Is Your 'Rehab' Making You Worse, Not Better?

When you hear about rehab - and the newly-fashionable prehab, which you do before you train so you don't have to do rehab - you expect a set of exercises carefully designed to restore natural and effective movement to damaged or twinged joints.

Instead, all too often, you're getting poorly designed exercises designed to correct a problem that doesn't exist and creating a new one in the process.

Before we go any further, let me say that if you're seeing a doctor, physio/physical therapist, chiropractor or other professional and you're getting better, don't think I'm saying you're wrong. I'm not. Good advice is the best thing you can get. 

Too many times, people want a quick fix to a problem they accumulated slowly. One-idea rehab programs, as we'll see, do more harm than good. 

We'll start with ankle rehab, and then look at shoulder rehab.

In each case, we'll try to figure out why recovery rates from these rehab protocols are so low.

Ankle rehab

Ankle rehab doesn't result in a 'fixed' ankle a lot of the time. If you've sprained your ankle once, there's a 70% to 80% chance you'll sprain it again. Every additional sprain contributes to the likelihood that there will be further additional sprains: it's called chronic ankle instability. There's a god chance you know someone who has it if you don't have it yourself, and if you ask them they'll probably talk about their ankle injury in terms like, 'it just went.'

The cause of the collapse - the reason your ankle 'just goes' - is usually ascribed to muscular weakness. The muscles that push the sole of your foot down towards the ground, called plantar flexion, are much stronger than those that pull your foot up towards your knee , called anterior flexion. Similarly, the muscles that turn your foot inwards, so the little toe is lower than the ball of your foot, are stronger than those that raise your little toe and push the ball of your foot downward. By far the most common ankle sprain injury follows that pattern - the little-toe edge of the foot is on the ground and the ankle turns over with the ball of the foot off the ground.

Add in the excessive movement caused by the tissue damage from the original sprain and the solution looks like: 

1. make the muscles in your ankle stronger, and

2. reduce the mobility of the ankle while it recovers.

See Also: Rehabilitating An Injury: The Rules

So along with non-steroidal anti-inflammatory drugs, you'll typically be given a brace or support for your ankle, and a regime of exercises to strengthen the weak muscles that got you hurt.

The Real Cause Of Most Ankle Injuries Is The Lack Of Control

Muscular weakness is involved, don't get me wrong, and so is excessive movement. But the real cause of most ankle injuries is the injured person's inability to control the ankle. The majority of ankle injuries take place when landing or performing fast footwork type movements - when the ankle has to resist force, often in more than one plane, and has to change the direction of force quickly. 

Most rehab programs for the ankle focus on restricting the range of motion, on the basis that too great a range of motion led to injury - but the injury wasn't caused by too great a range of motion, but by too great a range of uncontrolled motion. Immobilizing the ankle with straps, casts, boots and other hardware doesn't reduce range of motion permanently - when the boot comes off, your ankle can still be moved. But it does reduce active, controlled range of motion - exactly what was lacking in the first place.

Then they'll focus on building strength in the muscles around the ankle. Again, there's nothing wrong with making the ankle supporting muscles stronger - but doing band-resisted eversions or other highly specific strengthening exercises to target small muscles that most of us can't even find neurologically and which we often lack the capacity to voluntarily contract isn't the best way to do this.

So what should we be doing?

The key is to focus on function. We should be restoring range of motion as soon as possible, and gradually working to improve the mechanoreception of the whole joint complex. We need to recover the use of the ankle, and that's done by building active, controlled range of motion, then building strength on top of that.

Shoulder rehab

Shoulders are another common problem area, in particular, damage to the supraspinatus, a tendonous muscle that runs over the top of the shoulder and forms part of the rotator cuff. It used to be thought that supraspinatus' job was to abduct the arm for the first few degrees of movement, but it's now known that the deltoid can do this all by iself; supraspinatus is a synergist whose prime purpose is to pull the head of the humerus into the right position relative to the deltoid. This might seem a bit abstract, but it becomes important later.

The story you'll most often hear from personal trainers and sports/fitness professionals is one of thoracic kyphosis, shoulder overextension and chronically weak, underactive scapular retractors. 

You'll be retracting your shoulder blades and depressing them - even though chronic scapular depression is part of the problem. Try hard enough and you'll be able to create hyperextension at the transition between your lumbar and thoracic spine. That's how you make yourself 'pigeon-chested' - and it's how you learn to compensate for poor shoulder mobility by deforming your spine. Exercises like YWLTs, where you stand with your arms out by your sides and 'pinch' your shoulderblades together, have some use for some people, but because they're simple they're the go-to for any shoulder dysfunction, and they shouldn't be. In a lot of cases, people are doing these exercises to reduce the pain and discomfort of a shoulder injury or to prevent one - and they're getting one. If you do your prehab before you train, you're actually preparing your body to perform bad movement patters before you load it, then loading those patterns. So it's no surprise when things go wrong.

See Also: Rehabilitation Tips and Exercises for Ankle Sprain

What should we do instead?

Work to have conscious control over where your scapula is. Learn to foam roll or use some other soft tissue or myofascial release method and use it on your shoulders - especially the gap between your shoulder and your upper arm, where you teres major sits. This muscle attaches the shoulder blade to the upper arm, so if you have trouble disassociating the arm from the scapula a tight teres muscle could be why. Try to keep your shoulder blade slightly elevated and the bottom corner slightly forward - the opposite effect of the scapular retraction exercises we're told will fix our shoulders. Meanwhile, to fix kyphosis, learn to use your spinal erectors to pull your spine erect: hat way you won't isolate certain parts of it and set yourself up for an injury!

If you like what you've read here, or you think it needs correcting, or if you have hava a story to share, get in touch through the comments section below!