When training for rehab, aim for endurance rather than heavy resistance and a maximal strength focus. As I mentioned in Part 2, low back pain is correlated with reduced endurance of spinal musculature. This means you want to work on longer sets with lighter weight rather than shorter sets with heavier weight. For example, hold the plank for 1-2 min, or do 20 quadrupeds.

Always, always let pain be your guide. Your aim is to find the pain free range of motion and work within that range, gradually expanding it as you improve. A little discomfort may be felt, and it’s up to you to judge how much is okay. Do not do any exercise, no matter how good it is, if it causes you a great deal of pain. Assume the usual disclaimer: when in doubt consult with your doctor and/or a physiotherapist.

neutral spine

Neutral spine is the position in which the spine is evenly balanced, and the top of the pelvis is neither tipped too far forward (resulting in an exaggerated low back arch and protruding lower belly) nor too far back. It’s not a single position per se, but rather a dynamic state in which the spine is able to respond and correct itself throughout a movement. Neutral spine is the state in which the spine is most able to tolerate loading and mechanical forces acting on it. A happy spine is never entirely straight, but rather looks like a gentle S-curve when viewed from the side. There should not be excessive rounding of the shoulders and upper back, nor excessive arching of the lower back. It shouldn’t look like the letter C or the letter Z. And if it looks like the letter B, you should probably loosen your belt.

One way to find a neutral spine position was taught to me by my Olympic weightlifting coach. While standing, take a deep breath, and push your chest up and out slightly. The position your back gets into with this action is an approximately neutral spine.

To help alleviate and prevent LBP, neutral spine should be maintained as much as possible during loaded movements. Some people incorrectly misinterpret this as saying that the spine should always remain straight up and down. Then they try to squat and fall over backwards. Rather, the spine should form a generally straight line with slight natural curves, but it can retain this line at a variety of angles. This is achieved by bending from the hip, not the waist.

Below are some examples of neutral spine while sitting, squatting, and picking up a laundry basket.

neutral spine while seated

Here’s an example of improper sitting position. Most of us probably do this at our computers without even thinking about it. Upper and midback is rounded, shoulders are hunched forward, and head is also pushed forward.	In comparison, this is an example of neutral spine while seated. Head is carried further back, in line with the spine. Shoulders are pushed back and the posture is upright. You should be able to do this without back support, but if a lumbar roll or folded towel helps, then that’s fine.

neutral spine while picking up a load

As I mentioned, one of the most common occurrences of LBP is when doing household chores, but this principle applies in the gym as well. This picture shows the wrong way to pick up something from the floor; in this case, a laundry basket. The back is rounded, which effectively removes the assistance of the supporting spinal musculature. I’m cruisin’ for a bruisin’ here.

Here’s the right way to pick up that load. Squat down (see how useful squats and deadlifts are?), and use the legs to drive the load upwards. Also notice that this picture demonstrates neutral spine while squatting, and you can see that again, it doesn’t mean keeping the spine straight up and down, perpendicular to the floor. Rather, it means keeping the back in a relatively straight line at any angle, using the hips as the “hinge”. Don’t forget to hold your breath and tighten your midsection for a split second through the first part of the lift.

pelvic mobilization

Getting the lower back moving around after an injury will help with healing, strengthening, and pain relief. There are many types of exercises aimed at lower back rehab.

One that I recommend, though not shown here, is the cat-cow sequence from yoga. Get on hands and knees on a mat. Round your back, pressing it towards the ceiling, like an angry cat. Try to curl into a ball without moving your hands and knees. Look down and slightly behind you, so you can see your knees. Hold for a second, then slowly and gently relax, and let your midsection sag downward, pressing your belly towards the floor. Look forward and slightly slightly upward. This is the cow position. Hold that for a second, then smoothly and consciously move back into the angry cat position. Go back and forth between these two positions for several reps per set. Don’t forget to breathe deeply and consciously relax throughout. One of my clients who suffers from chronic back pain as a result of a tennis injury swears that this cat-cow sequence is better than ibuprofen for pain relief.

Below is another one I like: the standing pelvic tilt.

I ripped off this movement from belly dancing. Yes, it looks dorky, so let’s all just get past that and agree to do this when nobody is looking. You should be grateful that I was brave enough to look like such a goof for your benefit. It’s quite simple. While standing, tilt the pelvis back and forth as far as it will go in either direction. Do this slowly, consciously, and gently. Hold each position above for a second or two.

Anterior pelvic tilt (left hand photo) means that the top of the pelvis is tilted forward, and the lower back is arched, as in the photo above.

Posterior pelvic tilt (right hand photo) means that the top of the pelvis is tipped back, and the pelvis is tucked under the body, almost like you’re trying to curl into a ball while still standing, or like a dog tucking its tail between its legs. Do as many sets as you like, and as many reps as you like. Something like a couple of sets of 10 to 15 is a good goal.

Once you get comfortable with this movement, try its equivalent from side to side, slowly alternating raising one hip up and then the other.

torso strengthening

A good lower back rehab program should include some work on strengthening the supporting muscles of the torso. This includes the spinal erectors, obliques, and rectus abdominis, as well as the deeper torso musculature. Here are a few exercise ideas.

This exercise, known as a “Superman”, because it looks like Superman flying, strengthens the low back. Begin by lying face down, as shown in the top picture, with arms overhead. Then, raise arms and legs off the floor. The aim is to hold this “flying” position as long as possible. This exercise should be done for a few sets of at least 30 seconds per set. Don’t forget to breathe! And by the way, I don’t recommend doing them on a hardwood floor, as I did. Owie ow. Do them on a nice cushy carpet or mat. One caveat: McGill is not crazy about this exercise, as he feels it puts undue compressive force on the spine. If you are concerned, skip this exercise.

The exercise in the photo above is known as a plank position. Yoga folks will recognize it. It looks like the top position of a pushup. You simply hold this position as long as possible, while maintaining a good, straight, rigid body position. There should be a straight line from your head to your feet. No sagging in the middle! Like the Superman, do these for a few sets of at least 30 seconds, and don’t forget to breathe. These can also be done resting on forearms instead of hands. To get into this position, begin on hands and knees. Then, straighten out your legs until your body is in position.

This type of exercise is known as a quadruped, as it’s done on all fours. Again, do as I say and not as I do, and do this on a mat if you like your kneecaps. Begin on all fours, with a neutral-ish spine, as shown above. Don’t let your body sag in the middle.

Slowly and consciously, raise your left arm and right leg until they’re both out straight. Hold this position for 10 seconds or so, then slowly lower. Repeat for several reps. You can alternate sides with each rep, or do all the reps on one side first, then the other. I’m sort of looking forward here; find a position in which your head is comfortable. You can look at the floor if you prefer.

Address the immediate, acute symptoms. Manage the pain with over the counter medication and anti-inflammatories (if you can tolerate them). If the pain is a result of a particular event (such as bending over to pick something up and feeling a sproing), ice it for the first 24 hours. After that point, you can use ice if you prefer, but I have found heat to be much better for relieving muscular spasm symptoms. Find positions that make you comfortable. Avoid activities that cause pain for the short term.

