How should I know? Oh yeah, those initials behind my name that nobody really knows about. Whenever I give advice to someone in the gym it's the same as what I give my patients in the clinic. My general philosophy doesn't change whether you're an 80 year old knee patient or 25 year old Crossfitter. I'm a hugh fan of exercise and resist telling people to quit doing something good for themselves or that they enjoy. I also don't like telling people what to do. OK. I like telling some people what to do, but rarely will I tell someone to completely stop exercising. There are a great many benefits of exercise which help injuries heal. I'll say this at the beginning, we are not discussing situations such as when you experience chest pain, nausea, vomiting, headache, excessive sweating, dizziness or have difficulty catching your breath. These are obvious signs to hold off on your normal routine. With these you need to consult with your physician or GO TO THE EMERGENCY ROOM. We're not going to discuss pathologies like Complex Regional Pain Syndrome or Fibromyalgia right now. And please don't bring up Piriformis Syndrome. What I'm talking about here are those pains limiting your performance or causing you to doubt you'll ever be able to exercise the way you want to.

Let's make it simple. After ruling out the need to seek immediate medical attention, here are some of the factors I look at:

  1. Trauma I'm looking at some sort of major impact, a fall, twisting of the knee, dislocation etc.
  2. Location We take everything seriously, but chest, head and spine pain/trauma get our attention quickly.
  3. Warm-up Does it make it better, worse or the same?
  4. Function Does it make you limp when running, change your stance during squats etc?
  5. Irritability Does the pain shoot down your leg or arm immediately with even the slightest movement (mechanical pain like pressure on the dorsal root ganglion) or does it build up hours later due to chemical irritation?
  6. Swelling/Edema Is it visible, constant, warm to the touch, localized in a joint? Does it come on suddenly (a torn ligament will often bleed and cause swelling in a joint immediately) or does it develop insidiously over night (possibly synovial irritation)?
  7. Testing Do you need to have a test performed? XR, MRI etc. That's the doctors call, but I've been around long enough to read their minds. Well not really, but it often helps to get the ball rolling if you think they may need imaging in the near future.

Options or "What do I do now therapy-boy?!"

  1. ER - see above. Not all orthopedic trauma requires you to go to the emergency room but if any doubt - GO!
  2. Medical Consultation. Stop exercising until you can see your doctor. Also in the great state of Texas you can be evaluated by a physical therapist without a prescription.
  3. Stop Exercising and Monitor Do this for a minimum of 48 hours. Often this time period will help you determine how to respond. In my experience it helps to give an athlete a time frame or deadline before they must seek medical advice. If this rest helps then great. Go to number 4. If not then go to number 2.
  4. Scale and Monitor Adjust the intensity and volume, alter your progression or temporarily stop the exercises which cause pain. You can probably monitor for a longer period of time before needing to seek medical advice.
  5. Go For It If you are significantly better after warming up, have full range of motion and can perform the exercise without compensation then go ahead with your routine. Just gradually work up to your previous level. Let's face it. Some pain and soreness is involved with sports and intense workouts.

The above descriptions are general guidelines. Most people fall into categories 4 and 5, but whenever in doubt consult your physician. Below are 2 examples of pain/injury which I have been asked about recently.

THE FEVER
Your gastrocnemius-soleus complex hurts (those are your calf muscles people or as a French patient of mine once called it "the cow") It came on about 2 days after you did Annie (thats the name of a workout people. Get your minds out of the gutter) which consists of jumping rope and sit-ups. You have no history of trauma and you walk without limping. After you warming up you feel significantly better. Soreness is still present the next day but not as bad.

