A Systematic Approach To Working Around Injury Or Pain

By Brad Loomis with commentary from Nick Licameli, DPT

Before I get into my system for working around injuries, I need to clarify that I am not a physician or physical therapist. I am not qualified to say that this is the correct way to treat an injury or pain. However, I have a ton of anecdotal evidence from over a decade of coaching clients. This system has helped many of them continue their training with almost no time off, all while still progressing their lifting careers. I also deal with my own injuries using this system and I will provide examples of how to implement it.

As a physical therapist and the team Injury Reduction and Management Specialist, I would like to echo Brad’s point here. What follows is not meant to be prescriptive, but rather an explorative journey of the principles of injury management. As I’ve said before, principles are ever present and deep-rooted in all that we do, whether we choose to acknowledge them or not. If you learn the principles that we set forth, it will enable you to implement them into your own training and/or use them to have a productive conversation with your healthcare provider.

So first off, we must deal with the “bro” way of diagnosing an injury or pain. If you have played in any team sport or been in the military, you have heard this question. “Are you hurt, or are you injured?” Playing hurt is a part of any physical endeavor. However, there is a big difference between hurt and injured. A scratch, bruise, strain, cut, abrasion etc. hurts. It does not mean you are injured. A tear, rupture, or fracture of tissue or bone, and now we are talking injury. We will save treating injuries for the experts in that field like our very own Dr. Nick; however, I will disclose to you my first line of defense when it comes to dealing with being hurt. 

Essentially, what it boils down to is experiencing pain. Pain is extraordinarily complex. Before delving into the system I created, I highly advise reading Nick’s piece from a few months back entitled “A Guide to Injury Reduction and Management.” What will blow your mind about Nick’s blog is that pain is not necessarily the sign of an injury. In fact, a significant injury can exist in anyone at any time and they may not experience an ounce of pain. We have all heard the stories of the baseball player with a significant tear in their rotator cuff and never once did they experience anything more than general soreness after a game. I try to always keep this in mind whenever I feel pain during training. Because ultimately, whether I am injured or not, what I am truly after is continuing my training without having pain interfere. 

This brings up the question…What is an injury?  How do we define it?  Is it the presence of pain?  Is it the presence of tissue damage?  Is it pain and tissue damage together?  Is it time off from training?  If so, how much time off?  Is it time off from practice or time off from game play?  Is it only an injury if the individual seeks medical attention?  If we cannot define what an injury is, how can we possibly begin to tease out how to prevent it?  How can we prevent an athlete from slipping on damp dew-covered turf during a Saturday morning game?  How can we prevent a player from taking an opposing player’s knee to the shin while diving for a ball?  It is important to remember that injuries, like pain, are multifactorial, poorly defined in the scientific literature, extremely variable from activity to activity, and rarely are solely due to a single traumatic tissue-damaging event.

I do not pay too much attention to a minor ache or pain until it is repetitive. In other words, if I feel a pain 2 or 3 training sessions in a row, I consider it something to deal with. So, while I do not immediately start freaking out at the first sign of an ache or pain, I do jump on it aggressively once it’s repeated. Especially when I experience the pain 2 or 3 times in a row on a particular session or exercise.

Find exercises or loads that train the body part or movement and DO NOT cause pain

We know that we want to avoid spinning our wheels in the sport of strength and bodybuilding by hopping needlessly from exercise to exercise. However, having an injury or experiencing pain is the trump card. In this instance you have to make a change. If you are lucky, simply lightening the load and training with higher rep ranges while sticking to your progression method is all that is needed. Others can maintain load but must limit volume or RPE. In other cases, you will have to find suitable replacements. Essentially, try to train the same body part or movement with as similar a replacement as the exercise you originally had programmed. If you had a barbell biceps curl programmed as part of your training and that is the culprit of pain, do a hammer, preacher, or cable curl to find out if any of those cause the same pain. You may even have to change to a compound movement that trains the biceps like an underhand grip pulldown or row. 

One of the things I get asked a lot is, “What should I do if I feel pain during a rep while training?”  My answer is usually, “Do another rep.”  Pain is too variable and multifactorial to draw any conclusions from one single episode of pain. That being said, always be aware of red flags and seek out a qualified healthcare practitioner if you notice things like constant dull/achy pain that cannot be relieved or reproduced, loss of bowel/bladder control, history of cancer, episodes of your legs giving out, fever, traumatic injury, numbness/tingling, being awakened by pain, warmth and tenderness to the touch, being a young active female with low back pain, a suspected fracture, etc. 

Once red flags have been ruled out, we want to explore the symptoms in order to gain as much information as possible. Much like Christopher Walken said in the SNL cowbell skit, “Explore the space!” What are the characteristics of the pain (sharp, dull, numbness, tingling)?  Does it get better as the set goes on?  Does it get worse as the set goes on?  If you lighten the load, does it make it better or worse?  If you lower the RPE, does that impact it?  If you increase the load and decrease reps, how does that feel? Does changing your form change your symptoms?  How does partial range of motion feel?  

Using myself as an example, I had some serious right acromioclavicular pain I was experiencing on the flat barbell bench press during a competition prep in 2004. For whatever reason though, I could do an incline press of any sort and it did not reproduce my pain. For the remainder of 2004, 2005 and nearly all of 2006, the only compound movements I could do to train my chest were an incline barbell bench press and an incline dumbbell bench press at about a 15 to 20% of incline on the bench. When I finally returned to the flat barbell bench press in the fall of 2006, I started off with less of an incline. I would place 25lb plates underneath the bench press to give it just a slight incline. I continued doing this for a few weeks pain free before I finally ended up returning to a completely flat barbell bench press.

