I’ve been getting a lot of shoulder health questions lately and decided to compile some of the information into a series of posts. This first post is about posture and subsequent posts will be on shoulder rotation, mobility work for the shoulder, and applying this information to training or sport.
The shoulder is an interesting joint because it evolved to have good mobility, but poor stability; in contrast, the hip has poor mobility but good stability. The shoulder is composed of the humerus (upper arm bone) fitting into the glenoid fossa (the socket of the ‘ball and socket joint’) of the scapula (the shoulder blade), but is primarily held together through muscles on the anterior and posterior (front and back respectively) sides. The following video is excellent at showing the musculature of the shoulder joint (though the joke at the end couldn’t be crappier).
Improving shoulder health or mobility isn’t simple; it requires an understanding of how the upper body integrates in the ability to achieve good or bad positioning. Poor mobility in the shoulder will prevent the person from getting into good position and results in bad mechanics, or inefficient transfer of force. Poor force transfer loads structures incorrectly or incorrectly and wears them down resulting in trauma. Do this enough and there will eventually be an injury or dysfunction. At the very least you won’t be strength training properly and will poorly develop musculature and strength.
Given the shoulder’s unique anatomy, it often requires targeted care to maintain its function and alleviate discomfort. Registered massage therapy can play a crucial role in addressing the imbalance between mobility and stability in the shoulder joint. For those seeking professional help, trust Inspine Therapy to provide expert care tailored to your needs. Their skilled therapists use a combination of therapeutic techniques to address shoulder issues, ensuring a comprehensive approach to managing pain and promoting recovery. By focusing on the muscles that stabilize and move the shoulder, therapists can help improve flexibility, reduce pain, and enhance overall joint function.
In addition to the specialized services offered at Inspine Therapy, exploring other reputable options for shoulder care can also be beneficial. Facilities that provide a multidisciplinary approach, including physical therapy, chiropractic care, and acupuncture, can further enhance recovery by addressing the shoulder from multiple angles, ensuring a well-rounded treatment experience tailored to individual needs.
One notable clinic is a physical therapy henderson nv location that emphasizes a holistic approach to treatment. Here, patients are guided through personalized rehabilitation programs designed to address their specific needs. The therapists employ a variety of techniques, including manual therapy and targeted exercises, to restore mobility and strengthen the surrounding muscles. This clinic recognizes the importance of patient education, equipping individuals with the knowledge and tools necessary to manage their conditions effectively and prevent future injuries.
To address shoulder health effectively, incorporating professional massage therapy can be crucial. Massage therapy helps by increasing blood flow, reducing inflammation, and promoting relaxation in the shoulder muscles. This approach not only aids in improving mobility but also assists in preventing the trauma associated with poor mechanics.
For those looking to optimize their shoulder health and prevent injuries, visiting a specialized clinic like https://www.athleteschoicemassage.ca/ can be highly beneficial. These clinics provide tailored massage therapies designed to address individual needs, focusing on improving mobility and strength in the shoulder. With regular sessions, you can expect a significant reduction in the risk of shoulder dysfunction and a more effective strength training regimen, leading to better muscle development and overall physical performance.
Posture
The first step in understanding shoulder health is understanding posture. It starts with correct spinal positioning and finishes with proper shoulder positioning.
Most people look like “round shoulders” above. This is the “thoracic flexion, shoulder internal rotation, cervical flexion, and atlas extension” that I always talk about make fun of. The thoracic spine is the upper/middle back, and flexion means that it rounds. Shoulder internal rotation refers to the shoulders rolling forward; external rotation rolls them back. The cervical spine is the neck, and flexion means that it is rolled down towards the chest. The atlas is the C1, or first cervical vertebrae, and that flexes or extends the actual skull (named after Atlas in Greek mythology because it supports the globe of the head). Despite the fact that the cervical spine is flexed forward, the atlas can be in extension to bring the chin up (as in the “round shoulders” picture above). The result is a wormy human being who definitely doesn’t lift. To review these and other anatomy motion terms, watch this video. I will now proceed as if you know the anatomical terms.
The “correct posture” above is the goal. To do this, tighten the lower abs and lift the chest towards your chin. The chin itself will be level with the ground. You can check this relationship by making the “rock on” sign with your fingers (middle and ring finger pulled down with the thumb on top of them, the pinky and index finger extended) and place your manubrium (upper sternum) and put your index finger under your chin. That will more or less put your chin in the proper position. Your spine should now be in a “correct posture” that allows it to transfer force efficiently.
