Lifters commonly experience routine aches and pains in the context of their training, often affecting the low back, knees, hips, and shoulders. These are common places non-lifters experience pain as well. Whether the pain began suddenly or gradually, it can be a discomfort that worsens under load during training, or it may “warm up” and improve with activity, only to become more severe in the day or two after a training session. These episodes can be frustrating when they limit training progress, but become even more frustrating when the pain extends into routine day-to-day activities at home, work, or sleep.
It is very useful to develop the knowledge, strategies, and confidence to manage these situations. We have discussed our general approach to managing these situations in a previous article. However, there are three common mistakes people make when attempting to work through pain and injury: 1) Not reducing the load enough, 2) increasing load too quickly, and 3) not varying movement enough.
This article will provide a simple initial approach through examples that will be applicable to motivated lifters dealing with routine aches and pains.
Lifting With Pain
Case Study #1: Knee Pain
Let’s start with an example lifter with a 300-pound squat who has noticed a gradually worsening pain on the front of their left knee. This pain is noticeable during warm ups, and progressively worsens as the load increases. It continues to throb for several hours after the training session, and is more noticeable than usual during daily activities the next day.
They’ve been working really hard to achieve a 315-pound squat milestone. As a result, they are doing everything they can to get those last 15-pounds despite the worsening knee pain. They’ve received advice to use high doses of ibuprofen, to try using some light knee wraps or a knee sleeve, and have started looking up special warm up routines and technique adjustments to keep the knees from moving too far forward during the squat. They’ve even started to consider seeing a healthcare professional for an MRI or an injection.
Unfortunately, none of these approaches typically restore lifters to fully normal training without limitations. The main way out of these scenarios typically involves training modifications, lifestyle modifications, and much more patience than most people are used to.
Should You Lift With Pain?
A common approach to activity-related pain among the general public is to simply stop doing that activity. And while this approach may indeed help the person avoid experiencing pain, it often does little to actually rehabilitate the person, building them back up to tolerate the desired activity. Over time, this pattern of avoidance leads to people becoming less active, less capable, and eventually leading to common refrains such as “I’m getting old, and I can’t do what I used to do.” People in these situations typically need to be encouraged to re-engage in activity, and actually try loading themselves in new and different ways to build strength and resilience.
Mistake #1: Not reducing the load enough
In contrast to this common approach among the general population that avoids weight altogether, the most common mistake that motivated lifters make is not reducing the weight enough. This is often due to fear of “losing gains”, or regression from prior levels of peak strength. While this is an understandable feeling — especially for someone on the cusp of a milestone like a 315 lb squat — avoiding load reductions in an effort to maintain peak strength while rehabilitating a painful issue is unlikely to be successful. People often try strategies like those outlined in the case example above, hoping that it will help them resolve their pain without having to reduce the weight. This rarely works; in fact, it often results in the entire rehab process taking longer than necessary, before the person eventually “learns the hard way” what must be done.
So, how do we ensure that we’re reducing the load “enough”? The simplest way is based on the trajectory of someone’s pain symptoms. Signs that we are exceeding our current load tolerance include:
- Pain increases with each subsequent set as weights increase
- Pain worsens in the 24–48 hours after a session
- Pain never returns to the “baseline” level before the next training session
What are some strategies to ensure loading is reduced enough?
- Reduction in weight on the bar. Often this will need to be more significant at first than people will want or expect.
- Instituting a pre-emptive “weight cap” that will not be exceeded on a given day
- Reduction in the target exertion: for example, targeting 6 RPE instead of 8 RPE. We will define what this means below.
- Increasing the rep range: for example, instead of sets of 5 reps, training with sets of 12
- Adding the use of controlled tempo to the eccentric and/or concentric: for example, squatting with a slow 3-count on the way down and a 3-count on the way up
Sometimes a single strategy here is sufficient; in other, more challenging situations, combining multiple strategies may be needed. Recalling our previous example, someone who has been squatting up to a painful all-out set of 5 at maximal exertion with 300 pounds may be temporarily pulled back to squatting a set of 12-reps with a 3-second tempo in both directions, up to a max load cap of 95-pounds for the day. Note how large that reduction in weight is. Just taking 15- or 25-pounds off the bar does not represent a meaningful load reduction in this case.
We monitor the trajectory of pain symptoms during and after this session until the next training day. If symptoms are stable or improving, we’ve found our “entry point” to activity, and are on the right track to progress. However, if symptoms significantly worsen during or after the session, we have likely not yet pulled back enough. Don’t be afraid to do something that you would have previously dismissed as “too light” or “meaningless.” What was being done before did not work. A bigger change is necessary, and will only be temporary.