Keep the area moving as much as possible. As soon as you can walk around, do so. Keep moving frequently and regularly. Gentle walking is good, but you may also find swimming and yoga are tolerable. If you know any belly dancing, this is also a great treatment for LBP. Lying in bed is the worst thing for back pain, as it seems to exacerbate or prolong the symptoms.

Begin to do specific exercises as soon as you can. These exercises serve both a rehabilitative and preventive purpose. In general, these exercises fall into a few categories: spinal flexion exercises (rounding the back, such as curling into the fetal position), spinal extension exercises (arching the back), bridges, and quadrupeds. I demonstrate a few of these in Part 3. I highly recommend purchasing a copy of Robin McKenzie’s book Treat Your Own Back, which is cheap and available at the major online book stores, but if you want to spend a few extra bucks, invest in Stuart McGill’s book Ultimate Back Fitness and Performance. McGill is one of North America’s experts on back pain and spinal biomechanics. Many people find that these exercises, if performed at the onset of a LBP episode, can bring immediate relief or shorten the duration of the episode. Exercises should have the purpose of mobilizing the affected area, strengthening/stretching, and/or improving awareness of the low back/pelvic region. Research demonstrates that people with LBP appear to be less able to stabilize their pelvic region (for example, while sitting or standing), and that they have reduced endurance (note: not strength) of the spinal extensors, but whether this is a cause or effect of the original problem is not yet clear.

At work, if you spend a lot of time seated, change sitting position often. Get up and walk around for a few minutes as frequently as possible. Some LBP sufferers swear by sitting on a Swiss Ball.

One “home cure” recommended for DJS by Stuart McGill is to put on a lightly weighted, well fitting backpack (say 5-10 lbs) and go for a 15-20 min walk over uneven terrain. He’s found this to be a useful and free “cure” for students who show up at his university office with back pain from being hunched over studying for exams.

Be aware that you are most vulnerable to re-injury when fatigued, or for about half an hour after getting out of bed in the morning, or after getting up from sitting for a long time. During this period, take extra caution to keep a neutral spine and use proper lifting technique (more on this below). The most common injury moment occurs during household tasks for a couple of reasons.

First, people don’t pay as much attention to their lifting technique during household activities as they do in the gym. If you’ve read this site you should know how I feel about gym technique, and you are probably trying to be careful with your form in the gym. But you’re likely not paying as much attention to how you pick up groceries or rake leaves.

Second, household tasks involve a lot of stooping, lifting, and bending, frequently in awkward positions. So, you may be performing a perfect squat, but throw out your back when you bend over to put a dish in the dishwasher. A previous roommate of mine threw out her back for weeks after she coughed while bending over to open a low dresser drawer.

When lifting a weight of any kind, even a bag of groceries, hold your breath for a split second during the toughest part of the lift. Don’t hold it till you turn blue. Just hold it for a very brief moment during exertion. Imagine someone is going to punch you in the gut. This helps the torso musculature rigidify and stabilize the spine.

After your injury, start back to regular weight training slowly and carefully. Maybe you won’t be able to squat this week, but next week might be okay. Keep the weight moderate, stop before you are too fatigued, and check your ego at the door. Progress gradually, letting your body dictate the pace. You may find that more, shorter sets are better than fewer, longer sets. For instance, 8 sets x 3 reps might be better than 3 sets x 8 reps (using the same weight for the 3 rep sets as the 8 rep sets).

People with LBP can squat and deadlift and do any lift they like, as long as it does not cause pain. There are powerlifters with disk herniations who were able to return to squatting and deadlifting heavily with no ill effects. Different people will have different needs. Everyone has their own theories on what works. Some ideas may work for you. Some may not. Do what works best for your own situation. For some people, deadlifting is a great rehab exercise. For others, deadlifting is one activity that will need to be avoided. The only exercise that I consider a bit too high risk to attempt with LBP sufferers is the stiff-legged deadlift. That being said, some folks may find it an invaluable rehab exercise. So again, experiment (with care), be creative, and do what doesn’t cause pain. For folks who experience LBP from squats, Ironmind makes a hip belt that allows the lifter to attach the weight so that the load is distributed around the hip, rather than axially down the spine from the upper back (as in a regular squat).

Somewhat counterintuitively, standing exercises may be less painful than seated exercises. For example, a standing overhead press, because it allows the spine to move freely, may be less painful than a seated overhead press, where the spine is limited in its movement. In general terms, the freer the movement, the easier and less painful it often is. An unweighted squat may be pain-free, while a leg press on a machine may be quite problematic.

Combine your regular weight routine with rehab exercises. Do this as “preventive maintenance” for at least a month or two after the resolution of the pain, or forever if you like.

A weight belt may help with proprioception. Proprioception is the body’s awareness of what it’s doing and what’s going on. If a weight belt is worn by a lifter, the lifter can use the touch of the belt to help be aware of what the torso is doing, and to stabilize accordingly. Pushing against the belt during a lift also increases intra-abdominal pressure (IAP), which also assists in torso stabilization.

Drink lots of water. It helps keep the disks hydrated, happy and squishy. When disks get dehydrated, they lose their elasticity and begin to deflate.

If you are carrying a lot of weight around your midsection, consider throwing some of it overboard. This will reduce the load on the spine that is pulling it forward.

Keep a neutral spine as often as possible. Neutral spine isn’t really one particular position, but more like a dynamic state where the spine is allowed to find its natural and preferred position, depending on the requirements of the task. In general there should be a natural curve in the lumbar (lower back) region; however, if you are pressing overhead, you should tuck this curve slightly.

Squat to lift, always. Let the legs do the work. If possible, never move a load with the spine in flexion, i.e. rounded (unless it’s specifically a spinal flexion exercise, such as an abdominal crunch).

One of the main things that beginners need to learn is to trust their instincts. If you feel like something is wrong, and I don’t mean a general “Gee, this squat makes me feel kinda funny barfy-like” sensation, but rather a sudden, “Uh-oh, that ain’t right” insight, then STOP immediately! See the injury page for more on distinguishing between good and bad pain. Luckily, most problems in the gym are not really about injury, but more about not getting optimal results.

The second thing beginners need to understand is the importance of learning from mistakes. It’s not stupid to make a mistake, but it is stupid to make that mistake again and again and again without ever trying to use that mistake as an opportunity to do better next time. I once heard someone say that there is no failure, only feedback. Use your performance as output and evidence that guides you to make better decisions in future.

Finally, beginners benefit from setting short- and long-term goals. If you don’t know what you’re trying to do, how do you know if you’re succeeding or not? You need to be able to monitor your progress on a weekly, monthly, and yearly basis. I like to work in short cycles of 4-6 weeks. This is a long enough period for me to make noticeable gains, but not so long that I go on doing something mediocre forever without ever clueing in. At the end of each cycle, I look back on what I was doing, and evaluate it. Did I get the results I wanted? If so, what was I doing right? If not, what could I have done better? What changes could I make both for variety and improvement? What did I like and not like about the exercises, split, schedule, etc.? I also check my progress within the cycle itself, noting during workouts how I felt, which exercises didn’t really work very well, and so forth. For example, one day I might have a bad workout because I didn’t eat properly beforehand; I can see that immediately and remember that for next time. Or I might have felt a certain exercise was causing bad pain, so I can amend it for next time or strike it altogether and substitute something else. Your goal is to find a good balance of consistency and change. You want to stick with something long enough to see if it works, but you also want to notice what things can be altered in the short- or long-term.

