Treat the Issues, Not the Tissues

Treat the Issues, Not the Tissues
By Dr. Rori Alter, PT, DPT
In a world that’s becoming more digitalized by the minute, it makes sense that information is more accessible than ever before. Just a few years ago there was (and continues to be) an upward trend of people “self-diagnosing,” incorrectly treating, and worrying themselves because they saw “Dr. Webernet.”
Web-MD, Wikepidia, and MayoClinic.com, among many other sites, became go-to places where the general population first looked for answers because it was quick and convenient, saved them a trip to the doctors’ office and a dent in their wallet from ever-increasing co-pays.
The endless wealth of information on the internet definitely has its benefits. Accessibility to information has allowed businesses to expand, entrepreneurs to set out on successful journeys, and people to expand their knowledge at quick and affordable rates. BUT! Like the hazards of Web-MD and self-diagnostics, people often times misinterpret and incorrectly apply information to their individual circumstances.
With the increasing popularity of barbell sports such as CrossFit, Olympic weightlifting, and powerlifting, the online market for coaches, gurus, bloggers, and mobility devices has skyrocketed in the last few years. We see Mobility WOD, ROMWOD, body tempering, hip circles and 100s of mobility and programming templates available at minimal cost or even free to the public. But out of the bottomless pit of information out there, how do we know what’s just right for us or what’s really going to harm us? And do we really know if what we are looking at or considering applying to our own body is exactly what we need given our individual circumstances?
Well, it’s hard. As a physical therapists and barbell specialist who focuses on working with barbell athletes, I often come across individuals who try to self-diagnose and self-treat aches, pains, and “poor mobility” under the bar. Typical questions I ask in my screen process include a) do you do mobility work and b) how long do you spend doing mobility work?
People typically answer one of three ways:

• Person 1: The athlete who doesn’t do anything at all…“I know I should do it, but I don’t.”
• Person 2: “I spend a few minutes here and there when I feel I need to.”
• Person 3: The mobility-nast who answers with, “well, I typically spend 30-45 minutes rolling, stretching and doing banded distractions, hanging from the smith machine (because that’s all it’s good for), and smashing and mashing my intestines and pericardial sac.”