It is no coincidence that this spinal position is the same you should use while lifting. Note that the cervical position should remain the same in lifting, and therefore eye gaze will adjust depending on the back angle of the exercise (e.g. the high bar squat will have a forward eye gaze while the low bar squat will have a slightly downward eye gaze).
Since your thoracic spine is in neutral position (which may be considered “extension” if you are always hunched over), slightly pull back the shoulders. This will put them in neutral position, yet it may feel like they are “back” since they are probably routinely rounded forward. This is the alignment you should aim to have most of the time. If you cannot achieve this position, it’s likely that all of your athletic endeavors are inhibited. More importantly, you’ll never get tan as a result of being jacked.
If you have trouble with posture, make a conscious effort to improve it. The world sees posture and bases an initial assumption on it; it’s part of a first impression. If you see a guy walk in a room like “round shoulders” above, do you have a positive view of him? I don’t; it indicates a lack of self confidence and attention to detail. If someone walks in with “correct posture” above, it indicates confidence and self-assurance. A communications book I read gave the suggestion to realign posture every time you pass through a doorway. It said to imagine reaching slightly up and lightly biting a piece of leather; this lifts the chin and subsequently the chest and pulls the lips slightly back to make a smile. It gives a visual cue to set proper posture before one of the most important social challenges: giving a good first impression. Do this every time you walk through a doorway and you’ll end up doing it upwards of 30 times a day. Not only do you look like someone who actually lifts, but you’re getting constant reminders to set your posture throughout the day.
If you have poor shoulder mobility, I’d have to assume your posture is poor. Work on it with the tips above, because it’s vital for efficient force transfer in lifting as well as preventing injury.
If you have poor posture and sit down all day, also read this “Hyperlordosis” post.
In the three year history of this website, one of my main sources of writing material has been learning from my own mistakes. If I educate you about why something I did was stupid, then hopefully you won’t make the same mistake. Today is one of those days.
I strained my hamstring in the first couple minutes of a flag football game last night. I had done a couple of movement prep exercises, kick swings, some sprints, but it was all condensed into a several minutes. I returned a kick off with a full sprint. Then on the first play, I ran an out route, caught a pass, and was sprinting along the sideline when the left proximal (upper) hamstring yanked. I’ve never pulled a muscle during a sport. This was the second game and we’ve had a few practices, so it’s not like I just got up and started sprinting without any adaptation. I blame my lack of sufficient warm-up.
There is a traditional school of thought that says a good warm-up can prevent injury. There is another school of thought that would say the warm-up only serves a performance enhancement purpose and does not prevent injury or improve flexibility (this is actually the view point of Dr. Kilgore in the “Getting Ready to Train” chapter of FIT). It’s accepted in the physical therapy world that warm-up and mobility work can prevent injury. There are also many studies that show a decreased rate of injury after warming up (though the studies could be crappy or irrelevant). My experience in sport, sport coaching, and strength and conditioning coaching gives me the opinion that good warm-ups can prevent certain types of injury. At the very least Kilgore would have to concede that dynamic stretching can improve flexibility, because he experienced an increase in ROM after doing kick swings in the 4 week case study we conducted on high intensity conditioning!
Warming up for a sport like flag football is different than warming up in the gym. Let’s briefly discuss the benefit of warming up, general warm-up methods, and some specific methods dependent depending on what activity you are about to do.
Benefits of Warming Up
The first part of a warm-up is a general warm-up. Traditionally this involves yogging, jump roping, or rowing and aims to physically warm the body up. At rest, the body holds most of the blood volume in the visceral cavity — primarily the trunk. The blood focuses on all of the organs and the digestive processes. This is why if you eat a meal in cold weather, you feel even colder after eating. It’s because the focus of the blood flow is in shifts to the gut area reducing the blood (i.e. warmth) in the extremities. During a warm-up, the body starts shunting blood to the extremities in response to their increased use and activity.
Adrenaline is released to increase the heart rate and dilate the capillaries to allow for more efficient oxygen transfer to the muscles. It increases synovial fluid production, which acts as a viscous lubrication between joints. There is a lot more going on — like increased metabolism, glycogen being broken down for readily available energy, and increased enzymatic activity — but the result is that the body is better prepared for movement and activity. Most importantly, it increases the extensibility and pliability of muscle fibers and increases force production and speed of contraction.
This can all occur from several minutes of general warm-up. Let’s look at a few different activities that would qualify as a general warm-up.
General Warm-up
The beginning of a warm-up doesn’t have to be limited to running or rowing. Anything that increases the body temperature and takes the joints and muscles through a full range of motion (ROM) will work. Calisthenics are often used since they aren’t too stressful and usually include full ROM movements. Doing a short circuit of some push-ups, pull-ups, squats, and maybe some jumps will prep the body nicely. Personally I like to foam roll first, do whatever mobility I have planned (which isn’t a lot at this point), some movement prep, and then dynamic stretching.