Now that I’ve given you a nice lecture, have a gander at this handy troubleshooting guide and see if you can find a solution to your problem. If you don’t see anything useful here, drop me a line and I’ll do my best to help.

problem: strength gains slow or stalled

solution:

1. Diet. This is always the first place you should look. Are you eating enough? Don’t underestimate how much you need. Try eating a bit more for a week or two, particularly concentrating on getting more protein and fat, and see if you notice any improvement.
2. Overtraining. Are you weight training heavily more than 4 days a week? Are you trying to do too much in every workout? Weight workouts should be no more than 45-60 minutes, and the intensity should not be maximal every time.
3. Routine. Are you using compound movements such as squats and rows? Are you lifting heavily enough to challenge you but not so much that you can’t control it, or end up lying on the floor afterwards? You need a weight range that is neither too heavy nor too light. Are you focused on what you are doing?
4. Rest. Are you getting enough sleep? Have you been sick recently? Is there stress in your life, whether mental, emotional, or physical? Your body can only devote so many resources towards strength gains, and if it has to allocate energy to solving various other problems, your workouts will suffer. You can either decide to eliminate or minimize the stress somehow, or if that’s not possible try to give yourself more rest and allow yourself to be mediocre in the gym till the stress has passed.
5. Change. Have you varied the intensity of your training in the last 2-3 months? Have you been doing same-old, same-old for ages now? Intensity variation and progressive resistance (adding weight/difficulty over time) are important. Change one or more of these variables in your program: weight, rep tempo, number of reps, number of sets, rest intervals, exercise type, or workout split.
6. Timing. How slow is slow? As a beginner you will make gains with every workout. As you progress those gains will diminish, but they should still be occurring every 1-3 workouts, whether those gains are an extra rep or two, an increase in weight, a fuller range of motion, an ability to handle a slower tempo.

problem: fat loss slow or stalled

solution:

1. You may not actually have a problem. Fat loss is usually no more than 0.5 to 2 lbs weekly. Some weeks you won’t lose anything. The body is just like that. It doesn’t operate using nice mathematical systems. Faster weight loss will often happen if you begin at a higher bodyfat level. The closer you are to your ideal bodyfat level, the slower your fat loss will be. If you are trying to do more than that you will chew through muscle, lose mainly good lean body mass, and put your body into starvation mode (which will come back to bite you on the ass when your appetite hormones kick in to compensate). Understand that the scale is not always the best guide to fat loss. Since muscle is denser than fat, you may register a weight plateau or even a slight gain despite an actual fat loss. For a more accurate gauge of progress, use calipers, measuring tape, and a mirror. Take your measurements once every 1-2 weeks, not daily, and take them in the same way each time (I always do mine first thing in the morning since at the end of the day I’ve added about 2-5 lbs of water weight). Allow also for the temporary water weight fluctuations of your menstrual cycle.
2. Diet. Try cutting out all simple sugars and starches such as pasta, bread, potatoes, rice, sugar, pastries, etc. Fill in the gaps in your meals with more lean protein and fruit/veggies. You want to keep your caloric intake at about 9-12 x bodyweight. If you are sure that you have not dropped your calories too low, try eating slightly smaller portions more frequently. Do not try to purge fat from your diet; rather, try to get fat in the form of essential fatty acids like flax seed, hemp, or Udo’s Choice oil (believe it or not, eating these can actually help you drop fat).
3. Cardio. If you’re doing regular, low/moderate-intensity cardio, change 2-3 of those sessions per week to interval training.
4. Incorporate a regular “refeed” period where you eat 14-16 x bodyweight in calories for 24 to 48 hours. This helps “reset” the hormonal mechanisms that are responsible for preventing what your body perceives as starvation. The leaner you are, the more frequently you’ll need to refeed, but in general, once a week is probably OK for most folks. Usually it works best to pick a day or two on the weekend to do this, since it also fits with many people’s lifestyle.
5. Timing. Fat loss generally begins to happen quickly, especially (as I note above) if you begin at a point which is much higher than your ideal bodyfat level, then tapers off the longer you do it. Very overfat folks can lose up to 5 lbs. per week in the beginning with no ill effects, because 5 lbs. represents such a small amount of their overall mass. Later on, as bodyfat levels drop, 5 lbs. becomes a larger piece of the whole. It’s not uncommon to plateau for a couple of weeks too, then see a sudden drop. Have patience.

problem: squats make you want to hurl your cookies/roll into the fetal position/cry for mommy

solution:.

1. Don’t panic. First of all, this is normal.
2. Have patience. Squats become relatively easier as you get better at them. Stick to them; they are the grandmammy of all great exercises and have major benefits.
3. Sip (don’t chug) a sports drink during your leg workout. This will help keep your blood sugar level at a reasonably constant rate.
4. Eat beforehand, or don’t eat beforehand. Some people say that doing squats with anything in their tummy is barf city. I find it the other way around: if I don’t have a small meal within 60-90 minutes of squatting, it’ll be a terrible workout. Figure out what works for you.
5. Have a couple of antacids before the workout. This seems to work for some people.

For more ideas, see the Effluvia page.

problem: this exercise hurts in a bad way!

solution:

1. Always, always, always check your form! It is the first place you should look to determine why an exercise doesn’t feel right.
2. If after following my suggestions below, the exercise still hurts, don’t do it. Find a substitute. And if difficulties persist, check with your doctor/physical therapist to see if you have an underlying medical problem. Don’t try to work through serious pain. It will only make things worse.
3. Stretch around the joints that are giving you difficulty. Sometimes this can make all the difference.
4. Try using a lighter weight for the exercises. Not all exercises are optimal with lower reps.

problem sites:

Shoulders

Main culprits:

1. Bench press. If it hurts your shoulders, try switching to dumbbells instead of a bar or machine. Do supplemental shoulder exercises to strengthen the muscles around the joint, and don’t forget to include rotator cuff exercises.

2. Behind the neck presses or pulldowns. Just don’t do them. Pull in front of your head instead.

3. Dips. Try using a narrower set of bars (many gyms have a V-bar instead of bars that are parallel, so that you can use whatever width you like). Don’t go down below a 90-degree elbow bend. Use lighter weights (if you are using weight) or an assisted dip machine to allow you to work in a higher rep range.

Elbows

Main culprits:

1. Triceps extension. This includes lying presses, cable pressdowns, etc. If it hurts your elbows, don’t lock them.

2. Bench press. Same advice: don’t lock elbows.

Wrists

Main culprits:

1. Upright rows. Switch to a wider grip and a lighter weight. Or avoid this exercise.

2. Pullups/Pulldowns. Try a wrist wrap for the time being, and incorporate some grip work into your workout to strengthen wrists. Avoid, if you can, movements that jerk or pull at your wrists suddenly. Try to keep wrists straight as much as possible.

3. Biceps curl. Try using an E-Z curl bar (the zig-zaggy bar) and making sure wrists stay straight.

Knees

Main culprits:

1. Leg extensions. These are a double-edged sword. They can be a good exercise for healing knee problems, and for causing knee problems. They can help build the vastus medialis, which if it is weak is a prime cause of knee problems like patellarfemoral syndrome, chondromalacia, etc. To use them remedially, only use light weight and only work in the top 1/3 of the rep (from about 120 degree bend in knee to straight). If you are prone to knee problems, never begin a leg extension with leg bent more than 90 degrees, and use lighter weight.

