Chapters:
00:00 Intro
00:28 Lesson #1: You often don’t need to see a professional
05:44 Lesson #2: Imaging is often not useful
08:28 Lesson #3: You generally don’t have to know what’s wrong
11:13 Lesson #4: The treatment for most injuries is in principle the same
15:55 Lesson #5: Focus on what you can do
18:18 Outro
Transcript:
It was a nice sunny day in Mexico when my spine made a very loud popping sound… And i suffered a year of debilitating back pain. The pain was so bad that I couldn’t even shower while standing and I couldn’t walk for more than about a minute. In this video I’m going to show you what I learned during this process of rehabilitating my back back to squatting and deadlifting as if nothing had happened.
Lesson number 1: You often don’t need to see a professional. My injury was actually severe and lasted a long time. In those cases it is usually indicated to see a professional. Most injuries though, it’s really not necessary to immediately go to a physiotherapist or a doctor to see what’s wrong with you. In my case, I saw all the top back pain experts in the world. I worked with Stuart McGill’s team. I worked with some of the more modern, evidence based physios who have radically different views on some subjects. And in the end, none of them could actually provide reliable diagnosis of the problem. I never actually found out what was wrong with me and many of them had very different action plans to the extent that they even had a reliable diagnosis to begin with. So ultimately, nobody that I saw actually really helped me concretely in terms of what I should do to actually rehab the injury. And there’s actually also a lot of research that most of the benefits that people get from going to a physiotherapist or a doctor is a placebo effect.
It’s more the idea that you’re being cared for, that someone knowledgeable is looking after you, rather than that they’re really doing something that concretely is going to make you feel better. A famous quote from Voltaire about this is “The art of medicine consists in amusing the patient while nature cures the disease.”
I also know a doctor in the Netherlands and he used to joke, he’s a general practitioner, so like family doctor type that deals with all types of problems, including some musculoskeletal injuries, and he used to joke about that his job was basically: whenever somebody comes to him, he said: “I look for 3 red flags.” I don’t remember what they are, but they are like 3 medical red flags that can kind of fly under the radar and warrant seeking more urgent medical attention, and if they didn’t have one of those 3 red flags, he would just send them home and say: “Come back in two weeks if the issue is still there.” And the vast majority of the time, after two weeks, whatever was the problem has solved.
The body is very good at healing itself. The body is very resilient, very adaptable, and the vast majority of injuries heal on their own. We see this even with very severe injuries like herniated discs, which I had, and massive prolapses. Even those tend to reabsorb and heal on their own without surgery. It takes a long time, but even those types of injuries typically heal on their own. In support of this, a 2023 meta analysis found “…no clinically significant differences in pain function and quality of life between single and multiple physiotherapy sessions for musculoskeletal disorder management.” So people that go to a physiotherapist more often, that get follow up visits, they don’t actually do better on average. And there are multiple reasons for that. One is that, as I said, the injury typically heals on its own anyway, regardless of what you’re doing in the meantime. Second is that the physiotherapy doesn’t often have more information than you do, we’ll get to MRIs and the like in a moment. But they basically just know the same symptoms that you do. And even if they do have a diagnosis and it’s accurate, which is a big if, then that often doesn’t actually change the treatment plan.
When you have a knee injury, whether it’s your ACL or MCL, it’s not going to really change how you go about the treatment. Like if you have debilitating pain when you twist your knee in a certain direction, you’re not going to be like: “Oh no, it’s fine because it’s the patella.” Similarly, a 2022 meta analysis of booster sessions, so kind of follow up sessions with professionals after self-management of musculoskeletal pain, so people that just try to go about it on their own without having seen a professional “…had no evidence of an effect on improving patient-reported outcomes of physical function, pain related disability and pain self-efficacy.” The only thing that the booster sessions did accomplish is that they reduced pain catastrophizing. So again, that comes back to people feeling cared for and not feeling like: “Oh my God, I’m going to die! There’s something really wrong with me! I need to seek urgent medical attention!” Just some more reassurance. Allowing people to wait and be a little bit more tranquilo is often enough to just let the injury heal on its own. And because of this there’s actually a growing consensus among modern evidence based physiotherapists that patient education and self-management should be the first courses of action for the vast majority of treatments.
