E2 – Scaling and Modifying Around Injuries and Pain with Dr. Zach Long

Coach Johnny B: [00:00:00] Welcome back to the performance of this podcast. I am joined by Dr. Sack long. Uh, today we’re going to talk about scaling versus modifying around injuries and pain, uh, in your training. Um, but before we get to that, Zach, I want to know what is your biggest gym pet peeve? What is the thing that people do in the gym that drives you?

Absolutely.

Zach: I don’t, I don’t think that there’s the thing that people do, but I don’t like a dirty joke. Like I don’t want there to be. Dust and dog here and stuff like that around that probably just comes with like growing up with really bad allergies, like getting stopped up when I was around that stuff.

So even now when my allergies aren’t as bad, if I see that it’s just like an immediate turnoff of a gym,

Coach Johnny B: it was it across the gym yesterday, not the one that I regularly train at. Uh, and there was chalk like underneath every pull-up bar, all over the place. And I know it’s just [00:01:00]cause it wasn’t the end of the day and they hadn’t cleaned yet, but it was a.

Uh, it got on my nerves and it kinda made me, it made me start thinking about what is my biggest thing. And I realized it is when you go to a gym and they have a plate racks that are, you know, set up 40 fives, go here 25, et cetera. And people still put the wrong ones in the wrong place. Like they’re clearly labeled all the plates are blue there and you stick the yellows.

It drives me nuts. Cause it’s just so lazy.

Zach: I got a weird one that I’ll add in just off. I don’t understand how people can use different non-matching plates. Oh, but got a rogue plate on one side of the bar and you have a good RX plate. On the other side, I cannot do that. I refuse to, I will unrack every weight off the story of center to find the two matching plates.

No way I’m lifting an unbalanced too. OCD for that.

Coach Johnny B: Fully agree. I also, I will intentionally do that sometimes just [00:02:00] to see if I can perceive any different side to side. And every time, like, I feel like I’m going to die, especially back spots

Zach: was the city on the side, the side stuff. And it’s not because I think it’s a way it’s just that I need things to be balanced in summit.

And if we look at two spring collars and one is super wide and one super narrow at Olin, and you go to the bucket and find two, that match up, I don’t care which of those it is, but like, they gotta be pretty much the same amount of springiness that,

Coach Johnny B: that applied to everything. Is that a different level?

But that applies to everything in your life. So like, if you walk into a room and there’s a couch with two coffee tables that are like flanking it and kind of centering it and one’s a little out of position, does it drive you nuts? But I just,

Zach: I like organization things like you can see the bookshelf behind me.

Like those books aren’t really organized in a unique fashion. Like the Heights are all over the place, but like it’s clean by me. And that’s what I have to have.

Coach Johnny B: I am heavily [00:03:00] into like cemetery as well. That actually drives me nuts. Uh, I also, where you don’t like describing colors, I get really down the rabbit hole of colors, pairing well together and fonts and things like that. Um, if you want to like get me like going, you can show me some people’s Instagram page, where they ha every post has a different font on their image or whatever.

And it just makes me lose it. My wife hates it like. Rants about it. So, um, another question, are you a Metcon guy or are you a noble guy or are you a

Zach: for training the lightened nanos the best, but the best running shoe I’ve ever tried is, uh, the noble runners really? But dude, I got 20 pairs of shoes in my closet.

I’m a bit of a shoe freak, so. I have only expensive shoes, but I need a lot of shoes. I don’t wear the same shoe two days in a row. Wow. Or mismatch, socks. How does anybody in the world awareness snapshots?

Coach Johnny B: I dunno, that drives me crazy too. [00:04:00] Like you walk in the gym and you’ve got a pink and a yellow one.

Come on. Like how hard is it to just, uh right. Uh, are the Nobel runners really? That good. Sorry that got me. Cause. My wife loves him. And I’m just like, I’m a running shoe snob. Like I’m an ultra guy. And so like, I’m always like, oh, there are no bulls. They can’t be good running shoes.

Zach: So I found that ultra is just always, I used to buy a lot because they’re very comfortable.

I just feel like I broke them down super, super fast. I’m going to have him for two months and they were completely done. So I’ve had these novels for a while now. They’re still in great shape. I’m not running like four days a week and I’m running twice a week and they’re holding up

Coach Johnny B: for me. It’s funny.