2. Squats. As I said above, and on my injury page, problems here are usually a result of strength imbalances. Try varying your stance, including the degree of toe turnout, and building up the vastus medialis. Also check to see that your knees are not drifting out over your toes. If squatting deeply really hurts, then don’t do it. Front squats and/or stepups are usually good alternatives.

Lower back

Main culprits:

1. Squats. Lift with your legs, not with your back. Use lighter weight, and try to keep your back as upright as you can with a natural arch (women often have to lean forward a bit more). Do not round your upper back as you come up.

2. Deadlifts. Same advice. The drive comes from your legs, hips, and glutes. Back should be as straight (not necessarily upright) as possible with a natural arch in the lower back. At the top of the rep, squeeze your hips and glutes in a sort of pelvic tilt to drive the hips forward. As the hips come forward, the back straightens on its own. Use lighter weight till you get used to this sensation. When the weight is too heavy people are tempted to haul with their back too much. Think of your arms are just hooks from which to hang the weight. They should do nothing but keep the weight from falling out of your grip.

3. Weak lower back. Try adding in some extra lower back work and cutting back on squats and deadlifts for a little while until your weak link catches up. Don’t use good mornings if you are prone to problems; instead use slow, controlled back hyperextensions. Also make sure abs are strong. A strong abdominal and lower back column is your preventive measure against injury.

4. Lifestyle factors. Do you sit slouching at work? Do you work out immediately after getting up in the morning, when the tissues of the back are more sluggish in their response and prone to injury? Do you perform household lifting tasks with poor form, including rounding the upper and/or lower back? Examine risk factors outside the gym.

problem: boredom, lack of motivation

solution:

1. Check out my page on getting motivated as well as on setting goals and try some of the tips there.
2. Are you overtrained? See above.
3. Plan ahead. If you just go into the gym and wander around waiting for inspiration to strike you’re going to have a difficult time maintaining a consistent effort. Make a detailed plan of attack and stick to it. Get into the gym, train hard, then get out. Eliminate distractions and workout destroyers. Pack your gym stuff well in advance of hitting the gym so you can’t use the “oh-well-I-forgot-my-gym-stuff” excuse. Keep some extra stuff in the trunk of your car, or your locker, or under your desk at work, if you can.
4. Are you having fun with your workouts? If each trip to the gym is pure unadulterated torture and ennui, then you’ll have to rethink your plans. Find an activity that you enjoy to supplement your weight workouts and to give those workouts some meaning. If you like cycling, for example, remember that squats will help you when you hit those hills.
5. Get involved in learning a new and challenging skill, sport, or activity, such as Olympic lifting or kick boxing. Try a new exercise. Experiment with different kinds of workouts. Novelty is the enemy of boredom.
6. Get a workout partner. Sometimes just having to be somewhere to meet someone can get you going. A good partner can motivate as well as entertain you between sets and make the gym a positive experience. It can be lonely being one of the few, or even the only woman at your gym who trains seriously with weights. Find a supportive community wherever possible.
7. Some people absolutely swear by their iPod or mp3 player. Having music that makes you want to tear up the gym with your teeth is always a plus. I think any alternative to the cheese they play in most gyms is an improvement.

problem: bad workout

solution:

1. Don’t get discouraged – get angry! Transform frustration into creative energy. Finish the workout as best you can. Sometimes workouts that start badly manage to end on a good note.
2. Figure out why you had a bad workout. Are you under stress, did you eat enough, did you get enough sleep the night before, etc.? Then take steps to eliminate these factors next time. And there WILL be a next time… bad workouts are like falling off a horse: you just have to get back on again.
3. Bad workouts happen to the best of us. Sometimes the mojo just isn’t working. If this happens once in a while, get through it as best you can, then try to avoid it next time. If it happens often, look at possible overtraining.

problem: fear and self-doubt

solution:

1. This is the biggest, most evil bugbear in the gym. We doubt our capacities and skill, particularly if we consider ourselves nonathletes. The gym is full of large scary guys who seem to know what they are doing, and who we fear will laugh openly at us if we screw up. Remember that you have a right to be in the gym, and claim your space.
2. If you can afford it, get a trainer to show you the ropes. Familiarize yourself with the equipment, including the squat rack/cage and deadlift platform. Keep your eyes open and observe what others are doing, but don’t be deceived–the majority of people in the gym aren’t doing things quite right, and many are screwing up substantially. Hit the bookstore or local library and get out every book on strength training you can find. I particularly recommend anything by Fred “Dr. Squat” Hatfield, Stuart McRobert, and Bill Pearl (Dr. Squat and Bill Pearl also have great websites). Look at ExRx too; they have an excellent section for beginners.
3. Try hitting the gym when there are few people there. For my first attempt at squatting, I went to the gym early in the morning when it was nearly empty. This made me feel less shy about possibly messing up and I was able to concentrate on attempting the exercise.
4. Celebrate each small success. Did you add 5 lbs. to your bench press? Did you lose 0.5% bodyfat? Did you try something new? Each workout affords the opportunity to celebrate achievements. You are only competing against yourself, so don’t get down about how much you’re not doing. Get excited about how much you can do already, and by how much you’re going to do in future.
   Once you’ve done your homework, trust yourself. Allow yourself to make screwups, but know that you’ve done some research and know what you’re doing. Knowledge is power, after all.

Symptoms of PF typically include pain at the front of the knee while performing certain activities such as descending stairs or hills, running, or after prolonged periods of sitting. Crackling or grinding in the knee may also be experienced, although this is more likely to indicate chondromalacia.

The kneecap, or patella, is a roughly oval piece of bone, held in place by connective tissue, that sits in a little groove on the femur, and slides up and down as the knee bends or straightens. One of the most likely culprits behind PF is improper patellar tracking, or movement in its groove, and this can be caused by a number of things. Bear in mind that not all explanations are equally accepted by all members of the medical establishment. Also, some things are a bit chicken-and-egg. Which came first, bad structure or bad movement patterns?

1. Women tend to have wider hips than men, and as a result, their femurs must swoop down to the kneecap at a greater angle. This is known as the Q-angle. This increased Q-angle can increase the likelihood that the patella will not be properly aligned.

2. Pronation (inward lean) or supination (outward lean) of the foot can also exacerbate PF syndrome. Pronated feet require the ankle and consequently the femur to compensate, and supinated feet provide decreased shock absorption when the foot hits the ground. Both of these conditions can be alleviated by purchasing good shoes, and using orthotic inserts. Check the bottoms of your shoes to see if you have this problem. Pronators will have the worn spot of the sole on the inside of the ball of the foot, while supinators will show wear along the outside of the sole.

3. Muscular weaknesses in the thigh muscle (quadriceps). Some suggest that a weakness in the vastus medalis (inner quad muscle above the knee) is the problem (see below for more of a discussion about this). Others add that weak hip muscles play a part, especially weak external rotators. We see this problem with trainees who let their knees cave together when squatting.

