Why rehab exercises often fail

How I came back stronger than ever

In 2019, I was determined to get the one arm chin up. I reckoned I was pretty strong, having pulled a 42kg chin up. I thought I was ready.

So I jumped into a training plan. Way too fast. I was doing hundreds of pull ups a workout, with weighted and single arm variations.

One day I noticed my right elbow was very sore after the workout. As I continued to train through the pain, eventually the pain developed in the left elbow as well.

I finally when to go see a physiotherapist: he told me I had medial epicondylitis - or Golfer’s Elbow, as it’s commonly known.

He told me to:

• stop climbing immediately and stop doing pull ups. Avoid making the problem worse
• start doing various wrist and elbow extension exercises as part of a rehab program

At first glance: this approach seems logical. Put out the immediate fire, and then work at rebuilding.

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But fast forward 1 year, I’d relapsed 3 times with the same injury in varying degrees.

What I’d been doing wasn’t rehabilitation. It wasn’t working. I wasn’t actually getting better. I decided to change a few things:

• I needed to stop protecting and babying my elbows.
• I needed to actually get stronger

These two simple changes made all the difference.

Over the next 4 months, I

• swapped all rehab exercises with ones that I could track and overload with weight
• more than doubled my max strength in all of them
• resumed climbing at full capacity, now climbing harder than I ever had in my life.

The lesson?

Rehab exercises should rehabilitate you

The problem with the approach that I took for the first years of my injury, and with the approach I see many people take is simple:

The purpose of a rehab exercise is to rehabilitate you

That’s obvious - let’s go deeper.

Rehabilitation means returning to previous levels of performance or function. What are the relevant attributes?

• the strength of the tissues
• the mobility of the tissues
• the performance in relevant movements
• the amount of pain associated with a movement

The latter is more complicated. But very often addressing the ‘physical’ aspects also addresses pain.

This implies a rehab program should focus on improving some combination of strength, mobility, or performance of relevant movements.

Do we know any other modalities that do this?

• Strength Training
• Hypertrophy Training
• Mobility Training
• Skill training (practice)

All of these function by progressive overload.

Many rehab protocols focus on skill training. Phrases like “activate the muscles” or “retrain the movement pattern” are thrown around. These can be useful, but to see continued progress, they need to become increasingly complex over time. You don’t learn to juggle 5 balls by only practicing 3.

There’s nothing wrong with working on a mind-muscle connection at all. But if that’s all you’re doing, you won’t get stronger.

Many rehab programs look like this:

Week 1: 3 sets of 10, with several reps in reserve

Week 10: 3 sets of 10, with several reps in reserve

Leaving 10 reps in reserve will not help you progressively overload.

Being afraid to push yourself will not help you progressively overload.

Not progressively overloading will leave you weak forever, and likely susceptible to the very same injury again.

We want our injured tissue to rise to the level of our healthy tissue - not to let our healthy tissue fall to the level of our injury.

Rest and stagnant exercises will detrain your whole system. Real progressive rehab will retrain both the injury and the rest of your system to new heights.

A more serious approach

My golfer’s elbow got better when I started slowly ramping up the volume and intensity of my pulling work. I turned my previous 1RM into a 10RM.

My shoulder impingement got better only when I started hanging with my whole bodyweight, then eventually swinging on both arms, and then one arm.

My biceps tendonitis got better as I surpassed my previous level of overhead pressing strength, after including extra shoulder isolation work.

My wrist sprain got better only when I increased the loading, carefully pushing through a bit of pain, now I’m back to doing handstands on it.

Here’s what I learned:

1. Treat each (p)rehab exercise as seriously as any other exercise.
   • Go hard in whatever rep range you’re working in.
   • Improve measurably week over week.
   • If not improving, reassess & vary the programming until you improve.
2. Continue your sport, while accommodating the injury
   • You want to maintain as close to your regular level of activity as possible. Not drop to zero. In climbing, that meant avoiding deep lock off movements, and using more of an open hand rather than crimps. This varies drastically depending on injury.
   • The point of this is to not lose strength, conditioning, and skill while the healing happens. If you neglect this, once you’re healed, the rest of your body will have fallen to the level of your injury. Instead of bringing your injury back up to the level of your healthy tissue.
   • ReTrain - don’t DeTrain

A framework for rehab exercises that work:

• Specific: it targets an attribute you want to develop
  • Doesn’t mean it has to look like the target activity.
• Measurable: you can put a number to it. Could be weight, tension in a band, centimeters of range of motion, or a pain score out of 10.
• Overloadable: can load it for a long time, so that you can track progress over months to years timelines
• Range of Motion: Allows a large range of motion (ROM). The only limiting factor should be your ROM, not the limits of how the exercise can be performed or loaded. You might only have a limited ROM now, but if the exercise isn’t set up to allow progression, you won’t progress,

Try these out next time you’re recovering from an injury, or to bring up one of your weaknesses.

Thanks for reading - Have a fantastic day!

-John

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