If you don’t have something like complete range of motion, skin discoloration which indicates there might be like extreme muscle strain, like a muscle that was torn completely off the bone. If you don’t have very obvious signs that something’s really wrong like that then often, if you have a decent understanding of what to do, like you’ve watched videos like these, for example, you can go about it on your own for at least the first couple of weeks. And that’s also what a good physiotherapist is supposed to do. If you do go see one and you want to check if they’re good, because the first visit can be useful to get that education and plan for rehab, but the plan for rehab should not just be a list of exercises and stretches that are like the magic that will heal you, it should be more a general principles of how to interpret your pain signals and how to go about the process in general, rather than follow this exact plan, because there, as we’ll get to later, there is no magic healing exercise plan.
You also have to remember that when you see an expert, they are an expert on that field but that doesn’t mean they’re right and they’re still just people. Many people have a tendency to over-glorify especially doctors, with the idea that they are magical and they know everything, but is really just a person. If you studied at university think of all the other people that you studied with, and it’s just one of those people that you might be seeing. And many of them really don’t care about their job many got poor grades, you know, how they were at school, weren’t, you know, all that intelligent, all that competent or anything, they’re just, you know, making a living. That’s the type of person you’re seeing. You’re not seeing God. Now, that’s not to say that there are no professionals. Of course, there are a lot of good physiotherapists. It’s just that very often the good physiotherapist will even acknowledge themselves that you don’t need to see them for most types of injuries. And in my case also, seeing many of the top experts in the field did not actually concretely help me.
You might be wondering why not just do an MRI then you know exactly what the problem is. Magnetic resonance imaging is a very accurate way to see inside the body. You might be tempted to think, and this was my first intuition before I became aware of all this literature, that doing an MRI was the best way to see what’s wrong. And the main reason you go to an expert is to get high quality imaging done, because then they actually have more information than you do and then they can see: “Okay, I see exactly where the exact problem is and therefore we know how to go about the treatment.” Wrong.
In the vast majority of cases, MRI is not actually useful and there is a growing consensus among professionals that MRI scans are actually contraindicated, and the same goes for ultrasound and almost any type of imaging you can do for musculoskeletal problems. The scans are not useful because they don’t always reveal the problems that are actually there. They might be too small to see on a scan. It might be very difficult. If you’ve ever seen MRI scans like here, you can see that it’s actually not so crystal clear. It’s not like there’s a red dot on the screen that tells you exactly what’s wrong. And indeed, in my case, I did have MRI done and I saw multiple experts about it, and they all pretty much said something different. That’s why the title of this video is Herniating a Disc or 3, because there was pretty much a consensus that at least one of my discs was pretty severely herniated. But depending on who you asked, it was a different disc.
One of them said one of them was anterior and the other two were posterior. The L4-L5 herniation was pretty clear pretty much everyone I asked, but then it was one above it or below it, depending on who you ask. And some people said that my symptoms were perfectly in line with the problems on the MRI. Others said: “Actually, your symptoms are not at all like what you typically see in a disk herniation” because I was, for example, extension intolerant instead of flexion intolerant, which is much more common a disc herniation and that’s why one of them thought that the little thingy on front side might be an interior disc herniation as well around the chest area and that’s why I was extension intolerant.
Now it turns out that if you do MRIs of people, then you will pretty much always get something’s wrong. Even in people that don’t exercise, that they’ve never had any symptoms, no injuries, no pain. You will find something’s wrong with them on an MRI scan. Sometimes actually, things that are… look really wrong, like massive prolapses or herniations and these are very often asymptomatic. Doesn’t mean anything, the body’s really good at working around these types of injuries or abnormalities because some people just have different shapes and their spine just doesn’t look like you see in a textbook. That doesn’t actually have to be a problem. So you get lots of false positives. You might not see the actual problems that are there on the scan, because there might be much more neurological components rather than biomechanical components. So the current consensus is pretty much that imaging doesn’t offer much help, especially not in the early stages of an injury. When it becomes long, severe injury and it becomes very unclear what’s wrong, then you can consider doing a scan, but know that there might be a lot of false positives. At this point, you might be thinking: “Okay, so if I don’t go see a professional and I don’t have imaging done, then how on earth do I know what is wrong with me?”
Which brings us to lesson number 3: “You generally don’t have to know what’s wrong with you.” As I already alluded to earlier, when you have a knee injury, for example, whether it’s your MCL, your ACL, or even your patella or your tendon, bone, whatever, it often doesn’t actually change the treatment plan. The treatment plan is generally always exercise and specifically exercise below the threshold of your current recovery capacity. When tissue is injured, and we’re assuming for a moment there is a biomechanical injury and it’s not purely psychosomatic pain, then that threshold, the recovery capacity that you have is typically diminished because the tissue is weaker if there are tears in the tissue, if you collagen structure has not fully remodeled to full strength yet that will make the tissue weaker and mean that you cannot handle as much volume, you may not be able to handle certain exercises at all that you otherwise would so you have to gradually build back up. And that is really the whole essence of rehabilitation: Working around the current injury, finding what you can currently do without aggravating the injury or the pain, and then gradually working back up to your former levels.