4. Inflexibility in some areas, particularly the iliotibial band (a piece of connective tissue running from the hip to the knee along the thigh), hamstrings (back of thigh), calves or lower back. Again, folks are divided on this. PTs argue that the IT band can’t be stretched. On the other hand, stretching of the aforementioned muscles can do little harm and is quite likely helpful. Hamstrings are involved in bending the knee, and inflexible hamstrings can cause pressure to increase between the patella and femur.

5. Poor running mechanics. If you run, you should probably be striking the ground with the forefoot (ie the ball of the foot) rather than the heel. For more on the biomechanics and proper technique of running, see Ozzie Gontang’s page on mindful runnng and Michael Yessis’ excellent book Explosive Running.

so, your knee is screwed. what to do?

immediate treatment

1. Rest. Quit doing whatever you’re doing that causes pain, if possible. That means jogging, skiing, high-impact aerobics, allowing your two-year-old to whack your knee with her Pokemon doll, whatever. Chronic overloading is one of the most significant causes of PF pain.

2. Ice. Wrap some crushed ice in a ziploc bag, or a bag of frozen peas in a dishtowel and sit with it on your knee for 10-15 minutes (no longer). Do not allow ice to touch skin directly, if possible. Do this 1-3 times daily, especially after activity if you’re able.

3. Pain relief. Now, I stay away from anti-inflammatories because they upset my tummy. That means ibuprofen, naproxen drugs like Anaprox, and so forth. You are welcome to try them over the short term, since they do help reduce some of the underlying cause of pain, which is the inflammation. Dietary supplementation with things like bromelain (pineapple enzyme) and fish oil are a better choice for long term anti-inflammatory, as they does not have many of the negative effects of OTC anti-inflams. If you just want some short-term pain relief, acetaminophen (Tylenol) is fine.

4. Accurate diagnosis. See a doctor and make sure what you have is really PF. One quick test you can do at home (but I warn you, this is painful) is to sit with leg out straight in front of you. Relax your leg. Then have someone put their hand on your thigh, just above your kneecap, and exert a gentle but firm pressure downwards, towards the floor (not down your leg towards your foot). Flex your thigh. If you feel a sharp pain, it likely means you’re having kneecap tracking problems. When I read about this, I tried it on myself, and I can attest that it does hurt. I then tried it on my somewhat unwilling but PF-free husband, and he had no problems with it. However, this test has a few problems. First of all it hurts like hell, and second it is likely to return a lot of false positives (in other words, it can cause pain for people who don’t have PF).

long term treatment

1. Quadriceps strengthening. It used to be that PTs would try to strengthen the vastus medialis, believing that its weakness relative to the other quad muscles allowed the patella to be pulled out of the groove. More recent studies agree that since the quads are designed to work in concert, you can’t really isolate a single one. So, attention is now focused on having people do compound exercises that strengthen the entire thigh muscle group.

Despite all that stuff about squats supposedly being bad for your knees, full depth squats are actually great for knee rehab. They strengthen all the leg muscles with a compound, natural movement. If you can squat without pain, then by all means do so, even if you can’t use any weight. If you can’t squat the full range, squat in the range of motion that is pain-free for you, and gradually try to increase the range. Front squats are an ideal exercise, both because they put more emphasis on the quads, and because they seem to put pressure differently on the knee joint. When I was having real PF problems, I could do full depth front squats with no difficulty whatsoever.
Some folks recommend leg extensions, but I am very hesitant to recommend these. Putting frontal/lateral as opposed to downward force along the shin (tibia) can actually worsen knee problems with the shearing force that is created in the joint. If you choose to do leg extensions, do them with very light weight, and only the top 1/3 of the movement (like from nearly straight leg to straight leg) and don’t lock your knee.

Other exercises to do if you cannot do squats at all without pain, try these:
-Step up onto a step or block with one leg, then step back off (land gently, and don’t lock knees). Over time, increase the height of the step. Focus on driving through the heel of the foot on the step rather than pushing off with the back leg.
-Step down from a step with one leg, then back up
-Sitting on the floor with legs outstretched in front of you, slowly raise one leg, keeping it straight, as high as you can go; hold it in the air for 10 seconds, then lower slowly. This can be done with ankle weights.

2. Hamstring, hip, and calf stretching.

One good stretch given to me by my PT is this. Stand with right side facing a wall, feet together about 6 inches away from the wall. Take your right foot and cross it over your left leg, placing it on the floor. Stick your hip out to the left like Mae West workin’ it, and turn your upper body to face the wall, placing hands on wall. Push outward on hip to the left. You should feel a stretch along your left hip and down the outside of your left thigh. Hold for 30 seconds, then repeat for other side.

For lots of folks, though, this stretch doesn’t do much. So I came up with a better one. It’s like a standing hamstring stretch with a twist — literally. Stand facing a staircase. You can do this on any elevated surface, but a staircase works best, because you can wedge your foot into the corner so that it doesn’t turn. Lift the right leg and place the right foot on the second or third step. Keep your leg straight.  That’s step 1. Step 2: turn your entire body except for the elevated leg (especially your hips) slightly to the right. You want to turn towards your elevated leg, but leave the leg where it is. Now the elevated leg is slightly across your body at a diagonal rather than straight out in front. Step 3: Just like a regular hamstring stretch, bend forward from the hips (not the waist). You should feel this down the outside of your hip, thigh, or even the side of your calf. You won’t be able to go down very far. Repeat on other side.

To stretch hamstrings and calves: stand, cross one leg over the other, then bend at hips as far down as you can go. You should feel a pull along the back of the rear leg. Repeat for other leg.

Other stretches can be found here – click on the body part you want to stretch.

3. Hamstring strengthening. Again, full squatting is useful here, so do it if you can. Also, you can do stiff legged deadlifts and hamstring curls.

4. Shoe orthotics. If you do indeed pronate or supinate, orthotics will help. Also, folks in athletic shoe stores are often very knowledgeable about which brands of shoe are better for which problems.

5. Checking exercise form. Many people allow their knees to cave in while squatting or leg pressing. Bad!! When ascending from a squat, focus on pushing knees outwards. You won’t really push them out much, but it will feel like you are. When going up stairs, shift your weight back onto your heels as much as possible. Same goes for the stairmaster.

6. Supplementation. Supplementing with glucosamine and chondroitin sulfate may help. Other supplements such as bromelain, fish oil, and MSM will help reduce inflammation.

7. Soft tissue therapy such as Active Release Technique and self-massage of the soft tissue of the thigh with a rolling pin.

8. Surgery. This should be a final, final, final option, after all other non-invasive avenues of treatment have been tried.

Recently a friend emailed me to ask for my assistance. Her lower back was hurting her and she was miserable. I fired off a series of questions to her. What was the pain like? Had she been doing anything unusual, such as moving house, recently? Etc.

Once my interrogation was over, I made my diagnosis. She was afflicted with an ailment that is epidemic in our sedentary culture: Desk Jockey Syndrome. Not to be confused with Disc Jockey Syndrome, which usually involves a predilection for dumb crank calls, playing the same annoying hit three times an hour, and what is generously termed “a face for radio”, Desk Jockey Syndrome (DJS) affects a majority of people in North America at one time or another. It’s characterized by back and neck pain, as well as frequent shoulder pain and repetitive strain injuries. In this section I’m going to address the issue of lower back pain, or LBP to those of us in the know.