Mobility is the term that means any specific manipulation that improves ROM or function to achieve better positioning for the workout (i.e. stuff like MWOD). Note that the ability to hit proper positioning, AKA efficient mechanics, is probably the single most important factor to reducing chance of injury. If you are sprinting, lifting, and moving with inefficient mechanics that place lots of stress on structures that aren’t designed to accommodate them, then it’s no surprise that injury will result. Good mechanics start at the feet and travel up through the body.
Movement prep is a term that I’m using to refer to non ballistic movements that would take joints and muscles through a full ROM. This would include stuff like walking and side lunges. I would include an example video, but almost everyone who teaches movement prep stuff is so god damn annoying and I don’t want to give them the traffic. (Edit: Here is an example from the USTA — just ignore all of the idiosyncracies).
Dynamic stretching refers to a stretching method that uses momentum to move the segments through the full ROM the joints would allow if it were done passively, but not exceeding the passive ROM (which would turn into “ballistic stretching”, which is forced beyond the passive ROM). This is pretty similar to movement prep, but faster. This would refer to torso rotations, shoulder circles, and kick swings (front/back and side-to-side). I’ve seen dynamic stretching poopoo’d, probably because it is interpreted to be ballistic stretching (which can be harmful). However, I’ve done it every training session for over a decade and have only once pulled a muscle in sport activity (which was last night). N=1 is irrelevant, but I think static stretching is effective at acting as that general warm-up through a full ROM, and I have always liked the way my muscles have felt after doing it. If there were a physiological explanation, I would expect the mechanism to be related to the muscular innervation associated with the fibers being stretched at speed followed by their immediate contraction. It’s not like it’s a training tool to improve the stretch-reflex, but in my opinion it helps prep that system for activity.
In reality, any of the above stretching techniques could probably be used by itself to act as a general warm-up. I pride myself on my mobility, how it allows for proper functioning, and how it acts as a preventative measure during activity, so I go through a few minutes of each of these phases. Again, n=1 doesn’t matter, but the length and type of your warm-up will be dependent on a) how sore and stiff you are, b) how immobile you are, c) the type of activity you are about to perform, and d) your adaptation to that activity.
Specific Warm-up
There is a lot of variability in what to do in a specific warm-up, because it’s relative to the planned activity. Barbell training will only require the standard light and progressive warm-ups with the bar. Even the strongest people in the world will begin with light barbell warm-ups. The number of warm-ups will be dependent on the person. For example, I know that I benefit from having a couple more warm-ups in my press and bench compared to my squat or Olympic weightlifting movements.
There are stories of guys walking up to a bar and deadlifting 600 pounds with no warm-up whatsoever, but consider them the exception. Warm-ups can’t prevent every injury, but they are still necessary for optimal performance. I remember a quote from either Starting Strength or Practical Programming that said, “If you don’t have time to warm-up, then you don’t have time to train.” This was in reference to the specific barbell warm-up, but good advice nonetheless.
Shari Onley of the Australian Lingerie Football League sprints in tryouts. American football has a good history of comprehensive warm-ups.
Whereas preventing injury in lifting activities is probably more dependent on general mobility, sports with aggressive movements (i.e. sprinting, starting and stopping, changing direction, etc.) are probably more dependent on a good warm-up to prevent injury. A structure like the hamstring is subjected to many more stresses and demands in a football, soccer, or rugby play than it will be in a back squat.
Specific warm-ups will need to include pieces or variations of the contested movements in a progressive manner. Start by using active movements in a controlled setting. Line drills are typically done in football or track and consist of walking frankensteins, high knees, butt kicks, and short sprints. Ladder drills could be used to prep the lower body for lateral and ballistic movements. (As a side note, I love the idea of programming ladder drills as a general warm-up. It helps maintain or improve athletic ability and allows a ballistic adaptation in the lower legs.) Follow these activities with short sprints, lateral shuffles that turn into a straight ahead sprint, and making cuts (i.e. changing direction) that turn into sprints. Had I had more time, I would have progressed my pre-sprint warm-up a little better (general warm-up, back pedaling, side shuffling, etc.), ran some passing routes (that include change of direction and sprinting), and done a few more sprints.
The drills that are used should be relevant to the sport or activity. A warm-up for volleyball would include more shorter, agility-focused foot work drills, jumping, and sport specific practice (passes, digs, hitting, etc.). Martial arts will probably have more movement prep and mat work before specific strikes or throws.