You said about ultra is actually, uh, the bottom of my ultra blue out running the 13 miles and a half Ironman last weekend. And. It really irritated me. Like I was to a point where I couldn’t run, but like, yeah, that’s a huge criticism. All right. I might have [00:05:00] to try it. The noble alright, outward and upward.

Let’s talk about scaling and modifying, uh, around injuries to thing that I specifically want to address that I hear a lot of questions of, um, when is it let’s use shoulder pain as our example, uh, I have shoulder pain. When is it? Time to stop going overhead altogether? Versus when is it time to just lower the load or maybe change.

So I’m

Zach: always going to lean more towards lowering the load or trying a different variation of it or adjusting the range of motion a little bit over anything else. Cause we want to maintain when something is injured as much. Tissue fitness as possible. We don’t want to just stop working out and lose all of the strength that we built, but we have to also respect that the tissues are mad and irritated and you know, might need some time to recover.

So really for me, it comes down to like how intense is what you’re feeling, you know, is it just as comfort? And in most cases, exercising with discomfort is fine. Um, is it lasting just [00:06:00]during exercise or is it staying, are things staying aggravated for 24 hours? So let’s say you’re dealing with like some, some shoulder tendinopathy.

If we work out today and it’s, you know, fairly low level discomfort that you feel during fine, keep exercising, but at that then has you extra flared up over the next 24 hours? We probably overdid it. Well, let’s, let’s say it’s the shoulder still like raising up and grabbing your coffee mug in the morning.

That’s a two out of 10 pain this morning. You work out today and tomorrow it’s a four out of 10, then we probably overloaded it yesterday. So really looking at the volume, the range of motion, you try and through the weight you lifted him. And what was your response to that? Did it seriously bother you?

Did it change your Texas? Did it leave, uh, increased soreness for an extended period of time when that stuff happens? That’s when we probably have to get a little bit more aggressive on what we’re doing to try to work around the injury.

Coach Johnny B: So. To, to split off questions there first is by, so let’s say it’s a [00:07:00]tendinopathy, right?

Which is probably a common thing. People go see their doctor for, uh, because they don’t really understand that they’re not dying and that their shoulder is not going to fall off. Uh, but the doctor, unless you go to really great doctors, probably gonna just tell you to stop lifting overhead or stop working.

How do you know the difference? And this is really hard, but how do you know the difference between an issue that, uh, where you should listen to the doctor potentially, and maybe where you need to issue the advice and go, you know what I’m going to, I’m going to go listen to Dr. Zack and just using empty barbell to do those push presses during Jack today.

And I’m not advertising that people go against their doctor’s orders. That’s just kind of this experience that I’ve had often as a coach. And is it there?

Zach: Uh, I just, uh, I’m the script, the question a little bit, but I’m gonna say this, like, I can’t think of the last time I told somebody that they can’t exercise an area in some way.

I think there are far too many things we can do [00:08:00] to change. The exercise, the intensity and whatever that we can still push your fitness forward without aggravating the tissue. So I’d rather say let’s find variation. Let me screw up your question altogether and just say we can, we can do a better job of finding things that you can do and stay active and stay fit.

Because like I said earlier, like if you just stop working out altogether, Not only the tissue that’s aggravated becomes more detrained, but all the tissues around it. And then you get back to exercising and now those tissues have been weakened. And that, that weakness, isn’t just your performance. It’s their ability to tolerate load and their resiliency against injury.

So I want us to try to maintain as much fitness as well. So I’d rather you and set up instead of avoiding the barbell overhead, press all together. Let’s see what happens when we go dumbbell, overhead, press just a different variation. Barna, you kind of stuck in a almost fixed plane. You don’t have much control over rotation dumbbell.

You can put that arm wherever you want to go with the dumbbell [00:09:00] to see if going wide or narrow. Does one of those have less pain than the arm? Maybe it is just that it really hurts at the end. Well, that’s not completely avoid all overhead. Let’s do a landmine. Where we have one into a bar on the ground, the other end of the barbells in our hand, and we’re pressing up, but we don’t hit that in range of motion, far too many things we can do to maintain tissue fitness today,

Coach Johnny B: just rest.

So the idea of resting, right? I mean, that is something that I think, you know, my parents and my coaches growing up, you know, oh, your ankle hurts. Just rest, just ice, just compressed. Uh, does the system need the reduced. Time, we’ll call it time and attention or loading to heal, or can it heal through, uh, the process while you’re still, it can,

Zach: it can heal through the process.

