5 REASONS WHY YOU MAY STILL BE DEALING WITH PAIN AND WHAT TO DO ABOUT IT
In recent weeks, I have been hearing this story time and time again - "My gymnast was dealing with some back pain prior to Covid, but has been feeling great the past few months. Now, after just a few weeks back in the gym, she is hurting again and I am frustrated." Now I don't know all of the specifics on these stories, but I'd like to talk about a few reasons why I think this could be happening.
Capacity to workload ratio, (for the back specifically) is off. If you want to learn more about workload to capacity ratio, you can read about it here but overall it refers to the gymnasts true ability to do something, compared to what they are being asked to do. Now, overall most gyms seem to be doing a great job of slowly returning, and are mindful of soft surfaces and low numbers as they start. Now I believe for gymnasts as a whole, this is the right way to go about it, but for gymnasts with a history of back pain they may be missing the mark. When doing basics like walkovers, handsprings, and standing tucks, the overall workload is low, but the workload for the spine and back muscles is huge. Gymnasts with a history of back pain may need to look at this build up a bit differently, and limit even basic skills, perhaps substituting with conditioning and PT until overall workload can be increased to skills that are less demanding of the back.
2. They lost strength. Yes, I understand they did zoom workouts. I understand all they have been doing is conditioning. I understand the lists and videos and emails of workouts that were being sent around. I understand they did outdoor workouts for a month before getting back to the gym. I sent those workouts too. I lead the outdoor ones. I prescribed a ton of conditioning, but very little strength. Strength refers to creating or withstanding high forces or pressures. Most of what was done at home was high repetitions of body weight exercises, possibly with some plyometrics or light weights included, but I did not hear about much true strength work. Doing actual gymnastics asks the body to generate, absorb, and withstand forces of up to nearly 10x bodyweight, something that is not often done in conditioning type workouts. It is possible that your gymnasts back was ok to perform the conditioning, but not to withstand those forces. To learn more about strength training for gymnasts, and why I think it is important all the time, not just post - covid, click here.
Quick personal story - I was diagnosed with a grade 2 spondylolisthesis and pars fracture about 18 months after stopping gymnastics. The doctors said the fracture had likely been there at least 5 years, possibly up to 10. I had never had back pain until about 3 months prior to diagnosis. I was still very active, participating in diving and keeping up with conditioning, but I believe it was that loss of strength that led me to first feel the pain.
3. They cannot correctly get into or control extreme positions. A lot of back pain I see in gymnasts is brought on or aggravated by an arched position. A lot of gymnastics is done in a controlled arch position. Think about backhandsprings, layouts, even giants. They all pass through varying levels of an arch position. It is up to our (gymnasts) bodies to decide where to create this arch from and how much to do it. For most daily activities outside of gymnastics, any arch we need to create can be done through the hips and upper back. However for gymnastics, we need to call on that lower back a bit. If we haven't been calling upon it much over the last few months it is likely stiff. What will happen is when we ask it to arch, our back will take arch from wherever it can get it, rather than trying to distribute the work from the hips to the shoulders. This leads to "hinging" at one area of the back which can wear it down pretty quickly.
Quick note - this can be why surgeries such as fusions can fail. The spot that breaks down is usually not the original problem. Typically, the junction that breaks down was the healthiest junction, so it did all of the work and then got worn out. Taking away the ability of that junction to do any work does not always help the spine as a whole. Often times, the spine will just call on the second healthiest junction to take on the work, and if we're not careful, that can wear out too.