Adding Weight During Rehab
Let’s say that we’ve successfully found our entry point at 95-pounds for a set of 12-rep tempo squats, with pain improving after this session until the subsequent training day. The next mistake our lifter might make is to make too large of a jump in loading, often out of eagerness to get back to prior levels of performance. For example, they might jump from a set of 12 tempo squats at 95-pounds in one session, to a set of 8 squats with 135-pounds at regular speed the next session. This may represent too large of a short-term increase in loading, leading to a recurrence of pain during or after the training session.
Mistake #2: Increasing load too quickly
Or if they stayed more patient early on in the process, they might reach a point later where they are feeling good performing sets of 5 at a normal speed, and excitedly decide to “test things out” by jumping to take a heavier set of 1 rep, after which symptoms frustratingly relapse again.
Both are scenarios where the person is doing too much, too soon — and this is a major source of aches and pains across many different activities. So, for lifters who are eager to get back to prior levels of performance, what are some strategies to ensure loading is not progressed too quickly?
Autoregulation For Pain and Rehab
Using a method of autoregulation such as Rating of Perceived Exertion (RPE), but accounting for pain symptoms as well. Autoregulation is a process where a lifter selects the weight to target a particular level of difficulty rather than an arbitrarily predetermined weight. In this case, instead of focusing on how much force the lifter can produce, pain symptoms would serve as the “brake” on exertion.
This often involves differentiating between “could I perform another rep today?”, versus “should I perform another rep today?” Although everyone loves to add weight to the bar over time, when using autoregulation, it is acceptable and often necessary to decrease load from a previous session if pain symptoms are worse, rather than forcing an increase that the lifter is not ready for on a particular day.
Load Caps
An individual can also use strict load caps, whether using absolute weight numbers or percentage increments: for example, “load cap for today is 115-pounds”, or “increment no greater than 10% load from last session.”
Both strategies can be useful to make sure the individual doesn’t increase the load too quickly and end up setting themselves back.
Use Double Progression
Progressing the load used or repetitions completed are both traditional methods for generating strength and muscle size adaptations via progressive overload. These can be used in the rehab setting as well to give the individual an “on-ramp” for increasing their tolerance to loading.
For example, set a rep range such as 8–12 reps and use the same weight on sequential training sessions until the lifter can increase from performing 8 reps comfortably up to 12 reps, at which point the weight can increase, and the cycle repeats.
Our lifter might be programmed to work up to a set of 10-12 reps of tempo squats at 95-pounds (or using autoregulation, such as 7 RPE). They perform 10 reps during the first session without any pain flare, so the next session they aim for the higher end of the range; if they perform 12 reps at the same 95-pounds without flaring up their pain symptoms, then the next session they can plan to increase the weight. This could be to the next prescribed load cap (e.g., 105-pounds) or by a percentage limit (e.g., 10%).
Increase Movement Variation
Lifters are often very motivated to make quantifiable progress on specific exercises, such as the squat, bench press, deadlift, or overhead press. In the same way people can be reluctant to temporarily lower their weights out of fear of regression, they can also be reluctant to modify the exercises in their rehab training.
Mistake #3: Not varying movement enough
However, it is often necessary to make temporary changes in exercise selection. This could involve substituting in exercises that are more comfortable, adding novel movements to get a person moving in a different way, or temporarily removing a very painful exercise from the program altogether. For more, see podcast #164.
There are many different ways to add movement variation to an individual’s lifting program:
- Simple variations on the “main” barbell lifts: for example, close-grip bench press instead of a regular-grip bench press, front squat instead of a low bar squat, or sumo deadlift instead of a conventional deadlift. Other options include the use of specialty bars such as a safety squat bar or a football bar.
- Unilateral exercises using bodyweight or loading methods such as barbells, dumbbells, kettlebells, or machines. Squat-type movements include “sissy” squats, split squats, lateral lunges, step-ups, single-leg leg presses or leg extensions; Deadlift-type movements include single-leg Romanian deadlifts, suitcase deadlifts, machine rows, pulldowns, or leg curls; Pressing-type movements include single-arm overhead, incline, or flat bench presses using dumbbells or machines, landmine presses.
- Rotational exercises such as rotating lunges or windmill presses. These are often used in the rehabilitation of back and hip pain.
- General “bodybuilding”-style isolation exercises such as biceps curls, triceps extensions, shoulder raises, or calf raises, among others.
- Ballistic/explosive movements such as jump squats, jump lunges, oscillating split squat, explosive push-ups, or medicine ball throws. Note that these should generally not be introduced until later rehab phases, once initial symptoms are under control.
- Conditioning work such as cycling, rowing, running, or other preferred modalities
These are just a few of the endless movement options available for experimentation in the context of rehab. In some cases, the “weirder” the movement, the better, as it provides a novel challenge and gets the person moving in a new way.
While many lifters who are focused on performance in a few particular lifts may be reluctant to introduce such variation into their training, framing it as an opportunity to set personal records on new movements is a useful strategy. Additionally, the incorporation of more conditioning or general “bodybuilding-style” work such as biceps curls, triceps extensions, or other isolation work can allow the person to push themselves and experience the so-called “muscle pump”, providing a feeling of productive training even if the main lifts are temporarily modified or deprioritized.
