4 Steps to Ensure Strong (and Pain-Free) Recovery

I recently worked with a woman in her late 40s suffering from left knee pain.

She was super active and loved working out, hiking, working with her personal trainer, and playing competitive tennis. Her left knee pain wasn’t completely debilitating but did occasionally swell during the day, and it was limiting her on the tennis court. We worked together to help with her knee pain, performed a biomechanical movement evaluation and soft tissue therapy, and did corrective movements.

After a few weeks, we were able to get her to a place where there was no more swelling, and she could go through her activities of daily living without any pain. We were on track!

However, the next week, she came for her session and reported that her knee was swollen. She also couldn’t bend it all the way.

“What happened?!” I asked

“I don’t know,” she said. “I played a few tennis games this weekend because I thought I was better.”

And there it was, the kiss of death.

Working with clients as a Movement Specialist for the last two decades, I’ve learned that there’s a common idea out there in the world of fitness, sports, and rehabilitation. It has people convinced they’re either one of two things: “injured” or “better.”

The idea is that there’s this “light switch” that’s either ON (better) or OFF (injured) and that all we have to do is somehow flip the switch to “better,” and Tada! Off you go!

If it was only that simple.

We Have to Fix Your Trajectory, First

One of the most important concepts I teach my clients is the difference between trajectory and destination.

Destination is where you are at this moment. Trajectory is the direction you are headed. Although knowing and being aware of where you are is important, knowing your current trajectory is critical.

If you came to see me as a Corrective Movement Specialist, my first objective would be to change your current trajectory. In coming to see me, you’re asking for assistance in getting out of your current situation and into a more desirable one. The only way to do that is to change the trajectory you’re headed in.

If we do nothing more in our first session together than ensure you’re on the right trajectory, then you’re way ahead of the game.

As Jim Rohn famously said:

It's not about getting the light to turn from off to on—it's about getting the light to go from dimmer to brighter.

When it comes to rehabilitating an injury, this must be taken into consideration. We have to stop thinking that the symptom, or the “pain,” is the on-off switch between “better” or “injured.”

Where Pain Lies in the Movement Continuum

Pain is the LAST and final communication that something needs to be addressed. And the unfortunate reality is that 95% of traditional health professionals are focused on getting that symptom light switch to turn off.

Below is a diagram I draw for my clients to help them understand how this concept applies to soft tissue injury and recovery:

What this diagram illustrates are three key pieces:

1. The black arrowed line, representing the Movement Continuum.

2. The far left of the line, representing “Perfect Biomechanical Movement.” This means someone who is moving in the most optimal way possible. To my knowledge, this person doesn’t exist and potentially never has—but let’s say it exists, conceptually.

3. Anything to the right of this line, which is considered “imperfect biomechanical movement.” Meaning there is some degree of inefficiency within their movement patterns. When the dysfunction gets bad enough, eventually, the line of “disabling pain”/injury is crossed.

As one moves down the line of dysfunction and towards “disabling pain,” there can be some discomfort, tolerable pain, and other signs of dysfunction—but not enough to get that person to stop.

Often these smaller signs are managed with modalities like anti-inflammatories, ice, a cortisone shot, a chiropractic adjustment, or some physical therapy. The more tolerance and ability to compensate an individual has, the longer they can “get away” with dysfunctional movement patterns.

But everyone has a threshold they will eventually cross when they are “forced” to stop. This is “disabling pain,” and depending on the person, it can happen at different levels of dysfunction.

An example that illustrates this is someone who has been lifting boxes for many years with improper mechanics.

Although this individual may have been lifting incorrectly for years and overloading their lower back, it may take them 10+ years to cross the threshold into disabling pain. For another individual, it may only take a few hours of lifting boxes incorrectly before their back goes out.

Pain Is Just the Tip of the Iceberg

The key thing to understand is that an injury or “disabling pain” is the tip of the iceberg.

When you reach this point, many signs were missed along the way that indicated you were heading in this direction. And ALL of these missed signs were signals of dysfunctional movement patterns. It wasn’t that you were “fine” and then you were suddenly “injured.” It's way more complex than that.

All this to say, when you cross the line from disabling pain to no pain, this is simply an indication that you are heading in the right direction. It doesn’t mean you have healed, or are “better,” or that the dysfunction that caused the injury has been thoroughly addressed.

The distance between you and that threshold is your body’s tolerance level. If you are right next to that pain threshold line, you may not be in pain at that moment, but you have VERY little tolerance to stress the system.

