Preface: Last year I gave an intern the task of documenting what I tell patients for different injuries then fact checking what I suggest or do against the latest scientific literature and document these topics. The goal was to get the most up to date info for common injuries and pain suggestions and share the information with others. He did a good job. At the end he recaps one of the topics which I will share here:
Dr. Tapplin's approach is consistent with the latest evidence and research. He notes that “we have so many more treatment options now than they had in 1978”.
Here are the topics he chose:
Should you Ice and Injury
Shoulder Pain
Back Pain While Squatting
Tendinopathy
Hip Pain
Should you ice an injury?
Dr. Tapplin receives this question a lot simply because it is a fantastic question that does not have one simple answer.
Dr. Tapplin's Recommendation:
In his office setting, he will utilize laser therapy and it is contraindicated to ice when using laser therapy. The reason for this is because studies have shown ice slows metabolism and inhibits the effects of laser therapy. Dr. Tapplin recommends that within the first 24 hours of an injury it is okay to use ice to numb the injured area. He believes that ice does not speed healing but is a great pain reliever and is a safe option. If patients love icing, he will recommend they can certainly continue but will just have to wait a certain amount of time after having treatment to resume with icing. Of note, Dr. Tapplin is a huge fan of whole-body cryotherapy and has an ice chest freezer in his basement filled with cold water. He notes there is a difference between whole body cryotherapy and utilizing ice on an injured area.
Scientific Research:
Digging into the scientific reasoning, I found that there are several arguments on both sides. Gabe Mirkin, in his Sportsmedicine Book in 1978, invented the R.I.C.E acronym. This acronym stands for Rest, Ice, Compression, and Elevation in terms of treatment of an injury. However, Gabe recently discovered that this tactic could potentially delay the healing process.
In an interview that took place on July 22, 2020 by Dr. Kelly Starrett and Gary Reinl, Gary states that individuals should NOT be icing after an injury. The reason behind this is that icing will cause more damage to tissues and nerves, prevent the flow of oxygen, and trap waste in the injury site. Instead, he recommends the best approach is active recovery. Active recovery means using the injured muscle directly through small muscle contractions. This will allow the body to preserve the tissues and help heal the destroyed ones around the site of injury. A saying that is used a lot preceding an injury is “Walk it off.” Although that may sound like the opposite thing to do, it is considered active recovery and can be very beneficial to the healing process.
However, not all research points in the direction that icing could be detrimental to recovery. On the flip side, icing an injury can have several benefits if done right. According to Mike Reinold, cryotherapy “...can reduce secondary injury and reduce edema formation if applied within the first 36 to 48 hours.”. Another benefit of icing is that It also acts as a pain reliever which can have an increase in mobility allowing for active recovery to take place.
Overall, in a podcast on the British Journal of Sports Medicine, Christie Aschwanden speaks heavily on the idea that there is simply not enough research and scientific evidence that suggests icing is beneficial for healing of the injury. Instead, icing could be more detrimental because it impairs the adaptations that muscles make following an injury or post-exercise.
Final Thoughts:
Dr. Tapplin's approach is consistent with the latest evidence and research. He notes that “we have so many more treatment options now than they had in 1978”. Instead of icing, active recovery and rehabilitation should be the mainstay of treatment for many injuries that were previously treated with the RICE method.
Is Shoulder Pain Affecting Your Workout?
Causes of Shoulder Pain:
In the gym setting, there can be several reasons as to why someone is experiencing shoulder pain. Some examples include overusing the shoulder muscles, too heavy of weight, or simply inflammation of the shoulder joints.
Common Diagnosis:
Rotator Cuff Tendonitis
Biceps Tendinopathy
Shoulder Arthritis
Shoulder Impingement (This is the most common diagnosis for shoulder pain associated with the gym)
Most Common: Shoulder Impingement (Subacromial Pain Syndrome)
Shoulder impingement is the most common condition seen with 44%-65% of shoulder pain being caused by this. Shoulder impingement is when the rotator cuff is rubbing between the humerus and the top outer edge of the shoulder. This condition can be very painful and can take anywhere from 3-6 months to fully heal.
Common Symptoms include:
Shoulder/arm weakness and stiffness
Pain and tenderness in the front of the shoulder
Pain experienced when arms are extended above the head
Pain when lying on the affected side
Pain or achiness at night, which affects the ability to sleep
Risk Factors:
Anatomical abnormalities within the shoulder
Arthritis or bone spurs
Athletic activities that require frequent overhead arm rotation
Valley Spine and Sport Recommendations:
For shoulder pain, we use an individual approach to find the cause of the pain by using various soft tissue techniques and mobilization of the muscles and connective tissue. Depending on the diagnosis of the patient, and the impairments of the individual, we make specific recommendations that will best benefit the patient and their condition. However, before any rehabilitation occurs, we recommend a clear diagnosis is given.
Who Should You See For Shoulder Pain?
When an injury takes place, a common question that gets asked is if they should see a PT or a chiropractor for their pain. If shoulder pain is present as a result from the gym, here is a video that illustrates Dr. Tapplin’s guidelines on who you should see.
Back Pain With Squatting?
Causes of Back Pain?
There are two types of back pain associated with lifting at the gym.
The first type of back pain is extension intolerant back pain. This type of pain is present with extension-based movements. An example of this kind of movement would include bending backwards. The second type of back pain is flexion intolerant back pain. An example of this would be any flexion-based movement associated with the gym such as a deadlift or any pulling movement from the floor.
The most common type would be flexion intolerant back pain.