Note that the above strategy is the basic approach to every football practice and game warm-up. Good coaches combine “warming-up” with “skill practice”. Sure, injuries still occur in sports despite comprehensive warm-ups, but you can’t put a number on the injuries that are prevented. Not to mention many injuries are the result of external force trauma (e.g. a player falling into the side of a knee) or poor mechanics (e.g. player twisting their knee when the cleat is stuck in the turf). And who knows, perhaps if I would have warmed up better, I still would have strained my hamstring. However, are you willing to jump into aggressive movement without prepping the pliability and power production of your structures? It’d be stupid to do so.
Several years ago foam rolling was the “in” thing and everyone used and praised it. Self “mobility” work has since evolved away from foam rolling — even to the point of poopooing it — but it can still serve a purpose.
This is from the new “Foam Rolling Porno” DVD set.
Most Tommy Tough Guys will say, “Ptsh, foam rolling is too light, I just use a a PEEH-VEH-CEE.” An actual foam roller won’t correct any real soft tissue problem, but that’s not its effective purpose. Foam rolling is best used prior to activity or training to loosen up the soft tissue (which can include fascia, muscles, or tendons) to be more pliable and allow a comprehensive range of motion (ROM). Think of it as a part of warming up instead of soft tissue treatment.
Trainees lament that a large portion of their day is spent sitting down. And if they’re standing up or doing manual labor, they’re still probably not going through a full ROM and spend time in problematic positions (bending over, crouched down, on knees, etc.). Either way, loosening up the body with a foam roller will prep those structures for activity, whether applying force maximally or ballistically. This light soft tissue work will augment any movement prep like dynamic stretching or any “mob” that includes positional stretching. Heavy, invasive massages prior to training can have a deleterious effect on performance, yet light massages can make the structures more pliable, increase blood flow to the area, and even reduce Delayed Onset Muscle Soreness (DOMS) quicker.
At worst you’re increasing your warm-up by five to ten minutes. At best you’re enhancing that warm-up, improving recovery, and prepping your structures to train better.
One reason that a PVC may not be as useful in the context of a warm-up is because it’s more invasive and painful. Tommy Tough Guy Mentality says, “I can take it. BRING ON THE PAIN.” Just because you can deal with pain doesn’t mean you’re a) cool or b) doing anything useful. In actuality it’s not easy to undergo pain and completely relax a muscle. The point is to get some light massage through the muscle belly tissue, not to tense up and contract the muscle because it’s experiencing pain and try to massage a taught muscle. By using foam, you can reach deep into the tissue without tensing up or disrupting the cellular environment too much.
When I googled “sexy foam rolling” to see what would come up, I found this picture of my jacked friend, Mark. Care to explain, Mark?
This isn’t to say that PVC is worthless, but it’s most likely inferior for warm-up purposes for most people. Note that over time your tissues will adapt to the foam roller and you’ll need a harder surface to receive the same effect. That means if you’ve been foam rolling daily for a couple of years, then no, this won’t apply to you. Foam rollers can cost 15 to $20 and PVC can cost a few dollars. I think they both serve a purpose, especially when you don’t have a servant to give you a rub down prior to training (yeah c’mon). In case you’ve haven’t gotten on the internet since 2005, here’s a video of a foam rolling protocol, specifically what I do before training. I aim to loosen tension on my back, hips, and knees. I could probably accomplish the same with a PVC, but I know it’d cause some “tensing up” in my thighs or around my knees. The PVC also crunches on the spinous processes of my vertebral segments when rolling certain positions on my back. If all you need is a light massage, and you have access to a foam roller, then it’s a better tool. If you’re interested in exploring different options, consider the benefits of therapeutic massage as well.
I wrote a post and filmed a video explaining “Hip torque, toe angle, and squatting” to explain why a more forward toe angle in the squat was beneficial. It helps distribute force across the front and back of the thighs more efficiently which results in more muscular applying force to aid the movement. I followed this with another post and video titled “Should I point my toes forward?” The TL;DR on this second post was, “If you do not have the mobility to point the toes forward, then don’t do it.”
Not only are there people squatting with their toes forward — when I deliberately told them not to do so — these same people are getting tweaks in their knee and don’t know why. The sum of the “why?” is that they don’t have the mobility to do it and aren’t listening to Justin.
This is a public service announcement saying, again: Do not point your toes forward unless you have the mobility to do it. I created the following video that explains what occurs anatomically to cause a strain or tweak in the knee if someone ignores this advice. I also provide a method to quantify the amount of mobility a person should have before pointing their toes forward on a loaded squat (hint: it’s doing the “paleo” squat barefoot, toes forward, and knees out without pain or falling over). I also provide some “mobs”, specifically soft tissue work, that can help relieve tension in that area to improve the mobility to eventually shift the toes more forward. It would have been to difficult to explain this stuff via text, and a video is much easier. I’ve split the video into two parts, because the anatomical portion is a bit long by necessity.
