

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31

How can I avoid these injuries in the first place?

I’ve been really lucky to avoid any joint injuries and I want to keep it that way.

Interestingly despite being a strong sprinter and a good squatter I have always found my hamstring mobility very limited compared to others. Keeping my legs and back straight I can’t bow to much past a 45 degree angle. Is this something I should actually focus on or is this something that’s just part and parcel of being tall? What angle should I be aiming for? And will improving that with static stretching help?

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32

My honest take:

  1. Injuries are a part of life, and we have minimal ability to prevent them. The majority of injuries I treat stem from shit luck, recurrences and poor previous rehab, possible genetic factors or poor physical condition (below)
  2. The injuries that are preventable are mostly preventable by having an excellent training base and not being an asshole. That basically means having some level of balance in your weekly physical activity.

You can refer to this post for a few more details

Unless you need to get into that position under high loads, high speeds or high volumes in your week, then no

It’s probably just “who you are,” but being tall isn’t what causes it.

Regardless, restricted general flexibility - that is, flexibility that isn’t highly specific to sport or occupational demands - is not generally predictive of injury. That’s just a layover thought from the 1980s

“Normal” would typically be fingertips between lower shin and floor. Palming the floor is technically hypermobile

We know from stretching research that you generally need to hold a static stretch for 3+ minutes per bout to actually get improvements. However, I don’t think your toe touch is an issue if you’re currently healthy

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33

Super useful, and quick follow up — if I ‘feel’ tight or slightly off during warmups, what should I do? Ignore it, modify the workout in some way, or abandon the workout entirely?

34

I’d just take a common-sense approach with that

If it’s your first warm-up set, keep warming up.

If you’ve definitely warmed up “enough” and it still feels off, I’d cut volume and/or intensity for that specific movement. For example, back squat 3 x 5 @ 1 RIR → back squat 2-3 x 3-5 @ 3 RIR

If it feels really off or the movement itself isn’t important to you, substitute the exercise for a more stable equivalent and keep loading approximately the same (or a bit less taxing). For example, back squat 3 x 5 @ 1 RIR → hack squat 3 x 5 @ 1-2 RIR

I pretty much never recommend someone abandon the session completely unless they’re sick or significantly chronically under-slept

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35

I just wanted to comment about how helpful this thread is. Good on op for sharing what he knows.

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36

My pleasure! Thank you for the kind words

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37

Hello. Thank you for this opportunity. I am having an issue that’s complicated and difficult to describe but I’ll do my best. I had several Schwannoma tumors removed in 2008. They were on the right side of my back under my shoulder blade, primarily. From what I can recall, I had part of my neck bone, part of my T spine and a partial rib removed. I’ve had a numb area essentially from my spine to the separation of the rear/frontal plane since. Fast forward to October to present; I’m experiencing sporadic nerve tingling and occasional, unsolicited numbness along the length of my spine that runs along the medial shoulder blade, as well as at the lower edge of the blade. It is unpredictable, that’s what I mean by unsolicited. I feel I brought this on when I had a free pass to the gym in early October. Until that time I’d been training at home with a resistance band set up. Only one day of lifting in the gym, with its hard as steel benches is all it took. Bench press was the main culprit, I believe.
I’ve always had a difficult time keeping the right shoulder retracted as It wants to rise and internally rotate.
I’m going to stop my attempt at clarifying this and wait to see if you can unravel it. Then I’ll answer your specific questions.
Again, thank you.

38

Hey mate! Thanks for reaching out

This sounds like a pretty complex issue considering the osteotomies (bone removals) you’ve had done. Unfortunately, I won’t be able to meaningfully advise for this issue in this format.

You’re right in thinking that the change in exercise type and surface could promote increases in those nervey symptoms, however I cannot help set expectations/timeframes for improvement, rehab exercises (if necessary) and “risk” of this issue in this context.

My strong recommendation would be to follow up with your GP - preferably the same one who helped initiate the schwannoma care (if possible). They’ll likely order a cervical and thoracic spine CT and/or MRI, or refer you to a physio/physical therapist for further care

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39

Thank you. I thought it might be too complex. I was going to add that the same thing happened a few years ago and it resolved itself. It seems to be improving.

Any recommendations on how to keep my (right) scapula retracted. I’ve had trouble with it internally rotating and elevating for as long as I can remember. Setting it down and back is a continual thing. I understand these (probably) wouldn’t be stretches but more strengthening surrounding muscles with dislocates, pull-aparts, facepulls, etc.?

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40

These are both good indicators that the issue should resolve

Some specific exercises you might like to pair with your pressing warm-ups to support scapular retraction are:

  1. Behind the neck band pull apart.
  • Start like a regular pull-apart
  • Set the shoulders down/and back hard
  • Keeping the scaps set, bring the band overhead. Reset your scaps if needed
  • Lower your arms to the side, so the band is stretched behind your neck. Reset your scaps if needed
  • Reverse the whole movement. Make sure you check if you need to reset your scaps at all points
  1. Isolated scap retraction with a cable
  • Any set up you like is viable. My favourite is with the cable pulling forwards and up 45 degrees relative to my body
  • Allow the cable to fully protract/elevate your scaps, then set your scaps against resistance
  • Take this light enough that you have good control and range at all times

If this is something your really struggle with, you could consider applying electromuscular stimulation (EMS) to the affected muscles either at rest, or even during your scapular setting drills.

EMS works by passing an electrical current through the muscle, creating a muscle contraction without relying on your nervous system. It has been shown to help improve muscle strength and recruitment in a variety of populations. EMS is safe and effective for any muscle, provided you don’t have any implanted electrical devices underneath the electrode pads.

I recommend this unit to my clients because it’s cheap ($55 AUD, ~ 40USD, easy to use and just plain works

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