We just have to respect the feedback that whatever injured tissue has is giving us. So if we have, uh, uh, you’re irritated by patellar tendon, that [00:10:00] the tenderness in the front of your knee, if that’s irritating, And you go squat twice a week and you’re having six out of 10, eight out of 10 pain. When you squat.

And every morning you wake up, your knee pain is a little bit worse. You’re not listening to your body. And you’re kinda driving things down the wrong road. Instead, let’s find variations that let you continue to exercise with a low level of pain. That doesn’t last a significant period of time, and that’s not only going to help continue to, to keep fitness of those surrounding tissues up, but it’ll help that tissue heal faster.

So one thing that’s really important about exercising is when we’re dealing with an injury where we kind of have, I think there’s two components. We have the mechanical damage, the actual damage that has happened to that tissue. If we’re talking about an acute injury, And then we also have inflammation that happens as a result of that injury.

So the mechanical stuff we have to respect and that’s by building those tissues back up over time, the inflammation, we can really help if we [00:11:00] pump blood into that area. So if we just rest and we’re not really forcing a lot of blood to flow in and out of that lead, I think we’re potentially dragging stuff on more or causing more.

Let’s instead, let’s get on the assault, bike, this assault bike pump a ton of blood into the legs you get done with that. And the vast majority of the time after you work out, if it’s at the right dosage, you’re going to feel better. So let’s, let’s get the heart rate up and do things like that to encourage better movement.

Long-term.

Coach Johnny B: How we’re talking about loading these tissues. Like, do you have any kind of shortcuts as a PT to give people guidelines around tolerance? Right. And I think the thing that I always like to remember that I learned from you is that. As long as the, the loading isn’t greater than the tissue is tolerance.

You’re not going to cause damage to it. Right. So how do you find that sweet spot where the damaged tissue you’re not overloading and causing more

Zach: damage? Yeah. So let’s say we’re just talking [00:12:00] muscle and tendon injuries here. We’re not talking to joint injury. We’re not talking like a stress fracture or something like that.

That will just simplify our discussion because something like a stress fracture, like zero. If you have a stress fracture, you cannot do anything that creates pain. That’s a completely different animal. If we’re talking about a tendon or a muscle strain, I tend to use the silver nettle pain monitoring model.

Pretty simple process here. Red light, yellow light green light red light is you have pain greater than a five out of 10. That’s a stop green light zero to two. You have a little discomfort. You’re probably okay to continue exercising. Yellow lights is kind of in between those. And the yellow light, let’s say you’re having a three out of 10 pain.

Then it becomes monitor your 24 hour response. Like is walking down the Sierra’s more painful today than it was yesterday. If so you probably overloaded stuff a little bit. That’s one way of doing it or to just say, look, this is not an acceptable level of pain. Like, do you think that you are flagging stuff up?

Do you think that’s going to make you feel worse for the next two or three days? If the answer to that [00:13:00] is yes, then you’re probably doing too much if you’re significantly changing your technique, not because you’re choosing to change it, but because your body’s saying no, we are not moving that way.

That’s your body’s. No, and you don’t need to be doing that exercise. So if you find yourself doing really funky stuff in your, in your technique, that’s a pretty good sign that.

Coach Johnny B: All right. So now that was great. Again, I think for muscle tendon kind of more soft tissue injuries, that’s probably great. But what happens when it comes to the joint injury?

What if somebody has a labral tear? Uh, three guys that don’t know what a labor room is out there. It’s the little piece of cartilaginous tissue that keeps the glenohumeral joint. We’ll use a shoulder, uh, sucked into the body, so it doesn’t fly away. What if that thing’s knit and we have like the presence of instability, like how, how do you.

Zach: Yes, it was shoulder instability. To me. I’m just going to be, you know, a lot of times you just kind of that acceptable thing, like what do you think of this pain? Is that acceptable? Like, do you feel [00:14:00] like you’re making things worse with what you’re doing? And if we stop and are honest with ourselves about that question, usually that’s going to put us in the right door.

If you’re going to be stubborn and hardheaded about it, then the backup question is, are you flared up for more than like 12 hours? So if, if you’re going to be stubborn and say, no, I don’t think I’m making it worse, but then you look back and you worked out this morning and it’s nighttime. You sit down for dinner and your shoulder is still screaming at you then.