Part 1
Note that the popliteus gets strained because it isn’t extensible enough to handle the torque associated with the toes forward position. Also note that repetitive stress on the back of the knee from road marching, rucking, hiking, or high frequency or volume CrossFit movements can beat the structure down. If you try and apply torque on a crusty structure that is in a recovery deficit, then this is another reason why tweaks can occur on the back or side of the knee when doing knees forward squatting. If the structure is beat up, then give it more days of rest than you usually would before returning to squatting.
Part 2
Will everyone be able to squat with a toe angle of right outside of forward? No. Can most people improve their mobility to move their toe angle a little bit in from where it is now? Probably. Watch the videos and learn the reasoning that explains why shifting them forward too soon can result in a strain the popliteus (on the back or outside of the knee). This next video provides
Kelly Starrett’s MobilityWOD put out the message that icing is no longer recommended. After a lot of discussion and digestion, I posted a response about whether or not we should still ice. It looked at several issues from the MWOD post, including the cited research. The conclusion was that the research and practice were conflicting, and therefore it’s too inconclusive to definitively throw icing out the window. Furthermore, there were just too many unanswered questions about the effect of ice on things like lymphatics permeability and prostaglandins. The MWOD post also didn’t distinguish between different types of injuries, which is incredibly important.
To clarify, none of this is an attack on Kelly himself. Remember that he’s arguably done more for prehab and rehab in the last few years than anyone else. The fact that he’s so well respected is why I’m researching and discussing the “do not ice” claim in depth. It’s okay to disagree with someone; at the same time it’s still possible to learn from them, support them, or respect them.
Ultimately, the issue of icing comes down to the differentiation between injury types. For a brief literature review, look at yesterday’s post. We’ll try to generally talk about some injury types today and basic approaches to rehabbing them on your own at home. Take note that injuries are individualistic; each one is specific to a specific individual. Good PTs will have a specific protocol made for your specific injury, circumstances, and activity or performance goals. When in doubt, go to a PT. If you can’t, then always always always do the least invasive rehab and then wait until the next day to see if it’s the same, worse, or better. You’re doing all of this at your own risk.
Contrast Baths vs Acute Icing
First we need to clarify between two different types of icing. “Contrast work”, which can include ice baths, is not the same as icing a specific spot on your body. Trainees anecdotally report positive results with contrast baths or showers to improve general or systemic recovery. However, they are used by some PTs to treat acute soft tissue injuries or general inflammation in a body part. “Soft tissue” would include muscle, tendon, or ligament issues — usually in terms of sprains, pulls, or partial tears (the most common associated with training). “General inflammation” isn’t referring to total body systemic inflammation, but instead refers to something like soreness in the traps and shoulders or forearms from a lot of volume (e.g. lots of overhead work or farmer’s walks respectively).
One of my PT friends has found that ten minutes of cold immersion alternated with a heating pad works best. He uses five cycles of starting and stopping with ice. He found that by ending with heat left the lymphatic channels open and encouraged swelling, but he admits this may be contradictory to what we are learning now (referencing yesterday’s post and how ice seems to increase the permeability of the lymphatics). Remember that this is used for a specific acute injury or a specific body part.
This particular PT has had clinical and personal anecdotal evidence of this protocol working with acute soft tissue injuries. It has helped with lingering injuries that have lasted up to two months and removed the pain after one week of daily treatment. Interesting to say the least.
I think that this approach could be generally applied for systemic recovery, which can also be caused by high volume, frequency, and/or intensity training. In this method, the heat would be applied to the entire body as opposed to just an afflicted area. Think in terms of hot and cold showers, ice baths and hot tubs with spa covers, or ice baths and hot showers. Use caution when dealing with extremes in temperatures and I suggest you ask a PT or doctor before trying it.
The (admittedly) conventional wisdom behind why contrast stuff can work is that the alternating temperatures contract and relax the body and lymphatic channels, which helps push the waste up through the lymphatics. Take note that this also occurs in movement — we’ll talk about it regarding active recovery below. The contracting/releasing of the lymphatics idea is one line of reasoning as to why this helps both general systemic inflammation and acute soft tissue injuries.
Acute, Single Location Icing
Contrast work requires some preparation and a lot of time. For a non-professional athlete who has other responsibilities in life, they’ll need to get the most benefit with techniques that most efficiently use their time. Icing a specific spot will be a little easier, albeit potentially not as effective as what is written above.
