Dear Sirs
First and foremost, thank you for all the excellent content and information you guys have put out there to help people like me build their self-efficacy in managing pain and injuries.
The reason for my post is that I am suffering a crisis of confidence in my abilities to self-manage a lingering injury in my left quad after a recent visit to a physiotherapist.
I am 32 y/o and live in the UK. I am 6’3" and weigh 87kg. On a good day I have squatted 170 kg, deadlifted 210kg and benched 135kg, though I would estimate I’m at least a good 10% off all those numbers atm.
I have trained in some form or another for 10 years, with fluctuating periods of high adherance to structured programs. Over the last 18 months my training has been rather “freestyle” due to working 11-12 hour days combined with studying part-time for the UK bar and various other commitments, as a result of which I felt I could not fully commit to a program for largely psychological reasons (such as the demotivating effect of knowing that I had not completed the prescribed training volume for any given week due to my schedule for example) and so during this period I have tried to train as regulary as possible whilst keeping it flexible and trying minimise detraining. I therefore lack complete training records for that period, however in the past I have run LP, the Bridge, 12 week strength, and so I am broadly familiar with the key variables to be weary of when training.
In October last year I “injured” my back, by which I mean I had some low back stiffness that came on after a set of 7 at RPE 7-8, after which I could not complete my planned back-off sets. In the following days and weeks I suffered pain when trying to bend over. Thankfully I was familiar with the BBM approach and was able to assure myself that the stiffness and pain I was experiencing was an output of my brain’s protective mechanisms rather than an indication of any serious structural damage, that the solution was to adjust training load, and continued to train albeit with lighter weights, though in retrospect I was clearly too stubborn to drop the intensity down far enough at first such that it took longer to rehab my back than it should have. After a month or two of being frustrated that my back wasn’t improving, I dropped down to the empty bar on squats, abandoned deadlifts temporarily, and followed what was basically the Starr Rehab Protocol (not recommended for non-specific back pain I know, but the reduced intensity did the trick and my back started feeling better quickly).
I squatted 3x20 reps daily, increasing by 2.5-5kg each day. By the point I was doing sets of 20 with 80kg, I started to feel a new pain in my left quad. It felt like it was in the area of the vastus medialis/sartorious. I would feel it while squatting, though it was more niggling than a serious injury. I had full ROM, and the pain seemed to be sensitive to load. Over the next few months it would flare up with fluctuating severity, and after a heavy session I would feel it while walking up stairs. I considered it little more than an irritation that would go away, and continued to train.
By this point my back had fully recovered, but the niggling quad pain persisted for months. When the lockdown was imposed on the UK on 23rd March, my local gym closed, and so like so many others I started doing single leg training at home (romanian split squats, pistols from a chair etc). I was shocked to find how much weaker my left leg seemed to be, and how much more challenging the movements were to perform with my left leg compared to my right. The pain was also persisting, though again it was more a discomfort that I was able to train through.
3 weeks ago I returned to barbell training, starting off fairly light and not exceedng 3 sets of 5 (weary I would be sensitive to high intensity work given I had been using bodyweight at higher rep ranges for several weeks). My quad actually started to feel better on returning to barbell training. I am fairly confident that the injury’s intransigence was due to my reluctance to drop the weights low enough for long enough. However, given it had persisted for 6 months by that point, I thought I had better get it looked at just in case. I booked an appointment with a local physiotherapy clinic that I had been referred to by GP many years ago for a shoulder pain issue.
I gave the therapist a detailed history as above, and explained I had had another back tweak about 8-9 years ago. He did some manipulations, including the push test (he put his hands on each wing of the illium and rocked back and forth to demostrate there was movement on one side but not the other). He had me walk up and down and did some further manipulations before diagnosing me with anterior pelvic tilt (apparently my pelvis is twisted such that the left side sits higher than the right and points downward). He found some sort of tear in my quad which he explained had become chronic and was now a haematoma that would need to be broken up with shockwave therapy. He zapped me with a ESWT machine and then put an electromagnet over my leg until it got hot, which apparently stimulates recovery, then gave me a massage.
He said that the quad tear was likley a result of me loading the left quad more during a squat due to my twisted pelvis precipitating a bit of internal rotation of the left femur and a bit of valgus knee (or at least that’s what his physical demonstration seemed to suggest had happened). This seemed odd to me, as I couldn’t see why a slight increase in the relative loading of one quad over the other during a single sub-maximal squat would cause the injury - far more likley it was the fact that despite the low average intensity the starr rehab protocol had me doing 175 squats a week with a tonnage of around 20,000 kg.
He told me not to do any training at all before the next PT session a week later, and that in the interim I should limit myself to walking only (on an injury that was 6 months old and not causing me any debilitating pain). He gave me new rules to follow forever due to my susceptibility to reverting to pelvic dysfuction (which he claimed to have put right by way of his manipulations). I must now never cross my legs while sitting, as this will place too much load on one side. I must never bend over forward without bending my knees a little, otherwise the load on my back will be too much (I wanted to stop him at that point and check that it was OK to deadlift 180kg for a set of 5 provided I never again pick up a broomstick with stiff legs, but I didn’t think it would be productive). I must always stand in balance, and stop shifting weight onto one leg when I stand etc. It would appear I am particularly susceptable to back issues due to my lack of perfect pelvic alignment.
The week prior to the consultation, I had been pumped that I had been able to return to barbell training, and that my quad appeared to be cooperating. I left the consultation feeling skeptical given my prior knowledge, but in the back of my mind I kept hearing “What if he’s right? What if training squats tonight ruptures my tissues now that they’ve been broken up by shockwave therapy?”
That night I trained, though I switched to box squats so I could use lighter weights and stay in my hips to take some load off the quads. The session felt good, but that evening the pain in my quad was a little worse than it had been the previous week. I couldn’t tell whether I had done something stupid, or whether I was feeling pain because I now expected to. I was, after all, recklessly disregarding the advice of a trained expert. The next 24 hours the pain abated and i was able to train deadlifts and tempo squats without pain during or after the subsquent training session.
I am booked to return to the clinic tomorrow and again at the end of the week to go through stretches and isotonic exercises. I am tempted to let him zap me again with the ESWT machine (I asked him while he was doing it whether it had proven efficacy in treating chronic soft tissue injuries and was told it did, though I didn’t press him for a citation) on the offchance it has any capacity to aid recovery, though I am worried that the price I might pay for such treatment (in addition to the financial cost) will be another dose of nocebo.
I am fairly sure my problem was that I whilst I understood that load management is the correct tool to rehab an injury, I implemented that knowledge poorly due to a reluctance to take enough off the bar for a long enough period to recover. I’m sure we’ve all been there. The question is should I disregard the therapist’s advice, or does he have a point? Am I just being stubborn and seeking to have my baises confirmed in order to follow my preference of continuing to train?
Any wisdom greatly appreciated.