Getting Back to Fitness After an Injury

Enjoy my most recent article written for the American Council on Exercise!

August 1, 2016

Coming back from an injury can be challenging and frustrating, but don’t let it get the best of you. Take your time, stay consistent with your workouts and recognize when you need help. Consult with personal trainers, physical therapists and your doctor; and follow these fitness tips to get back to your fitness routine.

Form and Function

Proper exercise form is always important, but is absolutely essential when coming back from an injury. At the very least, review the correct form for any exercise that involves the previously injured spot. If you have any questions, consult one of the personal trainers at your gym. You can search for ACE Certified Professionals in your area here.

Regardless of the exercise, these cues will help you maintain good form:

1. Keep your spine long. This ensures good posture without overcorrecting.

2. Relax your shoulders. Stress and computer time make shoulders tight. Let go of that stress and your shoulders will sit naturally.

3. Move from your hips. During full-body and lower-body exercises, movement initiates from your hips. Keep your spine long and move from the hips to avoid lower-back involvement.

Choose the Right Exercises

It can be hard on the ego to take your exercises down a notch, but that is exactly what you need to do when returning to workouts post-injury. Either choose an exercise that is less challenging than the exercises you did pre-injury or choose to limit the weight and range of motion of the exercises.

For instance, when coming back from a knee injury, (Read More on the ACEFit Blog)

The Knees-In vs. Knees-Out Squat Debate – It’s not about the knees.

Recently I was introduced to Conrad Stalheim’s article, “Moderating the Knees In Versus Knees Out Squat Debate” summarizing an ongoing debate about knee position during the squat. This article does a great job introducing the topic and led me to the right links so that I could educate myself without getting lost (too much) in the personal tirades that are so often a part of an impassioned debate.

Because I’m an uber-geek, I had to weigh in on this awesome discussion. Though I think any professional discussion about human movement is an awesome one, this one gets me particularly geeked out. I want to start by saying that I am not a Crossfitter or an Olympic Lifter or a Power Lifter. I am not actually an ‘-er’ of any type . I love exercise and lifting heavy things. I love the intricacies of human movement and I specialize in applying those loves to athletes and active people who have chronic injuries preventing them from exercise or sport. I am highly rewarded by seeing my clients achieve movement or return to sport without pain.

I watched Kelly Starrett’s video series with Diane Fu and Roop Siota to establish an understanding of their coaching technique. I also read through Bob Takano’s blog series (referenced in Quin Henock’s article) to fully understand his input and that of the other professionals he involves in the discussion. Of course, I also read Bob Green’s article which seems to have been thrown in the mix though it wasn’t part of the initial discussion.

The squat is not about the knees
Though some of the back and forth between Takano and Fu reads differently, in his video series, Kelly Starrett continually states that ‘knees out’ is a cue, not a position. ‘Knees out’ is a cue that we all use or have used when someone is initiating their squat with a valgus knee position. Here’s the thing. It is a terrible cue. The knees are buckling in for a variety of reasons, lack of muscle control, soft tissue restriction, all of the above. Telling someone to push out their knees mid-squat doesn’t correct the problem. It simply puts them into a new bad position. The better cue here would be, “stop.”

Let’s take for instance the woman who has scar tissue thanks to multiple C-sections or the man who has scar tissue post hernia repair. Asking for these athletes to push their knees out will simply pull against that adhesion and cause for an abnormal response elsewhere in the chain. It is like tugging on a skirt that is too short in hopes of covering your butt. You are likely to cover the rounded bottom, only to expose the crack. By pushing knees out, you haven’t lengthened the tissue.

Can you lengthen tissue to improve your squat simply by doing squats? You bet. This is an excellent method of improving your functional range of motion while improving strength and stability.

Two rules for using squats to improve mobility and strength

  1. If there is a history of injury, you must first identify and address any associated adhesions and altered neuromuscular firing patterns.
  2. You must stay within the available range of motion while executing the movement. You will find that through repetition and intermittent static holds at the bottom of the squat, you will continually improve your range of motion.