Immersion is always better than a bag of ice, and a bag of ice is always better than a commercial ice pack.
Immersion can include a bucket of ice water for ankles or wrists, but it gets a little tricky for elbows, knees, shoulders, or the back. I suggest a standard blue ice bag that you can get at any pharmacy or grocery store. I like these because they don’t produce condensation and therefore don’t drip down your body or clothing. I suggest also getting some heavy ace bandage wraps — they can hold the ice on the awkward spots and they can be used for compression rehab.
The research showed that some superficial tissue damage can occur with prolonged icing as well as the potential “increase of edema” issue. Therefore, the recommendation said not to exceed 30 minutes and probably not 20. We’ll just use 15. Apply the ice on an area that encompasses the painful area and wrap it to ensure solid contact. Set a timer for 15 minutes. The heavy ace bandages can be useful for busy people since they can go about their business despite icing their knee.
Under What Circumstances Should You Ice
One supportive argument for icing is that when it’s applied soon after the onset of injury that it helps prevent secondary hypoxic cell damage. Edema is a result of more blood flow to the area along with the waste products. Specifically an “increase in the permeability of the vessel wall (with a) subsequent increase of the extracellular protein concentration” (Meeusen, 1986 — the article from yesterday). There are varying levels of capillary permeability and cellular response, and it’s dependent on the injury. Icing decreases the temperature of the tissues and reduces blood flow in the area. If icing occurs soon after the onset of injury, then it can help slow the blood flow to an area that is in the process of “increasing the permeability of the vessel wall” and dumping extracellular proteins — the thing that causes edema. This is how icing can prevent secondary hypoxic cell damage.
Of course, that edema is the body’s response to the injury. So we should let it be, right? If the goal is to expedite healing, then no. Look at the “Ancestral Argument” section from yesterday. If we wanted the inflammation process to occur unheeded, then we wouldn’t conduct massage, compression, elevation, or e-stim to the area either. These rehab protocols, combined with icing, return athletes to activity faster, and that’s shown in clinical research (and we’ve probably all seen it in anecdotal situations too).
Take very careful note that the situation I’m talking about here is an acute injury, specifically an acute soft tissue injury. This includes muscles, tendons (attaching muscles to bones), and ligaments (attaching bones to bones). This does not include broken bones, joint dislocations, bursa issues, etc. Your n=1 experience of your orthopedic doctor telling you to only move, compress, and elevate your dislocated finger is not proof that icing is useless.
Aim to get ice on the injury as soon as possible and continue icing on and off for the first 24 hours, but no more than 48 hours. The more severe the injury, the closer to 48 hours you could ice. After this deadline, rely on other rehab protocols to heal and alleviate the injury. They will be discussed below.
Lastly, I want to point out that if you notice a significant increase in swelling and you deem it to result from ice exposure, then stop doing it. I have a friend who does a lot of ballistic lifting, smokes regularly, and takes a lot of NSAIDs. Icing ends up making his situation worse, but he is not a relevant piece of data due to his smoking and NSAID use.
A Note On NSAIDs
A major injury will necessitate some NSAIDs. Or deca.
My general philosophy for minor soft tissue injuries is to not use NSAIDs. Quality nutrition (paleo) with appropriate protein and smart supplementation (fish oil, vitamin D, ZMA, and magnesium to start — post on this soon) will help keep non-training systemic inflammation low and facilitate healing these minor issues. Stuff like ibuprofen can be problematic for the gut, yes, so let’s avoid them…unless there’s a more serious injury. In such a case, you’ll probably be prescribed something. To be perfectly clear: I’m not anti-NSAIDs, but save them for the major stuff and let your efficient body and rehab protocols deal with the minor stuff.
Chronic Soft Tissue Injuries
As a general rule, you will not ice chronic soft tissue injuries. As I’ve said a hundred times before, chronic soft tissue injuries are usually due to improper mechanics or conducting mechanics with improper mobility. Barring a past acute injury, there’s an underlying cause as to why this chronic issue exists. Identify and diagnose what that is and fix it — if you don’t then the issue won’t go away no matter what treatment you apply.
Icingcan help chronic issues, but only when it is applied after aggressive rehabilitation. If you are self-massaging a tendon to break up scar tissue, you should follow up with movement to get blood flow, lactic acid, and proper structural stress to the tendon. After the movement-based rehab — which is absolutely necessary for recovery — you can ice. This helps people from an anedcotal perspective all of the time. The icing is okay and helpful because you’re essentially re-injuring the area via the “scar tissue breaking massage”. You created an injury, and the motto is that “icing helps acute soft tissue injuries”. That’s why it’s okay.