I often find in my practice that the most injured client is Person 3. Upon further investigation Person 3 has scoured internet resources, bought multiple e-books, mobility tools, watched many YouTube videos by “mobility specialists” and even purchased a membership to ROMWOD and has somehow self-diagnosed every joint in his or her body and spends more time mobilizing than actually training. This client even reports developing more irritations, “stringy” muscles, etc. in areas that were never injured previously. I’ve even had a client report he stopped strength training all together because he needed his muscles to be more “supple” so he could get deeper into the muscles for soft tissue work (are you serious?---yes, I’m serious…he said that…).
Where does Person 3 come up with this stuff? Well, Person 3 is like the person who self-diagnoses gastroparesis via Web-MD and Wikipedia. What seems to happen is a person develops a symptom in a general area. He or she has been following some mobility guru on the webernet who has an article or video (or thousands of articles and videos) with the “5 Best Exercises to Decrease Hip Pain,” or “THE 12 Techniques to Eradicate Rotator Cuff Syndrome,”. The only problem is “hip pain” and “rotator cuff syndrome,” and the likes, are general terms, non-specific, and can be caused by a myriad of factors (tissue, structure, poor form, poor programming, etc.). So, what’s actually happening is the general public is using an overflow of generalized information to self-treat individual issues with individualized causes.
Here’s the deal: If you can put out a mobility exercise every day for the last 5 years, and you can write a 300+ page book with over 200 pictures and bogus, non-evidence-based “clinical” reasoning behind 15 variations of 1 concise exercise, you’re over complicating simple and effective techniques to keep your social media presence interesting and the public engaged. If you’re spending 45 minutes “mobilizing” your body with 2 types of rollers, 3 different sized balls, a band, barbell and inversions before you put a barbell on your back…you’re over complicating things as well by implementing good tools incorrectly. You are also decreasing effectiveness, and ultimately wasting good training time, or worse, getting to sleep 45 minutes later than you could have. And you probably could have save some money by not purchasing $350 worth of mobility tools too.
Most commonly, internet scourers will implement a good portion of mobility exercises and tools that they find out there for the world to see and interpret. But what they fail to address is poor form, poor movement patterns and poor programming that likely contributed to their issue in the first place. Yes, there is a place and time for “mobility” and soft tissue work but just doing this is likely not, and usually not, the answer. Additionally, if mobility work is warranted, I can bet you that you don’t need all 5 of the “5 Best Exercises to Decrease Hip Pain,” or 25 of the 365 MWODs from 2014 to conquer your issue.
“Mobility work” that takes more than 10-20 minutes a day, utilizes a treasure box of tools and that hangs you upside down is over complicated, not worth the time and likely not addressing the root of the issue. Oh, and that massage you spend $80 a week on isn’t fixing the issue either.
Although soft tissue and mobility work may make you temporarily feel good, it’s like taking Advil for the headache you get every day at 4pm. Instead of masking the pain with Advil and putting stress on your liver daily, it makes more sense to identify the issue. Perhaps your headache comes on every day after sitting at your work computer for 5 hours. So maybe it’s time to get your eyes checked and put on some reading glasses, or maybe you’re hunched over at your desk and putting stress on your neck. If the issue is fixed, the headache goes away!
Everyone is trying to utilize the internet to make money and gain popularity so there is a constant need to be running on the content treadmill spitting out the same thing repeatedly in a different color. Because of the overload of fancy and enticing content out there, it’s not hard to believe that everyone thinks that an exorbitant amount of self-myofascial release and mobility work IS the answer to preventing and fixing aches, pains and injuries from barbell sports but in reality…it ISN’T the best answer.
As an athlete, if you’re having aches, pains or tightness on a regular basis that interfere with your training or daily life, spend the time you’d spend scouring the internet for cookie cutter over complicated mobility exercises, and the money you would have spent on all those funny tools, to actually identify the cause of the issue. If you are serious about your longevity in the barbell sports, taking the time to learn about your sport, and understand optimal and safe movement patterns versus foam rolling for 25 minutes a day is going to be key in remaining pain free. What people often fail to realize is that it may be something as simple as poor bar path, buttwink, elbow position, etc. that is causing their tissue to have pain and NOT the tissue itself. Without addressing everything as a whole and identifying the overarching issues, you will spend countless hours smashing, mashing, and tempering tissue without really addressing the problem.
Ideally, you want to see a professional specialist who is qualified to study movement, diagnosis orthopedic injuries (ehem…a physical therapist) and is a specialist in your specific sport, who will take the time necessary to accurately diagnosis the cause of your symptoms as well as assess your programming, mobility work and FORM. Or, take the time yourself to really evaluate and address your movement patterns.
So what if there isn’t a diagnostician easily accessible to you (who specializes in what you need) or you have been unsuccessful with local practitioners? Well, while the internet allows people to get carried away with self-diagnosis and self-treatment, it’s also a truly valuable tool for connecting people remotely. With the ease of connecting face-to-face from hundreds to thousands of miles away, and the ease of file sharing and smartphones, clients and clinicians can easily connect for a consultation, assessment, and recommended treatment plan.
There are also some incredible coaches out there in the wide world of the web who are excellent at analyzing movement and helping correct movement through video feedback. The key here is that you are getting specific information about YOU and not generalized recommendations based on a blog post, YouTube or Instagram video.
In efforts to provide you with some helpful information without falling into the guru-know-it-all-category, I’ve come up with a non-exhaustive list of things I commonly find myself addressing with barbell athletes I work with. Often times I find that addressing common lifting mechanic errors is enough to ameliorate symptoms. In cases where pain improves a bit but continues to linger, other areas also need to be address. In cases that are more complicated, I’ll often look at frequency and volume of training programs and add in appropriate mobility work particular to the individual without over dosing it.
7 Things to Keep in Mind to Decrease the Risk of Barbell Injuries:

1. Wonky Bar Path: Bar path is defined as the line of travel the bar takes from start to finish of a particular lift. The bar path should always be as straight as possible and deviate MINIMALLY from the lifter’s balance point. For most lifts (squat, deadlift, overhead press and variations of these lifts) the bar path is vertical to the balance point over the middle of the foot. For bench press (and variants) the bar path should be a straight line although it is slightly diagonal from point A (directly over the shoulder joint) to point B (somewhere on the chest between the nipples and bottom portion of the sternum).
2. Unsynchronized Joint Motion: The joints involved in the lift should unlock at the start of the lift and lock at the end of the lift simultaneously. Additionally, the rate of change in angle of the joints throughout the lift should remain in unison.
3. Spinal Motion Under Moving Load: Your spine should always be held in a rigid posture. For most lifts, this is going to neutral to slight extension. Some spines have abnormal curves that may not be able to be brought into a truly neutral posture, but that’s okay. As long as you set your back tight and don’t let anything change while you are lifting, for the most part, you’ll be golden.
4. Excessively Wide Stance: Stance is determined based on what is a) anatomically safe under load and b) where the most amount of muscles have the best mechanical advantage to produce force.
   •  Squat: Place your heels in line with the shoulder or slightly outside the lateral deltoid and no wider.
   • Sumo Deadlift: stance is highly dependent on height and the widest stance possible may not be the safest or the strongest. Determine your stance by the knee angle created when you are in the start position. You are looking for a 90 deg (10 deg) angle at the knee.
   • Conventional Deadlift: for most of the population, 6-12 inches between the heels is a good range. Again, this is also dependent on size but typically you’ll want the heels directly under or slightly inward of the hips.
   •  Overhead Press: plain and simple...same stance as your squat (see above).
5. Accessory Arm Motion Under Moving Load: Our arms have two jobs when we lift a barbell: a) move the bar directly or b) stabilize the bar against our body so we can transfer force from our legs to move the bar. When we are stabilizing the bar against our body our arms should not move! If our arms do move, they will either take some load through the arm that can eventually lead to tendonitis or cause the bar to move on our bodies. A rolling bar can lead to a wonky bar path, skin irritation, and abnormal loading through the upper extremity.
6. Inconsistency from Rep-to-Rep: If every rep you perform in a set and across sets looks different than the one before, you do not have a clear model (whatever that model may be) of how the lift should be executed. If you don’t have a model, you don’t know how you are performing your lift. Plain and simple. You need to know what you are doing…even if it is more wrong than right…your brain needs to have a plan for what the lift SHOULD always look and feel like.
7. Eye Gaze: Our eyes are one of our biggest connections to the environment around us. They give us a tremendous amount of feedback about where we are in space and where things around us are relative to us. For this reason, our eyes provide key input for how our bodies move in the environment. This is particularly important when we have 400lb on our backs or are bringing 350lb down to our chest. Fixing our eyes to one point that is within 5-10 feet of us and not moving them throughout the execution of the entire rep (or set) is one of the biggest ways our bodies can stay balanced while our moving joints travel under load.

After you have identified and practiced your movement model for each lift, it’s time to load it! But just because you could squat 350# x 5 x 3 sets with your old form that caused hip pain doesn’t mean you can jump right back to those weights with your newly re-patterned squat. Consider this a new lift you need to accommodate to. Find a load that is moderately challenging, maintains your form, and doesn’t produce symptoms that your old technique did. From there, progressively load the lift over 1-3 sessions per week for a few weeks to a) reinforce new and improved movement patterns over time and b) bring this pain-free improved lift up to speed.
For a few weeks, or even forever if you train alone, use video feedback to keep yourself in check. Does each set look like the model you have in your brain? Does each set and rep look like the one before? Are you consistent? Remember how you feel and remember what the set or rep that felt the best looked like and try to replicate that. If a set felt bad or hurt and you filmed it, look at it, identify what looked different from the sets and reps that felt good and remember that! Don’t do that again!
At the end of the day, don’t try to be a hero. If you really can’t figure things out and your aches and pains continue to linger for more than a few weeks, see a barbell rehabilitation specialist and get the kinks worked out. Whether it be adjusting your program, your form, or heading for an MRI, letting something linger for more than 4 weeks without resolve can lead to longstanding pain or a more severe injury.