Predisposing conditions for DJS include sedentary living and working, excess bodyfat, especially concentrated around the midsection (which exerts a downward and forward pull on the low back), and a lack of regular physical activity. To be candid, a lot of us spend a lot of our jobs wearing an ass groove into a desk chair or car seat. Often, the head is carried forward like E.T., the shoulders are rounded forward and hunched, and the spine is rounded. See the photos at the end of this article for examples. As a result, the neck, upper- and midback are tight, and the shoulders are in excessive internal rotation. The pecs are shortened, and the shoulder blades pulled forwards. If we do lifting as part of our job or daily life, we don’t squat; rather, we round the back, curling forward from the waist.

This creates what is called shearing force across the spine. Think of shearing force like a sideways force applied to a stack of books. If you push the top book sideways, eventually it’ll fall off the stack. Now imagine that you’ve put a rubber band around the book stack, connecting them together. If you push that top book, it won’t move as easily, and the strain will be borne by the band. Eventually if you push the book hard enough, the band will snap.

The spine is rather like that stack of books stuck together with a rubber band. It’s a chain of vertebrae linked by connective tissue and muscles. The deepest layer of musculature supports the spine intersegmentally. In other words, there are little tiny muscles that run along the spine, holding together a few vertebrae at a time (I mean this figuratively; I don’t mean that they actually run along the spine, scrambling madly to grab spine pieces).

There are several layers of torso musculature, and normally they coordinate their jobs nicely to both stabilize and move the spine. When we sit or lift improperly for long periods, and combine this with a lack of overall activity and back strengthening, then we are not providing the conditions for these muscles to do their job. For example, each time we round the back to pick something up, we are silencing most of the supporting spinal musculature. The load is borne entirely by the connective tissues of the spine: the ligaments and tendons that hold everything together. Eventually their union steward is going to file a grievance against you as management, and that means a world of hurtin’ as the muscles set up little picket lines with burning oil drums, and chant “No justice, no peace”.

The spine provides a framework that houses the network of nerves that allow sensation and movement. Nerves branch away from the spinal cord and run to the extremities. This structure means that pain that is felt in one place may actually be originating elsewhere closer to the spine, or in the region of the spine itself. For example, pain felt in the arm or shoulder may actually be originating from the upper or midback. The condition known as “sciatica” is an irritation of the sciatic nerve that runs down through the hip and along the leg. People with this condition may experience tingling and burning all the way down to their foot.

Whenever I see a client with extremity pain, I try to address what may be the root cause or origin of the irritation. This means that I look at the length of the back to see what the client may be doing, how they may be moving habitually, how they may be holding their body (are they standing with one shoulder hunched up? Are they slumping forward? Etc.), and so forth. Then, in my exercise prescription, I don’t just target the immediate area but also any other area that might be related. Sometimes the practice of bodybuilding suggests that the body is a jumble of parts, to be trained individually. Never forget: the body is a system. The foot bone is connected to the ankle bone, and so forth. So think about how all the parts are related.

referred pain sites:

Pain felt in foot, leg, and hip: tends to originate in low back

Pain felt in hand, arm, shoulder: tends to originate in neck, upper and midback

Pain felt in head and neck, esp. at base of skull: tends to originate in neck and upper back

In the rest of this series, I am assuming a few things. I’m assuming that your back pain is a general DJS type of injury, that has not resulted from an acute event such as an accident, and does not involve any damage to or degeneration of the vertebrae itself. The type of everyday back pain I am discussing is usually a result of a muscular spasm and/or inflammation. It can be excruciatingly painful if the inflammation impinges on a nerve. You can be convinced that your spine is trying to tunnel out of your colon using its fingernails to dig a path.

The advice I am going to give can apply to both regular DJS as well as more serious disk herniations, but again, with a disk herniation, be sure to see your doctor first. A disk herniation can range in severity and symptoms. Many people with severe disk herniation can be entirely pain-free, while people with mild herniation can be in agony. It often depends on where the disk has herniated, and if it’s irritating a nerve.

In this type of everyday low back pain (LBP), pain can be felt in a variety of ways and locations. Generally it’s a dull ache without an exact location, but it can often be a sharp, localized pain. Again, if the inflammation and spasm is in a spot near a nerve, it can result in the characteristic tingling and burning sensation of nerve injury. It can be felt in the spot of the injury, or it can be felt elsewhere, perhaps in the hip. It can move from location to location.

Here’s one piece of good news. About 80% of spontaneous LBP incidents resolve themselves. Chances are good that your back pain will get better without any intervention from you. But now the bad news. Once you’ve experienced back pain once, it’s much more likely to recur. I like to think that one is never really cured of LBP, but rather, one learns to manage it and engage in preventive maintenance so that it does not recur.

In Part 2, I’ll give some concrete suggestions about how to deal with LBP. In Part 3, I show some exercises and discuss how to find and maintain neutral spine, an important part of good movement technique.

vomit

Experienced trainers know the feeling. You finish a set of heavy squats, or all-out sprints, and suddenly your stomach tries to make a break for it. Blowing chunks, technicolour yawn, talking to Ralph on the great white phone, whatever you want to call it, nausea and vomiting during a workout are no fun.

what causes this?

Explanations vary. In a recent discussion on the Sportscience list, the following reasons were proposed:

• Gastrophageal reflux brought on by the valsalva maneuver (holding breath through heavy exertion)
• Compromised esophageal sphincter tone (in other words, a looseness of the little ring of muscle that separates your stomach from the esophagus) or esophageal or peptic ulceration
• Intense activation of central nervous system due to stress or the neurological demands of exertion
• Change in blood pH produced by the anaerobic metabolism of pyruvic acid. Low levels of lactic acid are normally produced from glucose via normal glycolytic pathways; however, if increased lactate production or decreased use occurs, lactate can accumulate. As the body uses oxygen, it generates carbon dioxide and hydrogen ions, which increases the acidity and decreases the blood pH. We have buffering systems to keep pH constant, but if these can’t keep up, then it creates metabolic acidosis. Intense exercise that sucks up a lot of oxygen — such as squats or sprints — can produce a very mild form of metabolic acidosis.
• Shunting of blood away from gastrointestinal tract to working muscles; stomach responds by trying to expel contents involuntarily
• Psychological nausea brought on by the stress of executing a difficult movement
• Dehydration and/or low blood sugar

how can I avoid it?