A specific example is what I did with Brent a few years ago. He primarily did the Olympic lifts, but expressed a mild desire to bench again so that high school football players wouldn’t embarrass him and make him look like a shit head. However, the bench ROM was incredibly painful on the anterior portion of his shoulders, specifically the proximal biceps tendon. When I palpated them, they were significantly raised and inflamed with built up scar tissue. I worked on them with my thumbs, and he squealed like in this video, and then I had him press and bench the bar for some high reps followed by icing. We did this protocol several times (separated by at least a day or two), and in a week or so he was able to bench pain free.
If aggressive massage and movement are not applied to a chronic issue, then I would not recommend ice unless the person wants to use it as an analgesic. Ice relieves pain because it “numbs” the area. In the Reinl video, they claimed that it severed the “muscle and nerve connection”, yet this would take significant cold exposure to do. It does decrease the temperature, but if done within the parameters of our “15 minutes rule”, it’s not an issue. Whether or not icing a chronic issue such as this is detrimental to the recovery process is not known, but, again, the person can ice if they want to relieve pain. My opinion, which is not based on anything in the research, is that icing for 15 minutes will not be detrimental to the recovery process, yet it’s not going to accomplish anything other than analgesia.
Remember that I said that most chronic soft tissue injuries are due to bad mechanics or faulty mobility, but they can be from simply doing too much without enough recovery:
However, the degradation of collagen is also increased after exercise, likely at a greater level than the increase in synthesis. Consequently, for the first 36 h after exercise, the collagen metabolic system is in a negative balance with degradation greater than synthesis (Fig. 1). This may explain that repeated exercise without sufficient rest can leave an athlete in a state of repeated collagen breakdown, and the development of overuse injury (Magnusson et al., 2010).
— “Tendinopathy in Athletes.” Physical Therapy In Sport, 13, 2012: 3-10.
Hmm, too much volume and frequency with no rest. Sound familiar? This is almost every CrossFit injury ever. It’s also related to the actual acute injuries that occur from not having recovered structures. I wrote about this a long time ago, but hopefully people are starting to pay attention to the prevention and treatment of these things. The prevention is proper programming. The treatment consists of comprehensive recovery methods.
Rehabilitation Modalities for Acute Injuries
If you read yesterday’s post, then you know that the benefit of icing was always linked with at least one other method of rehab. At the very least, the raising of this “to ice, or not to ice” issue should teach or remind you that rehab must be multi-faceted to be efficient. We have addressed icing above, so let’s touch on the others.
Here’s a good spot for a random pic
Elevation
This is useful because it helps the lymphatics clear waste. The lymph system is similar to veins in that they have a one-way track to the center of the body. There are valves that prevent backward movement, and muscular contraction helps pump and pulsate contents through each type of vessel back to the trunk. Elevating a limb will a) help prevent blood or lymphatic waste pooling (which would increase edema) and b) allow gravity to assist the lymph system in pulling out the waste (in the same way that it helps drain the blood flow from the area).
Compression
It’s known that massage helps clear extracellular waste — the stuff of edema (it is known). Compression sort of does the same thing by preventing the increase of swelling and perhaps even helping to squeeze the bad fluid out. It facilitates the clearing of blood and waste from the area, especially when compounded with elevation. We’ll also see that compression with movement is very useful too.
Rest
In the Reinl/Kelly video, they poopooed rest because movement is necessary to recovery. And it is, but an initial period of rest is probably necessary. Let’s use the same “icing timeline” and say rest for 24 to 48 hours; the more severe the injury, the longer the rest. For example, you wouldn’t want to start moving a severely sprained ankle around a couple hours after the injury. Usually you’ll only rest for 24 hours.
Movement
This is the single most important thing for rehabilitation. Ever. I’ve written about this hundreds of times — soft tissue injuries need to heal by receiving stress through a full range of motion. If they heal or scar with no motion, then any new motion will irritate or re-injure the area. And obviously healing with a partial range of motion isn’t helpful for when you eventually hit that end ROM that it isn’t prepared for. I’ve successfully rehabbed hundreds and hundreds of people, and movement is always the reason.
Keep in mind that the movements need to be progressed. I’ll repeat one of my rehab rules:
When rehabbing, try the least invasive movement and then wait until the next day to see if it’s the same, worse, or better.
The key is the “least invasive movement”. If you can’t put weight on your sprained ankle, then just move it through a range of motion. If you’ve already moved it through a full ROM, then add light resistance. If the light resistance doesn’t make it worse, than slightly increase the resistance or number of reps. In this Q&A post I give an example of an ankle rehab protocol. Is it comprehensive? Perfect? Perhaps not, but it’s a progressive plan. I might tweak those icing recommendations a little, but the basic tenets are there: ice initially, then progressively load it. I’d add compression and elevation to the protocol — these should be done as much as possible when not icing or moving the afflicted area.