The 4 Re-Entry Guidelines

For all these reasons, I had to figure out a strategy to ease my clients back into their favorite activities. I needed to ensure they not only didn’t get re-injured but that they were stronger when they returned.

This is why I created these 4 Re-Entry Guidelines:

1) The “Activities of Daily Living” (ADLs) Pain-Free First
2) Start Your Extracurricular Activity at 50% of What You THINK You Can Do
3) Add 10% More Intensity Each Week for Following 3 weeks
4) Add 5% More Intensity Each Week for the Next 4 Weeks

Let’s break each one of these down.

STEP 1: The “Activities of Daily Living” (ADLs) Pain-Free First

My first rule for anyone coming off an injury is that before they go back to engaging in extracurricular activities, they must go an entire week without any pain doing their normal activities of daily living.

Examples of “normal” activities of daily living:

• Sleeping

• Getting in and out of bed

• Walking down or upstairs

• Getting in and out of the car

• Picking up things off the ground (this could be a child)

• Walking around the house, work, grocery store, mall, etc.

• Sitting on a chair and standing up

• Getting on the floor and getting back up

STEP 2: Start Your Extracurricular Activity at 50% of What You THINK You Can Do

This rule is primarily to protect you from yourself.

If you are an “I could do that” kind of person like me, then you need this rule. Just because you can, doesn’t mean you should.

The tendency is for the mind to be way ahead of the body. Although a 3-mile run may seem easy, it isn’t for your injured area.

If you were correctly rehabilitated and the root cause was identified and addressed, there is a period where the new and improved motor pattern must be conditioned. This takes time. This is how you get far away from that threshold of dysfunction that caused the inhibiting pain/injury.

Starting at 50% intensity enables you to return to your favorite activities without overdoing them. It allows the injured area and new motor patterns to be conditioned so that the recovery is sustainable.

The other reason why this rule is helpful is that it positions you to start with a win. Nothing is worse than getting back to your activity and having pain—super discouraging. So if you leave that first workout thinking, “I feel good, I could have done twice as much,” then you are WINNING!

Enjoy these wins and build on them.

If going at 50% intensity for that first week is COMPLETELY pain-free, move on to step 3.

STEP 3: Add 10% More Intensity Each Week for Following 3 weeks

This creates a gradual progression of intensity and allows the new motor pattern and injured area to be conditioned and integrated back into the activities seamlessly.

Here are a few examples:

Weight Training
Ex: Barbell Snatch - Before injury: 5x5 with 120lbs

• First Week Back: 60lbs 5x5

• Second Week Back: 70lbs 5x5

• Third Week Back: 85lbs 5x5

• Fourth Week Back: 95lbs 5x5

Running
Ex: Running 10 Miles 3x/week (30miles/wk)

• First Week Back: 5 Miles, 3x/wk (15miles/wk)

• Second Week Back: 6 Miles, 3x/wk (18miles/wk)

• Third Week Back: 7 Miles, 3x/wk (21miles/wk)

• Fourth Week Back: 8 Miles, 3x/wk (24miles/wk)

The same could be applied from an “effort” standpoint using a perceived exertion scale. If you were working out, playing golf, tennis, or doing yoga at a perceived exertion of 8/10 before the injury, then that first week would be a 4/10, and then you’d build from there.

Moving up 10% each week only happens if the prior week was completely pain-free—but you already knew that, of course ;)

STEP 4: Add 5% More Intensity Each Week for the Next 4 Weeks

Now that you have built yourself up to do 80% of where you were before the injury with no pain or injury relapse, you then add 5% each week for the next 4 weeks.

This is not only the best way to safely and confidently get back to where you were pre-injury, but there is a bonus that you will discover at the end of this stage: you will be STRONGER than you were BEFORE the injury.

Being patient and building this solid new foundation with the new motor pattern will not only prevent a relapse with injury, but the new motor pattern you’ve been slowly training will also be a more efficient movement pattern and, therefore, stronger.

This is always my favorite part about this process and methodology. When you address the movement inefficiencies of the body, you are doing rehabilitation, injury prevention, and performance enhancement, ALL AT THE SAME TIME!

The key steps to remember when coming off an injury:

1. Activities of Daily Living (ADLs) must be 100% pain-free before doing other activities

2. When beginning other activities, start at 50% of what you think you can do

3. Add 10% each week for the next 3 weeks

4. Add 5% each week for the next 3 weeks

Yours In Vitality,

Matt