Barring trauma to your GI tract (as, for example, in the case of a trainee who has gastric reflux, in which the esophageal sphincter doesn’t close off effectively enough and allows stomach contents to make a run for the border), the best way to avoid nausea is through prevention. Some tricks:

• Pop a couple of antacids before your workout
• Have 1000 mg of powdered ginger capsules. Ginger is a potent antinauseant without the side effects of other anti-nausea drugs like Gravol
• Figure out which is more likely to make you feel nauseous: food in your stomach or an empty stomach. I have to eat something before I work out. Others need to have an empty tummy.
• Sipping at a sports drink or juice during your workout may help if the issue is low blood sugar.
• Add some cardio to your workout routine. Quite often, this will help improve your ability to tolerate the workload of activities such as squats, particularly if the cardio is reasonably intense. Start with a few minutes of intense cardio and work up to about 10 minutes per session.
• If it’s long squat or deadlift sets making you hurl, try shorter sets. Instead of 3 sets of 10 reps, try 5 sets of 6 reps. Alternately, try resting longer between sets. And make sure to suck in lots of oxygen.

urine

From PhotoshopDisasters.com, a poorly considered paint splatter graphic at the 2008 World Cyber Games in Cologne

Urinary incontinence of varying degrees is common among women who’ve given birth at some point in their lives. But it can be caused by other things as well, such as a natural laxity of the tissues with age. The abdominal muscles act dynamically in conjunction with muscles of the pelvic floor. When the torso musculature contracts, as in a heavy lift, or even something like coughing, it can affect the muscles responsible for controlling urinary output. When the abdominal muscles are under tension, as would happen in a heavy squat or deadlift, sometimes the ol’ bladder lets it rip. The result? You’re a whiz kid, but not necessarily in the way you’d like to be. This is known as stress incontinence.

First off, stress incontinence is a common problem, so don’t feel like you’re some kind of pants-peeing freak. Solving the problem requires a multi-pronged approach:

• Go to the bathroom before you lift heavy. This should be pretty obvious. Unless you are a real sweat hog, you needn’t worry too much about dehydrating during the time you work out, so go pee beforehand and keep liquid intake moderate. If there’s nothing in there, nothing can come out!
• Wear a pad in anticipation of any accidents. Most women just wear a maxi but there are specialized pads too.
• Practice your Kegel exercises regularly, and consciously execute a Kegel immediately before and during the exercise that gives you problems. Start the pelvic floor contraction, then hold it, and perform the rep. You can hold it throughout the set if you’re tough enough, or relax between each rep.
• If you feel you have a real problem, seek out a physiotherapist who is skilled at dealing with pelvic floor musculature.

Physiotherapy has proven to be an extremely effective and non-invasive treatment. Indeed, physio can treat about 80% of cases, according to the first national study undertaken in clinical practice by researchers at the University of South Australia. According to PhD physiotherapy student Trish Neumann from UniSA’s School of Health Sciences, stress incontinence affects about one in three women of all ages. While women are the main sufferers, incontinence can also be a problem for men, especially after prostate surgery. For a long time stress incontinence was treated by surgical procedures, but the outcomes of surgery have not always been positive. Success rates are as low as 50 to 60 per cent, and surgery carries the potential of complications. Thus, physiotherapy should be tried first, as it carries no risks, and the surgery option remains open to people who fail pelvic floor muscle training.

Being able to understand how to contract the pelvic floor muscles the right way is essential for a successful outcome, according to Neumann. “About one-third of women who are given a brochure about pelvic floor exercises, get the basic action wrong and don’t do well on their own with pelvic floor muscle training. They need expert guidance to achieve the correct technique, not from a general physiotherapist, but a specially trained continence physiotherapist,” Neumann said.

Of the women who took part in the study, about 80 per cent indicated that they were still happy with the outcome of treatment. In all, only 15 of the women went on to have surgery. “Age is not a factor in the success of the treatment but maintaining a strong pelvic floor once the muscles have been strengthened with regular exercise built into their daily lives is the key to long-term success. Exercise takes very little time and can be done at times that suit participants, and as part of their everyday activities… Unfortunately, many people don’t realise that help is available and they suffer in silence.”

pooplets

This is a bit of a sillier topic. Anecdotal evidence from lifters suggests that lifting heavy weights increases interabdominal pressure. On some occasions, this can mean bad news for rectal sphincter integrity. Farts and even pooplets can happen (I’m not familiar with any story involving a full accidental training-inspired crap, though). As one poster to misc.fitness.weights writes:

It’s like this: if you are concentrating on not farting, you aren’t putting everything you can into lifting. Ab work, squats, and deads are notorious for pushing the gas out. If you have to fart, you are going to. Most of the time they get out on accident, but there is really nothing you can do about it.

Another agrees, and recommends:

the PSD – the pre squat dump. Unfortunately, it works but not perfectly… interabdominal pressure always finds that last bit o’ poop. Powerlifters — we may be many things but constipated ain’t one of them.

The risk of letting one rip in the gym is compounded by one’s choice of protein source. A higher intake of protein in general can cause some intestinal fireworks in folks who aren’t used to it, or who suffer from lactose intolerance and choose dairy as their protein source. Egg protein, particularly liquid pasteurized egg whites if you don’t cook them, is just plain bad news. Increase protein intake slowly if you’re used to a low-protein diet.

On the plus side, a good hefty egg fart can really help clear the area and ensure that you can have any piece of equipment you like! And nobody will suspect you because hey, everyone knows that girls don’t fart.

People often ask me how I know so much about sports injuries. Well, I’ve been weight training seriously since the mid-1990s. And during that time I gave myself just about every major injury there is. (Oh, the joys of learning through experience.) I’d like to say my gym injuries happened as a result of a spectacular accident involving humourous Leslie Nielsen-esque pratfalls, 45-lb plates, rubber chickens, and/or general laff-a-minit antics. I’d like to say they were from rescuing babies stuck up in trees or kittens from a burning building. I’d like to say stuff like “You should see the other girl!”

But no, my problems came about in the same rather mediocre and uninteresting way that so many other physical misadventures in the gym do — overuse, fatigue, and biomechanical mismatch.

where do gym injuries come from?

While weight training has a reputation for being dangerous, it has a much lower incidence of acute injury than many other sports. In other words, it’s very unlikely that you will break a bone, sprain something badly, cut yourself, get a concussion, or tear a muscle or connective tissue. Sports such as football, hockey, skiing, and running have far greater rates of injury than weight training. In fact, weight training is generally used as part of an injury rehab program.

The source of most injuries in the gym, particularly those which are chronic, generally stem from a mundane source: bad gym practice. It is very important to make sure that you use correct technique, you vary your exercises occasionally, that you work your stabilizers with free weights, you keep your ego in check, and that you don’t concentrate your efforts in one area to the exclusion and detriment of others (you know who I’m talking to, chest boys).

Overuse injuries tend to emerge when you’ve been doing the same thing with too much frequency, and/or too much intensity, especially if you’re not conditioned for it yet. Overuse injuries often include common complaints such as achey joints and tendonitis (an inflammation of the tendon). Overuse injuries are particularly nasty because they don’t always result from big heavy movements. Rather, like carpal tunnel syndrome or Blackberry thumb, they come from tiny things done over and over and over. They may feel worse after you do the offending exercise, ache between workouts, and be restricted to a particular area. Overuse injuries generally respond to rest and reduction of the problem activity, icing, aggressive supplementation (see below) and if necessary, physiotherapy.

Overuse injuries also tend to pop up in smaller joints: wrists, shoulders, ankles, etc. This tells you that you may not be distributing the loading properly. A good example is the preacher bench biceps curl. In my opinion, this exercise is an easy path to elbow tendonitis. The upper arm is fixed in place, and there’s only one moving joint — the elbow. Because biceps curls are an ego exercise, folks love to load up the barbell and grind out the reps. When a lot of weight is hanging on one joint, that’s an E-Z-Bake recipe for trouble.