Position Creates Power
Any motion is about creating maximal Ground Reaction Force to elicit the equal and opposite reaction of movement. As Quin Henock says in his article, “ Where I come from, the goal of a squat is to stand up, so maximally loading the muscles that help you do that is probably a good idea.” Pushing your knees out during the decent phase of a squat may make the squat look like it is supposed to look, but it will also put your femur into an externally rotated position. By putting the femur into an externally rotated position, not only do you limit your flexion range of motion, as Henock points out, but you also lose your ability to load the muscles most needed to get back up. To create ground reaction force, you must push down into the ground. This involves quads, hams, gluts, adductor magnus, and a host of other muscles. For these to provide power at the bottom of the squat, they must be pre-stretched or loaded. If you are actively pushing out throughout the decent, you are not allowing these muscles to load; you are holding them in tension thereby eliminating any stretch reflex action potential at the bottom of the squat.

Instead, throughout the decent, relative internal rotation at the hip must occur which allows for the transverse fibers of the gluts and adductor magnus to stretch in the same manner that the sagittal fibers stretch during hip flexion. This is not knee valgus. When executed properly, the knee will track over the foot. From here, you have efficiently loaded your hip complex (like stretching a rubber band) and it is prepped for explosion.

Cueing Recommendations
Enough with the biomechanics you say? OK, I’ll move on (though it kills me, I love that stuff).
If knee valgus is simply a product of the awkward movements of a beginner, I cue two things –‘Initiate movement from the hips’ and ‘push into the floor’.

Why ‘push into the floor’? Your butt and your feet talk to each other. It is the tensional changes of the fascia in the foot that communicate to the hip complex proprioceptively. This communication calls for eccentric muscle firing providing a stable and mobile environment where the muscles of the hip complex can work synergistically to allow coordinated movement. Next time you have a relatively athletic person doing squats and there is some knee buckling, try the ‘push into the floor’ or ‘push through the floor’ cue and see what happens.

Knee movement is possible and important in knee flexion. This concept of ‘locking’ the knees while in flexion to create stability and to protect from injury will cause injury.
First, locking a joint makes it immobile. It may be stable, but that does not make it an efficient athletic position from which to move. Second, the knee joint locks through the Screw Home mechanism in extension, not flexion. The reason for this is clear. In knee extension, the femur rests on the tibia allowing for muscular rest while standing. In knee flexion, whether walking, running, jumping, or squatting there is a necessary internal rotation that occurs at both the femur and tibia in order to wind up or preload the soft tissue. My favorite demonstration of this range of motion is watching a Running Back who needs to change direction. The athlete twists his foot into position to apply opposing force upon the ground. With this ground reaction force, the joints of the foot, ankle, knee and hip often create angles our textbooks call impossible and dangerous. More often than not, the result is not a torn ACL, but simply the amazing movement and skill of a talented player. Here are some great stills: one of Mike Hart on and one of Ray Rice on Both of these guys had to place a massive amount of power through an apparent valgus knee and to my knowledge, they are both still on the active list. Mike Hart on

Ray Rice, Image from

In researching knee mechanics in order to better design an efficient prosthetic leg, Kamran Shamaei & Aaron M. Dollar*, find the normal rotation of the joint ranging from 2-23 degrees. That is a lot of rotation at a joint we call a ‘hinge’. Michol Dalcourt offers great visuals in his video describing this motion.

On to Dan Green’s initial point about knees in.
Dan Green’s initial comments about using a knees-in technique when driving out of the hole (not when initiating the squat) are momentary in the initial article, but caused so much discussion and misinterpretation that he needs to explain himself further here.

What I see in his video and that of Long Qingquan (and many others I’ve found) is a highly trained athlete using a highly skilled technique to generate improved performance. It is clear to me that the move improves Qingquan’s performance. (Man, I love watching this stuff!) It is also clear to me that his performance is far and above the caliber of most people in the world and the movement he is performing is highly specialized.

Training Olympic Lifters or Power Lifters to be better at their sport is not my job. It is my job to get them back to sport when they are injured. In my job, I will often examine form or movement during the sport to see if there are techniques that are contributing to the injury. What I see here wouldn’t raise major red flags for me. Why? What I note is that the feet are flat without any apparent inversion or eversion at the calcaneus. In a still photo, the knee comes into a position that I might describe as valgus, but in movement I wouldn’t describe it as such. It closer simulates adduction, where the normal range of motion is being taken advantage of to allow for additional pre-stress of the hip complex, thereby allowing for maximization of ground reaction force. Each of us is different and to anyone teaching or employing this technique, I would advise a close listen to the feel of the move and, as always, executing the move within effortless range of motion. In watching Green and Qingquan, the amount of movement each utilizes is very different. Not a novice move, this is something taught after skill and coordination have been mastered. Everyone I’ve watched execute this move are in proper hip flexion, foot position, and have more than 90 degrees of knee flexion. If I saw someone using it as a cheat, that would be a huge red flag for me.