Yeah. And you over did it, and you need to learn to kind of respect that a little bit more and go back to different modifications that we can do. Continue to try to push your fitness forward, get good workouts in while appreciating that tissues.

Coach Johnny B: So labral tears heal incredibly slow, right? So what’s the, you know, if somebody goes down that road, they’ve done Bajic and wing muscle for a long time and potentially created this problem.

Uh, how long are they looking at dealing with that? Let’s go first muscular scolio or like tendon issues. Uh, and then. Joint, like how long is that healing process probably [00:15:00] gonna take so tendon

Zach: issues. And it’s all going to depend on the irritability of that. Like, like you’ll have some tendon issues that when you just drop exercise dosage down a little bit and build up the tender with the right things that you could have a tendon issue that’s gone in two weeks, you can have other tenant issues that require.

Significant loading for, for up to a year. Like there’s a research study that recently came out that said, nobody should get a rotator cuff tendinopathy or rotator cuff surgery, unless they’ve done a rotator cuff strengthening consistently for a year. So it can take a long time. And the labor thing is a completely different discussion.

And I’ll try to not go too far down the rabbit hole, but like there’s research on labor and tariffs that show that 70% of people with no pain Howell. So I’m not as concerned about the labor and self healing, because it’s one of multiple systems that provides stability to the show. So we can work on the other things that provides stability to the shoulder and very [00:16:00] frequently have incredibly good outcomes and people that have labor materials that decide to not have surgery.

If they see somebody that really understands these movements that we do in CrossFit, then can kind of build them back up, strengthening the rotator costs and doing stability work and working on the right progressions of exercises. Uh, you know, for us working across to the athletes, a lot of times that is for me, it’s rotator cuff work, stability work.

Getting the lats super, super sharp. So the laps tend to kind of protect the shoulder when it comes to so many of the gymnastics movements that we do, uh,

Coach Johnny B: interject there. If you’re having issues, uh, don’t take this as medical advice. You can do an online console, Zack, uh, if you want that his medical advice, uh, or go see somebody and we’ll direct you to somebody that’s probably the right person for you.

Cause there’s a lot of people out there. That are in Zack’s line of work and other doctors that don’t understand what we do as CrossFitters. And we’ll immediately just tell you to quit CrossFit. And that is not the answer. Um, fitness is the most important thing that you can do for yourself. [00:17:00]Uh, and somebody telling you to stop doing that, um, is basically asking you to die younger, probably.

So, uh, don’t don’t listen to them, seek a different opinion. Um, all right, so let’s get it. Is there a point with this stuff where, uh, there’s a scale, right? Like I want to maintain, or I guess talking about scaling, I want to maintain the intensity of the workout. Is that possible to do while we’re working through some of these like painful conditions or do we kind of just need to accept, Hey, I might get my intensity from something.

I say I’m going to do assault, bike sprints, uh, for that stimulus rather than being able to hit Fran today, just cause

Zach: yeah. So anytime I’m modifying somebody’s training, the goal is to keep that as absolutely close to the intended stimulus of network as possible. So let’s say like you’re not tolerating basketball right now.

What’s the, what’s the different ways that we can modify that we could drop the weight down a little bit. And stays specific to that movement [00:18:00] pattern where we can change to a different variation like this. They don’t bother you. Well, let’s just go from backslash to front squats. We’re still getting a squatting stimulus.

It’s a slightly different stimulus, but maybe we can keep the intensity higher with that. Um, at times we have to go really crazy far down a scaling rabbit hole. Like maybe we can’t load your leg at all. I know, like maybe you had a knee surgery a week ago and we can’t squat at all on your white list. So the workout shows up and it’s back squats and you’re showing up in the gym.

What am I probably going to have that person do like single leg squats to a box that are loaded up. Like that’s at least load up the opposite leg as aggressively as we can and maintain fitness there. Yeah, so there’s a lot of options, but really the goal should always be how do you stay as close to what the workout is as possible and make as little modifications as you need to, but as much

Coach Johnny B: for the coaches out there where, uh, you have the person walk up to you at the whiteboard right after you brief the workout and they’re going to go buy low [00:19:00] back hurts.