As I said, in my case, I successfully rehabilitated my back after a long time and none of the doctors actually got me a real diagnosis. I saw all the top experts in the field. None of them could actually figure out what was wrong with me, and you don’t really need to know exactly what’s wrong to have an effective treatment plan. Research finds that there are only 4 things that you really need to know about an injury. That’s: Where is the pain or injury? How bad is the pain on a scale of 1 to 5? Like how would you describe the pain? That’s a little bit more subjective, but sometimes it can help. Like, if people say it feels electric or radiating, there’s a big neurological component probably. 3. When does it hurt? During which exercises? Be very careful when you test this. You obviously don’t want to go to a squat 1RM if you have a severe back injury. Just do the movement and stop at the first sign of discomfort, but at least have a sense of which movement patterns hurt, which exercises hurt and which things are completely pain free or even feel good. And then 4: Has this injury occurred before? Because re-injury is by far the number one predictor of injury.
When an injury has occurred it takes a long, long time before that tissue has remodeled to full strength. Many, many months, even if the injury is not that severe. If you had elbow tendinopathy, for example, when training your triceps or your biceps, you might be pain free in a matter of weeks, or maybe even one week, but the tissue has not remodeled to full strength. The collagen structure is not the same as it was before the injury and that could take many, many months. And during that time you are extra susceptible to re-injury. Even in some cases, the tissue does not fully heal and does not get back to the same shape as it was before, the same strength as it had before, and therefore it will remain somewhat more susceptible to injury for life. In many cases though, there is complete healing and it just takes a lot longer than most people think and a lot longer than you would expect based on your pain signals.
What you do with this information brings us to lesson number 4: “The treatment for most injuries is in principle the same.” It’s always exercise. Exercise is the best for almost all types of injuries. Exercise that keeps you as active as possible but does not aggravate the injury. And pretty much strength training is always indicated because it’s the best to actually strengthen the tissues, especially if you are a strength trainee. The strength training is the best to prepare you for further strength training.
The body is very specific, all types of tissues can adapt, they can heal, they can get stronger and strength training is very effective for that because it puts a lot of load and compression and force on the certain tissues. Force is really the great communicator in our body of tissues. You put force on a tissue and the tissue adapts to that. So usually what you do is you avoid the things that hurt and you do things that don’t hurt. It’s that simple. Pain signals in many studies are a really good indicator of what you should and should not do. It’s pretty much why the evolutionary signal evolved. Pain is a signal that tells you “not okay”, so you don’t do these things. Now, this assumes that there is a biomechanical injury actually there. I’m not going to go into in this video too much into psychosomatic pain and psychogenic pain even. There are types of pain that are not related to an injury.
Most strength training injuries, though, especially among serious trainees, which is my core audience, are overuse injuries where there actually is biomechanical damage. And for a long time, typically what happens is people train through pain. I see this all the time in my clients and my students. When they get to me and they actually tell me like: “Yeah, I have pain in my elbow.” Almost always, it turns out they were training through pain for a long time and that’s how you get injured. So most injuries are really not magical. You could see it’s coming for a long time, but people are stubborn, especially hardcore trainees, myself included, we’re stubborn, we like to keep training, we think, “Oh, it’s not too bad, I can handle it.” And that’s a very different question can you handle it vs. is there pain. If you listen to your pain signals you can avoid most injuries to begin with. And when they are there the pain signals will tell you what you can and cannot do. Interestingly, even if the pain is psychosomatic, and almost all pain has a psychosomatic component, there is a lot of fear and anxiety that aggravates pain, it almost always comes with being injured because being injured is very much a physical and a mental process.
It really sucks to be injured, especially if you care a lot about exercising, about strength training, then there is a big psychological component to any type of injury. Interestingly, though, the treatment is usually the same because what you want to do is find things that are pain free, develop confidence and comfort, help the tissue strengthen and it doesn’t really matter whether it’s due to the increased confidence or the fact that your tissue is now healing that you can gradually increase the intensity and you can start training through either a little bit of pain, or you can start increasing your pain threshold over time. So whether it’s psychosomatic or not, the treatment actually is very often the same. There is a lot of nuance to this that I’m not going to go into in this video because for most trainees the basics first are listening to your pain signals, because a lot of people, in my experience, don’t do that, that’s how they get injured and then it’s also what prevents them from healing afterwards.