MY RESPONSE.
I'd tell you to keep exercising as you are probably experiencing "The Fever" also known as DOMS (Delayed Onset Muscle Soreness). I'd avoid strenuous gastrocnemius exercises (jumping rope) for 48-72 hours, but if after warming up and stretching you are able to run and perform your weight-bearing exercises without compensating, go for it. Category 5

MY THOUGHT PROCESS.
There was no single traumatic event. You performed a great deal of eccentric exercise. The pain is in a somewhat diffuse muscular area and not localized in the achilles tendon. We don't know everything about DOMS but it is typically a result of excessive eccentric exercise in which microscopic tearing of muscle fibers and connective tissue occurs. More specifically myofilaments, sarcomeres and other really neat stuff. Elevated creatine kinase enzymes can be found in the blood signaling this muscle breakdown. It was once thought that lactic acid build up caused the pain but we know now that the acid is removed from the muscle within an hour. The pain may be a side effect of the repair process in which the inflammation sensitizes the nocioceptors.

THE TOUGH ONE.
"A while back" you were deadlifting and felt some discomfort in you lumbar area and buttocks. It wasn't severe enough for you to stop exercising it but never really went away. Now it only prevents you from lifting aggressively. The discomfort (you're a Marine and refuse to say the word pain) is primarily in your posterior thigh. Occasionally back and buttocks, but not often. Sitting makes it worse. You're still pretty young and you've had physical therapy focusing on aggressive hamstring stretching without success. (Not with me. We'll talk about this in my next blog)

MY RESPONSE.
Modify and monitor. I'm not thinking hamstring although the physical therapy might not have worked because he pulled a Ricky Bobby. (Remember when he's in the hospital and his crew chief asks Ricky how his physical therapy is going? Ricky Bobby says "Oh I gave that up the first day, maybe the first hour"). I am thinking it's related to his lumbar spine. I take all injuries seriously, but especially the spine. The higher up the more cautious I am. In this case there is no report of "serious" signs or symptoms. He has bowel and bladder control, he still functions at a high level etc. He can swim, do pushups and pull-ups without exacerbating his symptoms. The first step is to stop activities which reproduce his posterior thigh discomfort. Avoid prolonged sitting. Tough to do but try. Probably heavy weight training needs to be stopped for a while. Do I want him to stop exercising altogether? NO. He's already swimming, so let him keep doing that. Have him focus on core exercise like planks, let him be as aggressive as he can with activities requiring a neutral spine. Maybe lift with little to no weight, maintaining a stable position without pain. Take this time to work on perfecting his mechanics and neuromotor function. Work a little more on aerobics to get oxygenated blood to the area. NOW if after a couple of weeks using this concept of relative rest there is no change I'd advise further more severe restrictions of his exercises. If he can't report a significant improvement after this I recommend he consult his physician again. Category 4

MY THOUGHT PROCESS.
Severe hamstring injuries typically have a distinct onset. Let's put it this way, you are aware when it happens. Been there myself. In this guy's case he remembers when it started, but initially it wasn't really in the hamstrings. I also don't think of the deadlift as one of the main ways to strain the hamstring but it's possible. Also a lower grade hamstring strain usually responds to appropriate physical therapy and doesn't take months to heal. This is when a little medical advice is beneficial. This might be a Primary Posterolateral Disc Protrusion or Internal Disc Derangement (IDD). Occasionally a disc can be irritated in a certain location and just refer pain to the thigh without producing significant back pain. If that's the case you'd like to have seen this person a little sooner as they respond to physical therapy primarily in the first few months. That's also why I wouldn't monitor him more than a few weeks. Why is it taking so long? Maybe he hasn't been compliant with relative rest. He is a Crossfitter right? Also an IDD can be very frustrating due to the fact that it is indeed "internal". Not a lot of blood in there and you need it to heal otherwise the inflammatory response will lead to peripheral sensitization of the disc with it's "medley of neurophysiological responses". Gotta love the combination of music and science terminology.

Pain can be intimidating, scary and frustrating. Sometimes it is a simple reminder to correct your mechanics or that you need to back off. It also can potentially be a sign of serious pathology. When in doubt check with a medical professional.

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