It’s deadlift a, I don’t want to deadlift you don’t have the level of education. Uh, how do you make an infant? Um, scaling modification decision other than getting more education, like, uh, it, should we punt and just go bench press today? Or, uh, how do you advise somebody in that

Zach: situation? Yeah, that’s, that’s rough to do it on the fly when somebody shows up like a minute before classes even rough when people do it to me when I’m coaching and having this knowledge.

So that’s going to come down to a really quick conversation with them. Like how much is this really? Can we change it from a deadlift to like a, a Romanian deadlift. We’re still working the hip hinge pattern, just not going all the way into the floor and not as heavy of a wave. Is this really irritating you, then maybe we say, you know, can we build this specific muscle groups?

We talked last episode about our purchase. So maybe we’re looking at the demo back, glute hamstring, a little bit of quad exercise, and maybe we do. GHD hip extensions that are loaded. Maybe they tolerate that, that would at least [00:20:00] be specific to the muscle groups that we would be training that day. Um, and maybe there are times from either your time perspective as a coach or their irritability perspective where you just have to just completely go different.

All right. Today was supposed to be a strengthening. I guess it’s an upper body strength day for you. You’re going to bench press, or we’re saying, you know, we can’t, uh, you can’t deadlift heavy, so we’re at least going to get in some. High intensity intervals on the assault. Like I want you to spread all out for 10 seconds rest for 50 seconds, and we’re going to do that for 20 minutes and come sucks.

Coach Johnny B: That sucks. Yeah. That I don’t want to do that. I don’t deadlift through the pain. I won’t say anything again, coach Zach, if that’s the workout you’re going to give me, uh, that’s awesome. I think there’s a lot in what we just said. I think, um, that if you go back and maybe listen to this again, uh, You’ll find things in there, but the big things for me are, um, you know, don’t [00:21:00] stop moving that’s number one, don’t be afraid to do the movement pattern, but explore other variations, uh, that allow you to work through it.

Um, and in potentially keep the tissue strength up as you’re the injury or sorry. The healing process is happening. Um, And then, uh, the red light green light yellow light model for kind of, uh, judging if something is too painful. Um, and then being respectful of that and then modifying away from it as needed.

Um, any other thoughts on this? As far as, uh, modifying around pain in CrossFit or fitness goals

Zach: on the middle ground, where we tend to go as CrossFitters is to the extreme Sarah hammering. Or completely stepping away and just realize that even if you’re, you’re going at 75%, but staying consistent at 75%, that’s significantly better than being at either one of those extremes.

Coach Johnny B: Yeah. Um, how much does food play into the healing [00:22:00] process? Elderly people with that food? Yeah.

Zach: Significant. Yeah. So it’s a food and sleep are two lifestyle factors that I’m talking with about every athlete that I work with from a pain perspective, if you’re not fueling yourself or giving your body enough time to recover, you’re really opening the door for injuries to happen or injuries to stay around for longer than that.

Coach Johnny B: Yeah, I think from a coaching standpoint, a therapist standpoint, I see that more often than not that people, you know, I think biceps, tendinitis is biceps, tendinopathy. It’s probably the most common thing that I’ve seen lately where people have the issue, but then their diet and their sleep is garbage and it just lasts forever because they’re not actually going through the cycles of healing.

Did they need to do to always be respectful of that stuff. Guys, don’t neglect the importance of that in recovery from injury. So very cool Zack, uh, that was a great episode. Thanks for joining us. Uh, thanks for, uh, helping us out with this stuff. Um, if you guys [00:23:00] have any, uh, Any questions about this stuff, you can DM Zach at the barbell physio, uh, follow the barbell physio page and the performance plus program plage on Instagram.

Uh, there’s a ton of great information on there about all this stuff. Zach’s written a million articles, 250 plus articles in his life. They don’t talk about colors of clothes, but they will tell you. Uh, how, how to kind of judge stuff. So if you missed anything in there, you couldn’t pick it up, got any questions.

Those are great resources as well. Uh, any other things that you want to direct people to checking out if they’re thinking about modifying or scaling a workout around

Zach: pain circles on the barbell, physio.com that talks about all the different ways that, that I try to get it after modifying when people are injured, that should give you more tools and tactics to think through.

If you’re in this situation, you’re saying awesome.

Coach Johnny B: Well, cool. Thanks for joining us guys. Uh, make sure you, uh, comment review, share. It helps us out.[00:24:00]