Oww! That hurts. Should I Avoid it or Train it.

It is commonplace in our current healthcare system for people to hear, “If insert common activity or movement here is bothering you than just stop doing that” or “You know that you should not be doing that.”  The problem with this is that sometimes the things we are being told to avoid are things that are essential to our everyday life or are an integral part of the activity that we want to perform.  Here are two recent examples that I have seen in my own practice of such a thing happening. The first was an elderly patient that hurt his back while gardening because he was attempting to lift a bag of soil out of his truck.  He was told by his physician that he knows better than to be lifting things. This is a man that still lives at home, how is it possible for him to continue with his normal way of life and avoid all lifting. The second example of suggesting activity avoidance as a treatment option was a 16 yo female athlete being treated for persistent knee pain linked to patellofemoral issues, and whom had underwent arthroscopic meniscal debridement approx 3 months prior, sidenote the surgery had no effect on her knee pain.  This patient was told by her surgeon that she should go to physical therapy but not perform any squatting exercises since that hurts, but that she could return to basketball. In this situation we are expecting someone that cannot tolerate squatting to be able to work their way back into a sport that requires cutting and jumping, which are activities that lead to much greater compression and shearing forces at the knee. Which from a training perspective, how are we going to be able to return someone to basketball without being able to train the squat pattern, a very fundamental piece of jumping and landing. 

In both of the above situations the suggestions of avoiding the given activities were impractical for the situations.  If we have discovered weaknesses in a person's fundamental movement patterns, such as the hinge in the elderly man, or the squat in the female athlete, should these not be things we are looking to improve instead of avoid.  I would agree with the physicians that both of these patients were in a position in which their physical capacity did not match up with the physical demands being placed on their bodies during the activities each person wanted to do.  However, I do not agree that the answer is to avoid these activities, as common sense would tell us that if we avoid an activity how will our body ever develop to capacity to perform it. Instead of avoiding these activities we need to train them, and that is exactly what we did in both scenarios.  

In both cases we began with looking at the person’s movement patterns to look for either mobility deficits that would not allow them to perform the movements fully, or motor control issues that cause them to have poor techniques despite having the necessary joint range of motion and soft-tissue flexibility.  Once you are able to determine the limiting factor, which could be both, the solution to the problem becomes simple. Prescribe the necessary mobility and motor control exercises to improve movement quality. Then scale the movements in a way that allows the patient to perform the movement successfully and progressively load the pattern.  Often times we like to make musculoskeletal issues more complex than they have to be. There is nothing tricky about the two cases described here and so the solution does not need to be tricky either. A weakness in both patients was identified and a progressive loading strategy for the patterns in which they were weak were created to improve their physical capacity to perform the desired tasks.  The only tricky part is getting the person to understand how consistent and diligent we must be if we want to make true changes to our movement patterns and improve our physical capacity.

To recap, please stop telling people that they can not do things or that they must avoid certain activities because they are causing a pain stimulus.  Instead let's teach people how to move correctly and show them how to progressively strengthen themselves, as this is were a true resiliency against injury occurs.