Now, when it comes to what specifically you are doing during the rehabilitation, like which types of exercises you’re selecting, what type of exercise are you doing, many studies find that it actually doesn’t matter. There are studies where they do like rotator cuff exercises and the other group just use rows for the healing of shoulder injuries. There are studies on knee injuries where some people do more hip dominant, some people do more knee dominant training. Most of these studies find it doesn’t matter. For back pain as well, especially for, like, back pain even, I would say, many studies have found that the type of exercise you do doesn’t matter so much, as long as you are listening to your pain signals and you’re gradually increasing the intensity so you’re below the threshold of inducing more damage and you are gradually working up in the stress on the tissues so that they can adapt and heal over time. That’s what really matters.
So there are no healing exercises. It’s not like these magical rotator cuff exercises or the McGill Big 3 or whatever… There’s nothing magical about them. Like, the McGill Big 3, I did them as well. Whether they helped me or not I don’t know, I think they are exercises that for most individuals, especially with herniated discs, they offer a good stimulus to fatigue ratio. And that’s what his research also finds. You get a good ratio of muscle activity relative to the forces on the spine. However, there is nothing magical about them and it really depends on the type of injury, your specific situation, which types of exercises are the magic for you.
There is not to say that you can just do whatever and everything will be equally effective. To a large extent that is true, but there are certain exercises that allow you to keep training with more volume, more intensity and generally train more body parts more effectively. That is completely dependent on the type of injury you have and the body part in question. For example, I made a video that you can see here about elbow pain when training triceps, I go into very concrete recommendations how to deal with that. But this is really specific. What matters in general for injury management is knowing that the stress is below your recovery capacity, not that you’re doing some type of magic exercise. Speaking of exercises that you can and cannot do.
Lesson number 5 is that you should focus on what you can do. When people get injured there is a huge mental component. As I said before, being injured really sucks. It’s something we really care about. Pain just in general really sucks. It’s a very negative feeling and the restriction that comes with it, with feeling like we cannot do this, we cannot do this exercise, it really sucks. There’s no way around that but mentally you can make things for yourself a lot better by thinking about what you can do instead of thinking about what you cannot do. For many people, I know that not being able to do the power lifts, in my case, not being able to squat or deadlift for about a year+ really sucked. But if you’re not a powerlifter, it actually doesn’t matter that much. Like, my main purposes are not powerlifting, so I haven’t squatted and deadlifted much at all in the past two years and it’s fine. You retain your muscle mass, you can do other exercises that stimulate the same musculature.
Maintaining muscle mass is very, very easy. That’s also very reassuring. If you can do any type of exercise for a muscle group you will retain your muscle mass. And even if you don’t, you have to completely avoid training a muscle group, which I had to do for like two weeks, avoiding any type of exercise for the hamstrings, glutes, or lower back, you’re not going to lose a lot of muscle. First week you lose basically none, second week, yeah, there will be a little bit. But then muscle memory helps you regain that muscle mass really, really rapidly. So you really don’t have to obsess over not being able to do certain exercises or even, for a short period of time, having to completely skip training a body part. It’s not the end of the world. What I see happen all the time in my clients, sometimes even to a comic level is that they at one time ask me for more variation in the program, they don’t want to do this exercise anymore and then for example, they get injured a week after and they cannot do their exercise anymore, whether it’s Bayesian curls or whatever, and then they’re like: “No, I have to keep doing this exercise!” because mentally now feels like there’s this restraint, right? It’s like a forbidden fruit effect, that we have to do this exercise because that’s the exercise we cannot do. It really is, in big part, a completely mental game.
So again, focus on what you can do, focus on just being able to train all your body parts. If you can train all body parts, you will at least maintain muscle mass. If you can train them with a decent volume, with somewhat decent exercise selection, and you can even still make gains. If not in that injured body region, then at least still in other body regions. Keep training as much as you can, work around the injury as much as you can, and then it’s really not the end of the world if you cannot do a few of your favorite or optimized exercises.
All right! I hope this video helps you with your injuries, and you don’t have to spend months of effort, pain, and studying to learn these lessons yourself. If you like this type of evidence based content, I’d be honored if you like and subscribe. And if you’re a serious lifter that wants to learn everything about injury management, muscle growth, fat loss, strength development, optimum gains in general, then check out my Henselmans PT Certification program or the Personal Development Course for non-professionals. Check it out.