Fatigue-based injuries are often more serious, because you’re tired and maybe not using good form. Or, maybe you are using good form but you’re pushing your body past the limits of what it can comfortably do. Many years ago, I sprained my back. I was at the end of a long workout and decided to add weight to my last set of stiff-legged deadlifts. Because safe execution of this particular lift depends so much on perfect control of the spine, and because back injuries can result even from small deviations in vertebral position, this was a Very Dumb Idea. This back sprain stayed with me for many years, and even now I have to be careful lest I piss it off again. So, don’t go like that.

Wherever possible, don’t attempt difficult movements and/or movements that require a lot of careful technique, when you’re fatigued, because it increases your chances of injury. If you’re trying for a one-rep max, warm up well but don’t overtire yourself. Use a power cage and/or a spotter where possible and appropriate. Fatigue-based injuries tend to be things like minor sprains and strains.

Finally, there are injuries I call “biomechanical mismatch“. What this means is that the mechanics of some people’s bodies just don’t work with some forms of certain exercises. Frinstance, many people experience shoulder pain and eventual dysfunction from exercises such as the barbell bench press, upright rows, and dips. But yet they keep on doing them instead of finding substitutes. I see a lot of guys in my gym doing what I call the “chicken wing”. They do the bench press, then get up and crank one of their arms around while holding that shoulder with the other hand. They’re clearly in pain from it. But they continue to do it. For most recreational lifters, there’s no reason why you have to do a certain exercise if it causes you pain. You may need a temporary layoff, you may need to check your form and fix your technique, you may need to use less weight, you may need to modify the exercise slightly (e.g. bench press with dumbbells, or change the grip), you may need to find a substitute, or just junk the thing entirely. Don’t continue to do something if it’s hurting, no matter how good you think the exercise is.

uh oh. i think i hurt myself…

Here’s some general advice.

Learn to distinguish between good pain and bad pain. Good pain, which indicates that your muscles are being productively worked, manifests itself largely as delayed onset muscle soreness (DOMS), and is a general muscle ache or stiffness in the region that you exercised 24-36 hours before. Good pain can also be the “burn” that you feel at the end of a hard set. Good pain is diffuse, not overly localized to one spot. It often comes on slowly, rep by rep or hour by hour.

Bad pain, which can indicate injury or possible conditions for injury:

• tends to be acute and/or sudden
• usually occurs at a precise moment while exercising
• is more likely to be felt in a specific area like a joint
• may be accompanied by an audible sound like a crack or snap
• may feel like you’ve been suddenly struck in that area, or that something has torn
• may bruise and/or swell later

immediate treatment

OK, so you’ve got bad pain. Now what? The first thing to do is to take charge of the immediate situation. Remember the acronym RICE: rest, ice, compression, and elevation. Rest is obvious: STOP what you are doing that’s causing the pain. Don’t be an ass and try to “work through the pain”. I prefer to junk the slogan, “No pain, no gain” in favour of, “No pain, no pain” (yeah, it’s stupid, but it kinda makes sense).

Second, apply ice as soon as possible to the affected area for 10 minutes or so. Ice has both an analgesic and anti-inflammatory effect; in other words, it helps control pain and swelling. Wrap the ice in a towel; do not apply ice directly to the skin if you can help it. However, most healthy people with adequate circulation do not need to worry unduly about skin damage from brief cold application. A bag of frozen peas works well for injury icing, since you can mold it to the bumps and lumps of all your 2000 parts. It’s also handy to buy one of those gel packs and just keep it in the freezer for emergencies. At first you may feel a burning sensation on the skin as the nerves respond to the sensation of cold, but shortly a nice numbness will set in.

Never, NEVER heat an injury for the first 24-48 hours after it occurs, even if it feels good. You’ll get swelling and inflammation like you won’t believe. If your GI tract can tolerate it, take some ibuprofen, 200-400 mg every 4 hours. (Be smart with this stuff. Save it for when you really need it, as it’s hard on your insides.) This will control the pain and inflammation for the time being. Keep icing for 10-15 minutes every hour or two.

Third, compression. This will also help control swelling. If you can do so, wrap the affected area up snugly with an ace bandage (but not so snugly that you cut off circulation; you want compression, not a tourniquet… unless you’ve just severed your arm, then you probably do want a tourniquet). In a pinch, any piece of cloth will do. On a soccer field I’ve stolen someone’s head bandana to tie an ice pack to a player’s knee injury. Bad hair is a small price to pay!

Finally, elevate the affected part if you can. This might mean, for example, putting a sprained foot up on a chair while you sit with your ice pack.

long-term treatment

See a doctor if the injury is serious and/or persists for longer than a few days. The only way to take charge of your injury is to know what the heck it is. Is it the ligament, is it the bursae, is it the hard mass of the joint itself, etc.? Sometimes the symptoms for each can mimic one another, so it’s best to be sure. Try to find a doctor that understands a bit about sports medicine. If that’s not possible, ask your GP to refer you to someone who works with athletes and understands what their concerns are. Often GPs can be a little in the dark about what strength training involves, and don’t tailor their solutions to your problem.

Educate yourself. Learn some anatomy, see how the joint/muscle works, and understand what the problem is. Ask your doctor to explain exactly what’s wrong, and what you might have been doing to cause it. Try to suck in as much information as you possibly can. Critically evaluate your routine to see what you may have been doing. Were you working one group too hard without working the other (for example, were you working chest too often without regard to back?), or were you training on a machine that allowed your stabilizers to weaken, or that forced you into an unnatural movement pattern? Were you using improper form and uncontrolled movements? Did you just do too much of a good thing? Be ruthless in your critique. (If you fell down the stairs or got the snot beaten out of you in a title fight, you probably know what caused your problem, so you can likely omit this step.)

Investigate such things as supplementation to aid the healing process.

• Glucosamine sulfate is well-documented as a supplement for regenerating cartilage. 1500 to 2000 mg in divided doses is usually recommended for the hardcore weight trainer, and 500-1000 mg in divided doses for the average person concerned about connective tissue problems. Because of the relatively poor blood supply to connective tissues, glucosamine sulfate supplementation will take a while to show effects (and connective tissue injuries will take a while to heal).
• Fish oil, taken in therapeutic doses of 5-10 g daily, is also a good anti-inflammatory that can be taken long term.
• Daily intake of vitamin E and C (in food, not supplement form) can boost your body’s natural defenses.
• Judicious application of ice and/or heat (experiment to find what works best for your particular problem) can work to keep things under control enough so that you can work out. You can use heat once the initial swelling has gone down. Use your judgement here; if your foot still looks like a purple basketball with toes, keep icing. Alternating hot-cold treatments works well: place a heating pad on the affected area or immerse it in very warm water for a few minutes; then immediately switch to ice or cold water immersion for a few minutes. Go back and forth a few times, finishing with ice.

Allow yourself time to recover. Don’t try to work through an injury until it’s fully healed. Your body will not appreciate you re-injuring yourself and will reward your pigheadedness with a longer recovery time. Try not to let an injury destroy your enthusiasm for working out.

My injuries have made me wiser, and now I approach the weights with a new reverence, caring less about how much weight I do and more about how I do it. While injuries force some humility upon you, they can be an opportunity for you to re-evaluate your goals and motives for working out.