There were a handful of things about how my body was feeling that prompted my return to physical therapy—but I would not describe any of them as injuries. My shoulder is four years post-op, so it certainly doesn’t count as a recent injury. I do think, however, that most of the complaints on my list could be traced back to my shoulder.
(In case you missed it, part one talks about why I decided to return to physical therapy and you can find it here.)
Limited Range of Motion + Compensations + Kinetic Chain = Body not functioning optimally.
I think this serves as a pretty solid example of why we would be well-served by re-thinking physical therapy and the overall approach we take to improving how our bodies perform.
My left foot and ankle had recently begun to bother me. Occasionally, there was pain. My left knee would sometimes get annoyed with me whenever I would squat. And my left hip felt like something just wasn’t working right…
All of this felt somehow related to the way that my anterior core on my left side just never seemed to be able to fully switch on. During the first year after my initial shoulder surgery, I was trying so hard to get my arm to raise higher and higher above my head…and since I wasn’t being particularly closely supervised (and I didn’t know any better at the time), that meant that instead of that movement coming from my shoulder, I was doing a lot of arching back and flaring my ribs.
And, as it turns out, teaching my core on my left side to switch off. (I was also trying really hard to use my lats and my spinal erectors to raise my arm. They don’t really do that, but those muscles kept trying to help. Really, really hard).
My hypothesis is that this all somehow influenced how my diaphragm functions, which in turn, made things weird with my psoas. (I’m not quite sure if it’s possible to influence one side of the diaphragm or not, but it was feeling like something deep was just not working on that side). Following that down the chain, it ends up being not much of surprise that my hip, knee, ankle and foot were barking at me.
Knowledge Bombs from Dan
So, my new physio’s name is Dan Pope. (You can find Dan here: fitnesspainfree.com) After Dan was goodly enough to patiently sit through the telling of my entire shoulder—and now hip, knee, ankle, foot—story/saga, he took me through a thorough assessment. (It was reassuring to learn that my lower half actually moves reasonably well.)
From there, we decided to start by focusing on my shoulder.
Dan does a fantastic job with patient education and the things we’ve talked about have made for a significant change in how I think about my shoulder and pain. And since I’ve been thinking about it all quite a bit of late, I thought I would share:
Pain is a tricky thing.
The more scientific way of describing the effect (one effect) of pain is that injuries can lower your pain threshold. What that means is that you become more likely to feel pain when doing things that were previously nonpainful. This phenomenon by itself is a tricky, somewhat psychological, somewhat deeply protective, nervous system mechanism that can alter your perception of what’s actually doable for your body.
…which is a mixed bag.
There’s the obviously beneficial protective element to it that helps you to avoid hurting yourself again: more pain = bad.
However, pain isn’t always bad.
[alert type=”info” close=”false”] No discussion of pain would be complete without acknowledging that there are a variety of ways for pain to go awry. A friend and past-trainee of mine serves as the foremost reminder for me that pain is an incredibly complex subject. Most importantly for this discussion, pain is an experience that is always unpleasant and emotional. It is always subjective and consequently, no two people experience pain in the same way. [/alert]
In fact, you could view pain as a good thing: it’s your body’s way to telling you to be careful. The million-dollar question becomes just how careful.
That makes understanding your pain important.
Your beliefs about your pain are even more important and that’s where this gets personal.
As I mentioned previously, for me, pain has been a reminder that I need to be careful. Very careful.
I may have gone overboard with the “careful”.
The problem for me has been that the pain ended up being a reminder that my shoulder could get worse if I’m not careful.
What is perhaps more important is that I also took the pain to be a reminder that my shoulder won’t get better.
Having spent much of my life always training for something, I enjoyed challenging myself. I enjoyed pushing my own limits. Feeling as if pushing myself and challenging my limits would most likely just make my shoulder hurt more may have contributed to me developing a less-than useful way of looking at pain. And it meant that I didn’t do as much fun movement-y stuff as I used to.
Sometimes, pain is good.
Intellectually, as a strength coach and personal trainer, I think I could have pieced the one together—for my athletes and clients.
You know, people who are not me.
Shoulders that are not my shoulder.
So when Dan suggested that pain could be a good thing, well…Boom.
Mind. Exploding.
This is why it’s so important to get an outside perspective on your own training progression. Sometimes there are things you just can’t see by yourself.
When dosed appropriately, a certain amount of pain with movement is not only ok, but it can be beneficial. In fact, when some pain is allowed through the rehab process, people tend to have better outcomes than those who avoided pain altogether.
Again: boom. Mind-exploding.
