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  • Stubborn Deep Gluteal Pain

    Hey Docs,

    I have been dealing with off and on (mostly on) pain localized deep in the middle of my right glute since April 2021. My initial post about it is linked here: https://forum.barbellmedicine.com/fo...iriformis-pain

    Over the last 16-ish months, the pain has been anywhere between basically nonexistent to a radiating legitimate 7-8/10 nerve pain back in late February of this year (peaked there for a few days and gradually subsided over the course of a few weeks). Recently, it's been hovering between a 1-4/10 and is localized in the middle of the glute, no radiating since that period earlier this year. I would say that this is how it's felt for the vast majority of the last 16 months - more annoying than anything, but since that late February flare up I get a little more wary when it creeps up around 3-4/10 rather than 1-2/10.

    The pain occasionally increases after squat and deadlift sessions (usually doesn't bother me as much during), while walking, and for the first several minutes after I get out of bed in the morning. Sitting on the floor or a hard surface sometimes increases the pain as well, as do sudden changes in hip movement if that makes sense. It feels like a dull ache sometimes and a sharp pinch other times.

    A few separate times since April 2021, I have tried modifying loading, exercise selection/variation, and exercise frequency with limited success. In fact, for most of the last 6 months, I have modified my training rather significantly due to both the aftermath of the February glute flare up and an unfortunately timed lower back injury. The lower back is getting better slowly but surely, but the glute pain is still just hanging around.

    If I was guaranteed to never have another intense flare up again, I could probably just deal with this forever and train mostly normal with the help of autoregulation. I'm afraid that's not realistic, though. I'd love to get this figured out, but I don't know what else to do at this point.

    I realize this probably a kind of unique, individual issue and worthy of a consult.

    Thanks,
    Nate

  • #2
    When you say you have modified your training, what has that consisted of?

    Comment


    • #3
      Hi Derek,

      Thank you for your quick response. I assume you're looking for clarification about this quoted text?

      In fact, for most of the last 6 months, I have modified my training rather significantly due to both the aftermath of the February glute flare up and an unfortunately timed lower back injury.
      It has consisted of a lot of stuff. I'm not sure how detailed you want me to get with my answer, so here goes. The TL;DR would be that I have reduced (at times very drastically) squat and deadlift volume, intensity, and frequency. I have also modified (again, at times very drastically) exercise selection based on pain symptoms. Glute pain symptoms improved for a little while, to the point they were nonexistent more days than not, then returned.

      I train for powerlifting and am typically accustomed to training 4x/week with an additional GPP day. I haven't followed a straight up template for a while, as I've either programmed for myself or had a coach, but my typical training is somewhat similar (in terms of how it is organized, volume and intensity selection, exercise selection, etc.) to something you'd find in a BBM strength or PL template. I was working with Leah Lutz prepping for a PL meet when I had my really bad flare up sometime around February 20 or so. The pain had been ramping up for a couple weeks before it peaked around then. I was autoregulating load based on the pain, but likely not enough. I was 6-ish weeks out from my meet at that point and was stupidly trying to drag myself to the finish line, haha.

      At first, the pain was so debilitating that I completely rested for about a week. After that, I drastically changed exercises and substantially reduced loading, volume, and training frequency one week post severe flare up. I was basically just doing partial ROM goblet squats and kettlebell RDL 2x/week. I gradually increased those training variables and got slightly more specific with my exercise selection of the course of about 7-8 weeks post glute flare up as symptoms improved. After these 7-8 weeks, my glute pain had subsided to the point where it was nonexistent most days. Training volume was probably a good 50%+ less than normal, intensity was moderate.

      I attempted to ramp up training a bit more at this point - even more specific squat and DL variations (still no comp lifts though), moderate volumes/intensities, little more frequency, though I was still just on a 3x/week schedule. Admittedly, I almost definitely increased loading too fast and learned the hard way that my body wasn't as healthy and ready to go heavy-ish as I felt it was - I popped my lower back after like a week of feeling "back to normal." This was around mid April. I feel like the timeline from here on gets a little messy because I was making training decisions based on my low back, not my glute, and was definitely paying a lot closer attention to my back.