What about Tensegrity?
If you aren’t familiar with the term tensegrity, you must learn more. Without belaboring this point too much, I’ll simply mention that I haven’t seen any discussion regarding the effect of the fascia on the movement pattern. I quote Robert Schleip, “Recent ultrasound based measurements indicate that fascial tissues are commonly used for a dynamic energy storage [catapult action] during oscillatory movements such as walking, hopping or running. During such movements the supporting skeletal muscles contract more isometrically while the loaded fascial elements lengthen and shorten like elastic springs (Fukunaga et al. 2002).” Knowing this, the quickness of an Olympic lift is perhaps apt to rely heavily during certain points in the lift upon the catapulting action of the fascia. I would love to see a study along those lines. (Like I said, I’m a complete geek about this stuff.) If true, I would think that this creates a deeper chasm in the difference between the power lift and the Olympic lift. Food for thought.

My perspective on the squat
Here is my simplified perspective on squat form and cueing the squat. Whether teaching someone else or perfecting your own:
1. Create a solid foundation of hip and foot mobility and stability by eliminating any soft tissue adhesion or neuromuscular mis-firing left over from any injuries. (See someone skilled in this area of exercise.)
2. In the absence of injury, set that same foundation by slowly and methodically improving your squat range of motion by executing moderate load squats within the range you do have. Employ intermittent static holds at the bottom of the squat to ‘push you down’.
3. Use the cues – ‘spine long’, ‘move from the hips’, & ‘push into the floor’. Allow the knees to track naturally over the feet, they are following instructions from your hips.
4. If those cues are not enough to keep the knees tracking naturally over the feet, go back to steps 1 and 2. You are lacking mobility, strength, motor coordination or all of the above. You may need help from someone who specializes in corrective exercise.

As someone who first experienced knee pain at the age of 16 thanks to chondromalacia and now can execute a deep overhead squat without pain, I am a firm believer in the squat. I love the saying, “Shut up and Squat.” Just make sure you have the mobility and motor control to do it right.

(Aside. Those of you with Mel Siff’s 6th edition of Supertraining – 2003, check out the pictures of Mel in the front. At the bottom of his snatch, he appears to be “knees-in”. These pictures were taken in the 70’s. I met him in 2003 and he was still doing ass-to- heels snatches without knee pain. More food for thought. )

*Shamaei, Kamran & Dollar, Aaron M.; “On the Mechanics of the Knee during the Stance Phase of the Gait” 2011 IEEE International Conference on Rehabilitation Robotics, Rehab Week

Improve your posture in 10 minutes a day

Have you noticed that you aren’t quite as tall as you used to be? Catch your reflection as you pass a mirror and notice that your head is so far forward you are starting to resemble Igor from Young Frankenstein?

Hours of sitting at a computer, in a car, and on the couch puts your body in the same position for most of the day. Even a regular exerciser can see changes in his/her posture when most of the day is spent sitting. Poor posture can lead to back pain, headaches, overall stiffness, and even symptoms that mimic Carpal Tunnel Syndrome. For athletes and regular exercises, poor posture can lead to injury, most often the dreaded chronic, overuse injury.

Ready for the good news? It is reversible. Commit yourself to 10 minutes each day, these movements can even be done while watching your nightly dose of TMZ … I mean, the news.

    • Drink water throughout the day and move while you are doing it. Before you can affect the soft tissue (fascia, muscle, and ligament) you must rehydrate it. Soft tissue that isn’t moving becomes rigid and dried out. Kind of like the beef jerkey you bought at that gas station on your last road trip. The water you are drinking isn’t immediately absorbed into the tissue, but if you are both regularly moving and regularly drinking water, your bloodstream maintains a consistent hydration level and your moving muscles and fascia will pull that water in like a sponge. HOW: Get up off your butt and guzzle some water every time you answer the phone or open your Facebook tab while at work. Walk, stretch, wiggle, twist…do anything that moves your whole body. TIME: Sixty seconds every half or full hour when you are wasting time anyway.