Common Symptoms:
Pain with flexion-based movements
Examples of these movements include:
Sitting at the computer
Driving
Bending down to pick something up
Bringing the knees to the torso
Things to look for to diagnose flexion intolerant back pain:
Some questions when suspecting flexion intolerant back pain:
Does the patient have first thing-in-the-morning pain or are they actually awakened by the pain? The reasons for this are due to the swelling of the disc that occurs overnight
Does the patient have pain putting on their socks and shoes?
Did it occur from a lifting or bending injury?
Does the patient have discomfort or pain presented when getting up from sitting?
What can be done to help with low back pain?
According to Dr. Stuart McGill, “The first step in any exercise progression is to remove the cause of the pain, namely the perturbed motion and motor patterns”. He recommends eliminating spinal flexion completely which has been proven very effective.
In a study published by the Journal of Strength and Conditioning in July 2015, found that the deadlift exercise has a positive impact in decreasing pain presented in the lower back. In the study, 70 participants that have mechanical back pain participated in deadlifting 12 times over an 8-week period. The average pain intensity was measured on a scale from 0-100. 0 meaning no pain is present and 100 meaning the worst possible pain.68 participants had an average pain scale of 42.6 at the beginning of the trial. At the end, the average score decreased to 22.2.
Dr. Tapplin's Recommendations:
Recommendation:
Avoid any stretch that has the back in a rounded position.
Avoid positions as possible that put your back in a rounded and compressed position. This includes sitting.
Stretch/mobilize and move in the direction opposite of the original injury. So, for example, if you injure yourself with forward flexion/bending you’re going to want to restore extension movement as soon as you can. Exercise: McKenzie press up.
Bedrest is old school as most people know by now. It’s important to keep the muscles that attach right under the spine activated as these shut down in the presence of flexion tight back pain.
Walk as fast as you can for 10 minutes or less.
Use the bird dog exercise as described by Stewart McGill. It activates the small muscles on the back to prevent those muscles from disengaging/atrophy.
Hip hinge with all movements in this acute stage. The phrase I use is “preserve the curve”. Restoring the hip hinge is a huge piece of the puzzle for prevention and that should start immediately and continue from then on.
Erector endurance is prioritized over erector strength. Wide stance good mornings, Romanian deadlifts, The reverse hyper all with impeccable form and focusing on time under tension/endurance are important for prevention of future episodes.
Tendinopathy?
In previous years, it was called tendinitis. However, research suggests that there is not a lot of inflammation present. Tendinopathy is the breakdown of the collagen in the tendon and is most likely caused by overuse or sudden stress on the tendon. The reason that this is important is because to treat inflammation we would treat it with rest, ice, and anti-inflammatory techniques. Instead, to help the tendon heal because there is not a lot of inflammation, we want to use tendon loading exercises.
Common diagnosis:
Golfers Elbow- Medial Aspect of the elbow
Tennis Elbow -Lateral Aspect of the elbow
Rotator Cuff Tendinopathy
Patellar Tendinopathy
Common Diagnosis Found in Runners:
Gluteal Tendinopathy
Achilles Tendinopathy
Proximal Hamstring Tendinopathy
Hip Flexor Tendinopathy
Symptoms:
Pain, tenderness, redness, or warmth near the injured tendon
Stiffness in the joint near the injury
Increase in pain during the night and in the morning
Dr. Tapplin's Recommendations:
According to Peter Malliaras, when strengthening the tendon muscle, the blood is getting pumped into the tendon at a rate of 7x the normal rate. It is detrimental to the tendons to give them complete rest and is not healthy to the metabolism of the tendon. The reason why tendon loading is so effective is because tendons have very poor blood supply. When we increase the blood flow through tendon loading, it increases the amount of nutrients that are needed for healing. Following this link, Dr. Tapplin describes what he recommends when it comes to Tendinopathy.
Hip Pain From The Gym?
Hip injuries are very common in the gym setting. The most common injury associated with the hip would be femoroacetabular impingement/hip impingement. FAI according to the American Academy of Orthopedic Surgeons, is a condition in which extra bone grows along one or both of the bones that form the hip joint. When this occurs, the bones will rub against each other during any movement especially in the gym setting.
Symptoms:
Pain or aching after movement or prolonged sitting
A locking or catching sensation within the joint
Difficulty with trunk flexion
Low back pain
Types of FAI: (According to American Academy of Orthopedic Surgeons)
Pincer: This is a type of impingement in which the extra bone that has grown extends out over the normal rim of the acetabulum
Cam: A cam impingement is when the femoral head is not round and cannot rotate smoothly inside the acetabulum. As a result, over time the cartilage inside the acetabulum will decrease.
Combined: When both types of impingement, the Pincer and the Cam, are seen it is called a combined FAI.
Dr. Tapplin's Recommendations:
If FAI is suspected, the first thing Dr. Tapplin will do is perform an extensive physical examination with the patient to ensure a proper diagnosis. Everyone could have different physical impairments with FAI and it is important to understand these impairments to develop the appropriate rehabilitation program. When an FAI injury is diagnosed, one of the first things is to gain adequate control of the hip before putting it under load. According to Dr. Joanne Kemp, in her article titled Conservative Management of Femoroacetabular impingement, she states that “A number of studies have suggested exercises to activate the hip abductors, hip extensors, and rotators…” This will focus on decreasing adverse hip loads through the implementation of hip muscle strength programs and modification of external joint loads. By doing this, the symptoms associated with FAI should begin to decrease.
Sources
https://www.aspetar.com/journal/viewarticle.aspx?id=157#.YJXzEMA8LDs
https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/femoroacetabular-impingement/symptoms.html
https://emedicine.medscape.com/article/327227-overview
https://www.healthline.com/health/tendinopathy#causes