      From mid April until late May, I tried to train around the low back injury as best I could, but it wasn't getting better. I believe I attempted to add comp squats back in during this time and attempted to go back to a 4x/week schedule, but neither went great. I was basically doing stuff like high bar and block pulls again, as well as belt squats, lateral lunges, and unilateral RDL. Had to really scale back on the volume and intensity during this time - my top sets were basically "work up to a tolerable load" rather than an RPE target. At some point during this time the glute started to get painful again, but I wasn't sure if it was just pain radiating out from my lower back or not at first.

      Since June, I have gotten to the point where I'm able to tolerate more volume and intensity, a bit more specificity, and as of last week a 4x/week schedule. I am still a bit (maybe 15-20%?) under what was "normal" prior to February of this year in terms of volume. On the intensity side of things, my squat and deadlift top sets have not exceeded RPE 7 in a long time, and most of my squat and deadlift work has been around the high 60-low 70% e1RM range. Exercise selection wise, I just started doing comp squats and deads again, but am keeping assistance and supplemental movements fairly non-specific.

      The minor glute pain has proven to not be just low back pain radiating outward, though, because it has hung around and gotten a bit worse on some days even as my back has started to feel pretty close to 100%. Like I said, it isn't bad enough to affect training, but it's definitely there most days. I just sort of want to stay out in front of it a little better this time and hopefully avoid another bad flare up, though I'm pretty sure I could avoid it getting to that point now that I know how bad it can get and the warning signs.

      Comment


      • #4
        Hey Nate, that is what I was asking for clarification on. I'm going to focus on two big areas here to offer some advice.

        I was basically just doing partial ROM goblet squats and kettlebell RDL 2x/week. I gradually increased those training variables and got slightly more specific with my exercise selection of the course of about 7-8 weeks post glute flare up as symptoms improved. After these 7-8 weeks, my glute pain had subsided to the point where it was nonexistent most days. Training volume was probably a good 50%+ less than normal, intensity was moderate.
        Admittedly, I almost definitely increased loading too fast and learned the hard way that my body wasn't as healthy and ready to go heavy-ish as I felt it was - I popped my lower back after like a week of feeling "back to normal." This was around mid April. I feel like the timeline from here on gets a little messy because I was making training decisions based on my low back, not my glute, and was definitely paying a lot closer attention to my back.
        To the first quote, I would say this is a pretty drastic decrease in volume. Good for symptom control and management, but likely on the low end for trying to garner any positive tissue adaptation. While in the initial phases the goal really is symptom control, too often there is a bit of an inflection point where when things feel good, we jump back into training a little too hard without accounting for current volume/intensity. It's easy to feel better with rest but it's really hard to be better with rest. With a more PL style of programming, if squats and deadlifts need to be struck from a program or heavily modified, it's often a good time to get that additional volume/intensity from things like machine/isolation work. While not a 1:1 transfer of strength by any means, it's a good way of minimizing deficits as things calm down. I likely would have tried to keep you >70% volume but used machines as the meat and potatoes here. If you think about it as a bit of a math problem, if you are doing <50% of the work and start pushing into 60-70% of prior intensity, there is a bit of a gap there.

        I will often have athletes run machine/isolation work at the start of the session to 1) get the feeling of actually having worked out 2) be able to use that pump as an additional governor for weight selection on squats and deadlifts. If I run you 4 sets of [email protected] for knee extensions prior to squatting odds are we're going to take down the weight a little bit here. We're getting the work, and getting exposure to the squatting motion, but likely not leaning as hard into symptoms. If goal 1 is getting you feeling better, goal 1a is keeping you in as good of shape as possible while that happens. As a generalexample, if I were to structure the outline of a program in your instance right now it would likely look something like:

        Day 1:

        GHD back extensions
        3 sets to 2RIR with a controlled tempo

        Seated knee extensions
        4 sets of 10 at RPE 8

        Seated hip abduction
        3 sets of 10 at RPE 8

        3-0-0 back squat to tolerable depth
        3 sets of 6-8 at RPE 7

        Bench
        as usual

        RDLs
        4 sets of 6 at RPE 7

        Day 2:

        Machine Hamstring curls
        4 sets of 10 at RPE 8

        Curtsy lunge
        3 sets of 8 at RPE 8

        Dumbbell split squat
        3 sets of 10 at RPE 8

        Bench as usual

        Deadlift
        Off blocks if needed
        4 sets of 6-8 at RPE 7

        You could run this as an A/B type split for a 4 day plan if need be but I am willing to bet this is a much more expanded program than what you were running. The back extensions offer some isolation work for back symptoms, it's almost impossible to avoid using your hip abductors on a machine so you're checking that box, and odds are you'll be nice and fatigued by the time it comes to squatting and pulling. But even then, you can use the heuristic of:
        • light and slow
        • heavy and slow
        • light and fast
        • heavy and fast
        With injuries like this, most of the time speed is one of the exacerbating factors. Running some tempo work is a great way of checking that box for feeling like you are getting a challenge as well as exposure to comp movements. This is just a backbone but I think it conveys the point. It would be titrated according to symptoms as well as how in shape you are. With these type of injuries, the real question tends to circle around "it is starting to feel better, when can I start pushing more." The answer is often, give it an additional few weeks. Patience is your friend here, and there are still a huge amount of exercises that you can perform.

        Comment


        • #5
          This is a tremendous and detailed response - much more than I expected. Thank you.

          To the first quote, I would say this is a pretty drastic decrease in volume. Good for symptom control and management, but likely on the low end for trying to garner any positive tissue adaptation. While in the initial phases the goal really is symptom control, too often there is a bit of an inflection point where when things feel good, we jump back into training a little too hard without accounting for current volume/intensity. It's easy to feel better with rest but it's really hard to be better with rest.
          The rest and then the drastic, ~50% reduction in volume was not ideal, but definitely warranted for symptom management. Things were very bad for about a couple weeks and pretty bad for a few more - I had gnarly nerve pain/radiculopathy, could barely walk, and was taking multiple minutes to get in and out of bed at first. I most likely did try to ramp training volume and intensity back up a little too quickly after symptoms had subsided, but we were trying to get myself ready for an upcoming PL meet, so I guess it was a bit of a calculated risk that ended up not working out.

          I will often have athletes run machine/isolation work at the start of the session to 1) get the feeling of actually having worked out 2) be able to use that pump as an additional governor for weight selection on squats and deadlifts.
          With these type of injuries, the real question tends to circle around "it is starting to feel better, when can I start pushing more." The answer is often, give it an additional few weeks. Patience is your friend here, and there are still a huge amount of exercises that you can perform.
          These generalized training recommendations are immensely helpful - definitely more machine and isolation work than I'm doing or ever did during the process. Doing this stuff first makes a lot of sense, too.

          As for the second quoted section, this really is the crux of my issue. Dealing with the off and on symptoms for so long has been frustrating, even when they have been minor for the most part, but the silver lining is that it has given me some good trial and error data about what has and hasn't worked, and what pushing too quickly can look like. I'll implement some of the training strategies you suggested to hopefully get these annoying pain symptoms calmed down again, then just ramp things back up a little more slowly than I have previously. I think I have had the right idea before, but just haven't been patient enough.

          Thanks again!

          Comment


          • #6
            hi Nate
            curious that your squat and deadlift frequency / volume and load
            you said you with a 3-4x frequency does it mean that you going for 4 squat and deads 4 times per week?

            Comment


            • Nate B
              Nate B commented
              Editing a comment
              No, the 3x or 4x per week was referring to the number of workouts per week. I guess that was a bit unclear. Squatting and especially deadlifting 4x/week would be pretty brutal.

              In the context of my post, when doing a 3x/week schedule, I was generally squatting 2x/week and deadlifting 1x/week. In a 4x/week schedule, my normal schedule, I generally squat 2x/week and deadlift 2x/week. There are some additional knee and hip dominant accessories in both schedules. That's just frequency, there's some nuance involved, of course, with the exercises selections, volumes, etc.
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