4. They never truly finished PT - now before you say, we went until the doctor told us not to, or until our insurance ran out, or until the PT said we were good to go, read on to see why these may not truly mean you are "done with PT." Just like in any profession, there are good PTs and bad PTs. There are PTs that may be able to keep the NY Giants healthy and on the field, but couldn't help your grandmother if they fell and vice versa. You may have gone to the best PT for swimmers in the state, but did they know enough about gymnastics to help? I feel I can say this because looking back I can't help but realize that on my first day as a PT I wasn't very good at all. Despite my shiny degree, my high score on the board exam and my six figure student loans, I really wasn't all that sure what I was doing, or how to look at PT as a big picture. Since that time, I have done a lot of learning and talked to a lot of experts and have come a long way. But that being said, just because your gymnast is still having back pain, it doesn't mean that "PT didn't work." It could mean you didn't have the right PT, who used the right tools, for the right amount of time, for all of the physical and psychological needs of your gymnast. They could be the best PT in the world, but the body is not a machine. We cannot plug in a tester and see what is wrong and know exactly what needs to be fixed. There are thousands of different methods out there, and sometimes it takes just the right combination, for the right amount of time.
PT needs to be thought of as a spectrum. It should begin (before) at the first sign of pain and continue at least until you are back fully in the gym, and if I had my way, even longer. (Read here. While it may not be as feasible to actually "test out" your tumbling at PT, prior to returning to tumbling in the gym, your PT exercises should mimic the forces and positions you will need for gymnastics. If your PT is only massage, ultrasound, and a few exercises lying on the table, you will not be nearly prepared enough for returning to the gym. This would be like giving a second grader (basic PT work) an 8th grade math test (gymnastics) and wondering why they didn't do well. Find a performance PT who can bridge that gap from rehab to training.
5. Nutrition/sleep/hydration/hormones are not being considered. Pain is a very complex phenomenon. Although some people like to point to a spot on imaging and say "that is your pain" it is much more complex than that. That is why some people with "normal" imaging have pain, and some people can have multiple fractures/disc issues, etc and feel totally fine. It is why two people with the same diagnoses can have vastly different experiences. There are many factors that contribute to pain, but nutrition, sleep and hydration are some that we can control. I read a study recently that in women with knee arthritis, those that consumed the recommended serving of vegetables, despite no weight change had a 25% decrease in pain. We can hypothesize that the nutrients in those foods help with healing. Hydration and sleep also play important roles in our perception of pain. Finally, hormones play a large role as well. If your gymnast is past puberty, certain times of the month lead to actual changes in ligament laxity due to hormonal variations. Those of us who have had our menstrual cycles for years may recognize that ashiness or soreness that comes around once a month. When you add that on top of an already injured area, it can exacerbate the pain for "seemingly" no reason. Although we can't control that, if it is something your gymnast notices, they may need to adjust their training during that time of the month.
So what do we do about this?
Hopefully one of those reasons above resonated with you, and you may understand why you(r gymnast) is still having back pain. But what do I do about it?
Have a talk with their coach to make sure they are heard and their training can be modified accordingly. Yes, there are more important steps but many of the others take some time, and if they feel like the "have to" continue to train despite pain, they may do more damage. So take care of this first.
Begin/return to PT. I understand as a PT, I may be biased in this but I truly believe they are the correct professional to deal with this type of injury. Back injuries in gymnastics are usually the cause of faulty movement patterns, and those need to be evaluated and identified to truly solve the problem. If you need help finding a PT that specializes in gymnasts, or if you are interested in a consult, email me at firstname.lastname@example.org.
Seek a second opinion. As I mentioned earlier, there are many methods/thought processes regarding back pain. This goes for doctors, PTs, chiropractors, etc. If you(r gymnast) is not getting better, seek a second opinion. Even if you went to the best doctor in the country, or the one your team recommended, no method works for everyone, so you just may need to try another.
See an alternative professional. If you believe that nutrition/sleep/hormones may be a big contributor to pain, or if you've tried everything above, seek out a professional in one of these areas. Sign up here for a nutrition audit with Kerry Bair of @thegymnastrd to take a deep dive into you(r gymnasts) nutrition and what changes could benefit from them. Use code PERFECT10PT for 10% off!
Not quite ready to do any of this? Want an easy at home solution to improve and maintain back health? Click here for my 4 week program put together specifically for gymnasts. Learn the muscle activation patterns and body positions you need for a healthy strong back to continue tumbling for years to come.
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