[alert type=”info” close=”false”][Note: my own recent experience with this suggests that the smartest thing you can do is to make sure you have an experienced rehabilitation professional (you know, like a physical therapist) working with you to navigate and dose the amount of pain you experience as you’re working to heal and/or strengthen previously injured or weakened tissues.
However, if you are a circus artist-athlete who has pain that has been there for more than a week—you know, because you “tweaked” your (insert muscle here)—this is not a suggestion for you to just train through it. No: you probably have an injury that needs to be evaluated by an orthopedic doc.][/alert]
So on the one hand, pain can be the thing that inhibits (and discourages) movement. And then, whenever movement approaches the edge, the pain comes back and reinforces the notion that you shouldn’t move that much.
However, on the other hand, movement helps to reduce pain and to reduce the inhibition that accompanies the pain.
The vicious cycle that can unfold—where you move less to avoid pain and then pain reinforces that inhibition—perhaps needs a bit of pain—a bit—at first, to disrupt the cycle.
The Magic of Simple Movement
My homework from my first session with Dan was simple and straightforward: daily “letters”.
I, Y, T and U. Your basic rotator cuff stuff.
(Below are Dan Pope and Dave Tilley showing you versions of these exercises that folks with healthy shoulders should be doing).
My Y’s, T’s and U’s are, of course, without weight. My arm feels heavy enough.
For the first two weeks, all of these movements were really hard for me. I was amazed at how sore I was from just moving my arm. Truth be told, there were several times the soreness woke me up in the middle of the night. Because my shoulder was so relatively deconditioned, this was basically like starting a strength training program.
U’s were especially brutal for me. Doing the supine version featured a mix of conditioned trepidation and just plain restricted motion. Flip over onto my front and my goodness: it took so much mental effort just to get into position. My muscles were not at all accustomed to moving in this particular range of motion and without the assistance of gravity and consequently, it felt like my brain had to scream HEY! MUSCLES! MOVE!!! in order to produce the slightest twitch.
But within days, my shoulder was moving noticeably better. My range of motion had improved and, most significantly, the “pain” I felt at the edges of my range had subsided.
I’m almost eight weeks in now and just yesterday, things seemed to turn a corner:
For the Y’s and T’s, I feel able to really engage the muscles when I’m in my end-range. Most enjoyably, U’s have begun to feature more range of motion and (slightly) less mental screaming to get there.
For the first time in a long time, I tried doing glenohumeral CARS with my left arm. I wish I had a video from before I started working with Dan, but I suspect that the biggest differences are with the quality of the movement and with proprioception (which are difficult to capture on video). Nevertheless, I thought it would be fun to share:
Not only does my left shoulder move better, but I make some pretty great faces!
Self-Soft Tissue Work vs Movement
This recent experience has got me thinking: for years now, I have done all sorts of self-soft tissue work to try to get the muscles around my shoulder to settle down and allow me to move more/better. On its own, I got relatively little return on my efforts. Sometimes, I would get some release…but nothing that ‘stuck’.
And I think the reason for that is twofold:
- While I was definitely foam rolling daily, I was admittedly lax when it came to targeting my lats and posterior cuff (both of which are part of my homework from Dan). The irregularity with which I addressed those particular tissues is definitely correlated to my lack of results.
- I did not combine it with any other interventions. Currently, I am not only regularly doing some self-soft tissue work on the muscles that need it most, but I am also doing positional breathing exercises (to influence tone) and my basic movement exercises. The combination of interventions is key, methinks.
And that’s the big idea that’s been running around in my head of late: in the world of fitness and athletics (and circus), self-soft tissue work—with foam rollers, lacrosse balls or theracanes or other fun tools—has become a big deal…particularly when people have a cranky (insert muscle name here). There are probably a number of folks who contributed to this, but I would point to Kelly Starrett as the one who lead that particular charge.
I think that self-soft tissue work is an important part of the self-care equation, but I think also that all too often, it becomes the main piece of the puzzle. The other important factors in the equation, like purposeful movement tend to get left out. And my recent experience has reminded me of the simple power of movement.
Deliberate, purposeful movement.
Note that Dan didn’t just ask me to move my shoulder around. An instruction like that would have almost inevitably lead to me restricting the movement to comfortable ranges of motion. Instead, my task was (is) to move my shoulder in ways that are both challenging and functional. (Here, I am using ‘functional’ to mean ‘(as close to) how it’s supposed to be able to move’).
Extrapolating beyond my experience, I think the key is also continuing to ensure that the functional movements you are performing are sufficiently challenging.
After I enthusiastically sent the video of me doing the glenohumeral CARS to Dan, his response to my improved range of motion was this: “Next we want to build a little strength in that new range!”
…which brings me to my thought for part three: sometimes, strength is corrective.