The concept revolves around a progression. I get creative with how I’m going to work a structure. At first, it might need to be in isolation, but the structure is always integrated back to compound movements. And it’s steadily, but consistently progressed. This is so important because you guys are so friggin’ impatient with your progress or don’t attempt to make any at all. I’ve talked to so many people who have an injury and they decide not to squat for three months. I’m not suggesting you squat with weight, but a body weight squat is a starting point. If that’s too much, then figure out a way to put work on the area. It’s your hip flexor? Then lift your thigh up. Groin? Move your thigh in and out, get on the yes/no machines (adduction/abduction) — just do SOMETHING.
It’s impossible to be comprehensive because there are so many different types of soft tissue injuries. Just know that you can ice initially, but then you need to perform movement that applies an adaptive stress to the injured structure. The structure has been reduced in its ability, so you have to progress it back to its uninjured state. This is the same exact concept of making a muscle strong, but now you must limit the stress to what that particular structure can handle.
Throughout the rehab process, I deem it acceptable to ice after the movement rehab, and especially if it’s still tender during rehab. Movement or massage may sort of “re-injure” the area by applying a stress that it isn’t adapted to. After recovering, it should be able to handle that same stress again easier, and that’s why you will progress to doing more in the next rehab session. Nevertheless, if the rehab resembles a re-injury (determined case-by-case), then icing after the movement rehab is probably not going to be detrimental. If edema occurs as a result of icing, then don’t do it anymore; it usually won’t swell with minor soft tissue stuff.
Whether or not you need to ice, compression and elevation will help. But, to hammer this point home, consistently moving the injury and progressing the adaptive stress over time is necessary to returning to normal function.
Movement With Compression
Wrapping your segments or joints with heavy ace bandages and then performing rehab movements will help them recover. The first reason is because it helps clear the cellular waste through the lymphatics through the effective methods of compression and muscular contraction. But the compression also applies a bit of tack and stretch to the muscles, which is similar to ART treatment where pressure is put on a tendon or muscle belly while the muscle lengthens and shortens through a full ROM. If you have used the “voodoo bands” — a term I absolutely hate — then you’ve experienced this before. I’ll be doing a post on this topic soon, but just note that light to medium wrapped segments or joints with rehab movement will add a bit of resistance compared to simply doing the movement without the compression. I’ve successfully used this on ankles, wrists, knees, and elbows.
Cryokinetics
This is the concept of icing to reduce pain, and then taking joints through a full range of motion actively or passively. I do not suggest any of you try this without the aid of a PT, because your Tommy Tough Guy attitude will probably just lead to you making your injury worse. However, if you’re going to be a Reasonable Rick, then you could do something like this: ice the knee, then passively take the knee through a full ROM. Just remember that since the ice is an analgesic, it’s going to block any pain you would normally experience. That pain is your body’s signal of saying, “Hey, don’t do this because it could or is causing injury.” We often push beyond this in our standard “movement based rehab”, but not receiving this message of pain could mean you do too much. The most stressful thing I would have you do after icing is a body weight squat in your living room.
Sequence of Events
Injury occurs. Ice it. Compress it. Elevate it. After day one, start figuring out how you can apply progressive stress via movement. After rehab, it is okay to ice. Otherwise, try to compress and elevate the injury as much as possible. Rinse and repeat, but ween off of the icing (since it will eventually not do much other than numb the pain after the early stages). For chronic issues, review the earlier sections of this post.
Conclusion
This all started with a conventional wisdom-breaking statement that said, “Do not ice.” After reading, discussing, and digesting all of the information, yesterday we concluded that the “do not ice” statement is premature and unspecific. It will depend on the type of injury and how icing is employed. This post looks at the benefit of icing and how to place it in a proper rehabilitation program. Whether or not you decide to ice is ultimately up to you. It can be helpful in some cases, irrelevant in others, and in a few cases (mostly within the context of non-injury pathology) it can be harmful. Most of all, I hope that this brings an awareness of comprehensive rehab. Kelly argues that a person should know how to work on your body and I agree. Icing is an effective rehab tool if you use it properly. It’s a tool that trainees, lifters, and athletes have access to even if we can’t get to a PT, yet it’s just one piece of rehab. Knowing how important compression, elevation, and — most of all — progressive and consistent movement are in treating an injury will make you a more knowledgeable trainee and help you perform better.