    • Invest in a tennis ball. OK, tennis balls and a foam roller is even better; a weekly massage, tennis balls and a foam roller is the best, but I’ll be realistic. Scoot over to Target and invest $2.50 on 3 tennis balls. Tape two of them together like the photo below and hold onto the third for another Self Myofascial Release (SMR) technique.

Taped Tennis Balls for SMR

Taped Tennis Balls for SMR

Here’s what to do during TV time; and keep that water close at hand. (Oh yeah. Do not engage in this or any exercise program without first consulting your physician or health provider.)

    • Sit on the edge of your seat and put the single ball under your foot and apply firm, but tolerable pressure. Slowly, while maintaining pressure, roll the ball from the heel to the big toe. Repeat this process for each toe. This will be uncomfortable so adjust the pressure so you can relax. You will find that progressively you will be able to add more and more pressure. You can repeat this as many times as you like.

    • Next, lie on the floor with the two taped balls under your back. The balls should be on the muscles along the spine, one ball on either side of the bony spine. You can start anywhere along the spine you would like. The idea is to spend a few seconds with the balls at each level in your spine from your tail bone to the base of your skull. Again, spend as much or as little time in each spot. The pressure should be firm, but tolerable. Feel free to wiggle around or move your arms while lying there. I like to spend a little extra time with the balls at the base of my skull. This is where the back and neck muslces attach to the skull and this tissue needs a little extra love. If lying on the balls is too intense, put a soft blanket or cushion on the floor under the balls, it will lessen the pressure.

    Now that your tissue is massaged like bread is kneeded before it is baked, it is time to reposition the soft tissue. These next two stretches can be seen in the video on the homepage. So, if you are more of a visual person, check that out.
    • Kneel on the floor with your toes tucked under your feet. Likely, this is hard to do and your toes are less extended and more like pushing into the floor. That is ok, everyone starts somewhere. Your goal is to get your toes to extend so much that the balls of your feet touch the floor in this position. So, position your body so that you are pushing your toes into extension. This may mean being on your hands and knees at first and working your way towards sitting on your heels. (This should not hurt your knees! If it does, try staying on hands and knees or skip the stretch and use the tennis ball longer.) TIME: Hold for 20 – 60 seconds. Longer holds, around 3 minutes have more marked effects, but I promised 10 minutes or less so…

    • Now, come on to your hands and knees and press yourself into a downward dog stretch. Keep your hands firmly on the ground with the fingers spread and push your hips up toward the ceiling while letting your heels drop toward the floor. Just as important, keep your head down, neck and shoulders relaxed. TIME: Again, hold for 20 – 60 seconds .

    Alternating back and forth between each of these stretches also increases the magnitude of their effect. This last one feels great and is completely relaxing so I save it for last.

    • Take a large blanket, fold it twice and then roll it firmly so that it is long enough to reach from your head to your tail bone. If you have a foam roller, use it. Lie on your roll with your head at one end and your tail bone at the other. Your feet should be flat on the floor and your knees bent at a comfortable angle. Put your arms out in a cross position or like a goal post (shown below). Now, just lay there and focus on relaxing your body. Your arms may not touch the floor, especially if you are in the goal post position. That is okay. Someday, they might. Notice in the photo that the chin is tucked. This helps correct your neck position and relieves tension there. Feel free to wiggle around a little bit and stay here as long as you like. You may not want to get up.

Goal post position on the foam roller opens the chest.

Goal post position on the foam roller opens the chest.

A few more tips. Take a “before” picture of yourself. A simple standing profile picture will do. Then, a week or two later (after actually doing this routine every day), take another picture and compare them. You will see some subtle differences. I guarantee that in 6 months, the differences in your photos will be dramatic and people will start asking you, “Did you lose weight?” or “Wait. Did you grow??” Challenge: Take your before picture with the date and, after engaging in the program daily, take an after photo in 6 months. Send me your results!

When it comes to changing your posture, you have to remember that it didn’t get bad overnight. You will feel benefit right away, but it will take months for anyone to see that improvement. Also remember, more movement, longer stretches, and more hydration is better. It might take you past my promised “10 minutes a day”, but I didn’t think “Improve your posture in 10 minutes a day, more or less with some intermittent tasks throughout your workday” had much of a ring.

One last thing, drink another 8+ ounces of water once you are done. With all that movement and self massage, you probably used all the water that was stored in your body so it is time to replenish.

If you are already struggling with chronic pain or overuse injury and need more individualized help, contact me today.