Once we find a combination of modifications that resembles the goal movement as closely as possible, we load that movement and progress through graded exposure back to the desired movement. It might look something like this:

Let’s say the goal is four sets of the barbell back squat. After our modifications, we ended up with three sets of a barbell box squat at a height that limits depth to above 90 degrees. We load that for a week or two and assess our response. It is tolerated well. Now we’ll do the first set with a lower box and the last two sets with the original box…ride that out for a week. Then we do two sets with the lower box and one set with the higher box…ride that out for a week. Then we remove the box on the first set but keep the lower height box for the last two sets…so on and so forth. 

The beauty of this approach is that if (and likely, when) something is not tolerated well and we have to pull back and regress a bit, all we have to do is follow the same steps backwards. This keeps us training as close to our edge of discomfort as possible while still getting a training effect and without re-sensitizing the pain stimulus. As previously mentioned, if pain is felt, it does not necessarily mean we have to regress back to the previous step. We have to assess our overall tolerance across a larger number of exposures, such as the training over the course of a week.

Brad’s bench press story is a perfect example of how the process should work. Brad found a variation of the horizontal press that resembled the flat bench press, loaded it, maintained a training effect, then gradually progressed back to a flat bench. 

Take a week off from training or at a minimum, run a deload that does not train that body part or movement.

Once you dial in a method or replacement, either subbing out the exercise or lightening the load, I always recommend a week off from training that body part or movement. You can run a deload for the rest of your program or body, but I still recommend taking a week off from that movement or training that body part. This is a self-explanatory step and as you probably know if you have followed Team3DMJ, taking one week off from training, or a deload, will not cause muscle loss in the slightest and often results in an increase in training performance upon returning to that movement or body part. It is worth noting that in some cases there is no exercise that works that movement or body part pain free. For example, I had some nasty right elbow pain for the better part of 3 years from 2005 until early 2008. As a result, I could not do curls of any sort. I could, however, do a lot of back/pulling compound movements, including underhand grip work, which worked my biceps a great deal. I simply had to go sans curls for this period, but I did not experience any significant loss in arm size. 

Great point here. A body part specific deload may be our best option if even the lowest level movement variation is not tolerated well. Like a car engine, sometimes things are just too hot to work on and rest is what it needs. 

Add back the exercises/movements that you discovered does not cause any pain. 

Once you have completed your week off/deload mentioned above, or have tested out the movement/loads causing you pain to find it no longer does, gradually introduce work that you discovered does not cause any pain. Do so by starting with 1 set only for a week or two. Then add sets slowly until you are at your programmed amounts. If this new work does not cause you any pain, stick to it for quite some time. As I mentioned above, I was able to stick to incline presses for my chest for nearly 2 years before returning to the flat bench press. Then once I did go back to flat bench pressing, I was able to do so pain free, and I was just as strong as the day I had to stop. If you are lucky enough to keep to the same movement/exercise but simply need to lighten the load or limit the volume, progress in a gradual manner as outlined in this step. Do one set only for the first week or two and then progress from there.

It is worth repeating that Brad did not lose a significant amount of strength on his flat bench press during his time of modified training. The incline press was similar enough to the flat bench that it elicited decent carry over, but dissimilar enough that it did not provoke the pain.

During every programmed deload, test out your preferred exercise/movement/load (essentially testing what once caused you pain).

It is difficult to assess if what once caused you pain, no longer causes you pain, until you try it out. Furthermore, pain is not necessarily a roadblock to progress. A good time to test the waters is during a deload when you can do 1 or 2 working sets, starting with a light weight. If there is no pain, it is a green light to put that movement back into the rotation and proceed to the next step. However, our goal is not zero pain. Our goal is to see how the body responds. Perhaps the first rep or two cause pain, but as the set progresses it is alleviated or goes away. Perhaps in a second set there is dramatic improvement. How does the pain feel for the rest of the day or days after? These are all responses that are important clues for how best to proceed. There is no right or wrong answer on how to do that but think of it as progression in training. You can be more conservative and try that movement out every deload, or more liberal and try that movement once a week and assess. The workaround will keep you on track with your goals, this is bonus work. Proceed as you feel comfortable, but do not feel like experiencing pain is a red light. Consider it more a “proceed with caution”.

That’s really well said, and I am going to echo Coach Brad’s point here. If you feel pain, don’t freak out…keep going and see how it feels. Get as much info as possible and assess your overall response because one bout of pain is usually too unreliable and variable to draw any conclusions about tolerance to an exercise.

Once there is no pain on your preferred exercise/movement/load, add back in the exercise as described above.

Once again do not rush it. You have years and decades of training still in front of you. A few weeks of gradually introducing the work back in is not going to set your gains back in the slightest. Furthermore, it will make you more resilient to injury and pain later in your lifting career. What you have done is analogous with overcoming a fear of snakes. When you started with your pain, you could not stand the sight of snakes. However, by keeping diligent with your training and working around your limitations, you essentially put a picture of a big snake on the wall 20 feet from you. With each passing session, you moved closer and closer to the picture until you were right next to it. At that point, you were ready for the next step, adding the work back in that made the pain to begin with AKA putting a real snake in a terrarium in the room with you. You cannot stand right next to the snake at first though, or you will be right back where you started. So, you stay back 20 feet from the snake and then slowly move closer each day AKA, add the work back in gradually. Pretty soon you have overcome the fear of the snake to the point that you can now reach in, grab the snake, and hold it (AKA made your body more resilient to pain caused by the exercise than it was before). Now, it will be harder for your body to experience that pain again.

This is key. Injury is a time of learning and enlightenment. Like many things in life, when we overcome a challenge, we become stronger and more resilient. We learn through failure. We grow from being broken down and building back up. We learn most during the hard times. Do not be so focused on the end goal of being pain free that you miss out on the journey to get there and all of the lessons along the way!  Always love the journey.