A stumbling block that some lifters encounter is the belief that only some movements qualify as worthwhile. Everything else is lesser and perhaps is suggestive of a moral failing or an admission that they have entered a period of inexorable physical decline. This needs to be cast aside, especially when injured. Things will get better, and all is not lost.
Ironically, the fastest way to return to some of the more traditional lifts, and their attendant heavier loads, is often by incorporating exercises that were previously dismissed. By putting aside feelings of being weak, frail, or incapable, and embracing what can be done on a given day as a useful step toward a return to the greener pastures of bigger plates on the bar, progress can be made. A pleasant by-product of this will likely be a new appreciation for those movements a lifter once looked down upon and a willingness to include some of those movements as more permanent features of their training going forward.
Sample Lifting Plan For Knee Pain
So, what might an initial rehab approach look like for our hypothetical lifter with knee pain?
The first step will involve listening to their story and concerns, while setting appropriate expectations for the rehab process. The most important expectations are that rehab — much like training — is not a linear process. Since symptoms will fluctuate over time for various reasons, progression should be flexible, and it is okay if the weight needs to temporarily decrease from one session to the next. Additionally, if the person is expecting a “quick fix”, for example a minor technique adjustment to resolve pain, or if they expect to be able to participate pain-free in a competition in a week or two, these expectations may also need to be adjusted. While some injuries resolve quickly, timelines involving many weeks and often months are common.
The initial training will involve a decrease in absolute intensity (weight on the bar), relative intensity (how close to failure they train), and an increase in movement variation. We will monitor pain symptoms during and after the initial “test session” with the programming.
For example, our lifter might modify their training to begin with two sessions per week involving the affected area, as follows:
Day 1
- Stationary bike x 10–15 minutes @ RPE 5–6
- Bodyweight front-foot elevated split squat: 2 sets of 8–10 reps per leg, controlled tempo
- Box step-up holding dumbbells in each hand: 2 sets of 8–10 reps per leg
- “Bodybuilding”-style accessory work: biceps curls, triceps extensions, etc.
Day 2
- Stationary bike x 10–15 minutes @ RPE 5–6
- Bodyweight lateral lunge: 2 sets of 8–10 reps per leg, controlled tempo
- 3-0-3 Tempo Squat: work up to a set of 10–12 reps @ RPE 6 (or load cap)
- “Bodybuilding”-style accessory work: cable rows, lat pulldowns, etc.
The remainder of their training (for example, upper body training, deadlift training, etc.) may proceed normally — but only if those movements are unaffected by pain symptoms.
If symptoms are stable or improving, we’ve found our entry point and can begin a gradual progression, with the following principles in mind:
Increments from one session to the next should begin conservatively, whether using explicit weight prescriptions, load caps, or percentage rules (e.g., 5–10%).
Rep ranges can be gradually decreased over time (say, from 10–12 reps down to 8–10, then 8–6, then 4–6, etc.). This should not be rushed in the early phase of rehab.
A slow, controlled tempo can be gradually returned to normal speed over time. The concentric tempo (slow “on the way up”) should be returned to normal speed first, while maintaining the eccentric tempo (slow “on the way down”). This should also not be rushed in the early phase of rehab. The eccentric tempo can be normalized later.
Exercise selection can be gradually progressed back towards “normal” loaded training. For example, bodyweight split squats can become loaded split squats; light machine leg extensions can become heavier single-leg leg presses. In addition, once basic tempo is normalized, ballistic/explosive movements can be introduced, such as oscillating split squats, box jumps/jump squats, jumping lunges, explosive push-ups, or medicine ball throws, depending on the affected area.
If symptoms are worsened during or after the “test” session, we will need additional loading modifications. This can involve:
Increasing the rep range further (for example, from 8 reps up to 10, 12, or 15 reps)
Slowing down the tempo further (for example, from a 3-count tempo on the descent to a 5-count tempo in both directions)
Further modifications to exercise selection, whether swapping movement variations or temporarily eliminating the “main” movement (for example, the barbell squat) out of the program altogether for a few sessions.
Reducing training volume (the overall number of sets and reps being performed) or frequency (how many days per week the affected area is being trained).
In order to provide a few other examples, let’s take a look at a sample starting approach for a lifter with gradually worsening low back pain in the context of heavy barbell training.
Sample Lifting Plan For Low Back Pain
Most of us will experience an episode of low back pain during our life and there are currently hundreds of millions of people around the world dealing with low back pain. Despite low back pain being common, determining an exact cause of low back pain is often difficult. Upwards of 90% of people experiencing low back pain do not have a single, clear cause of their back pain symptoms. The experience of low back pain is also variable, as it can be a pain in the middle of the back, more to one side or the other, or perhaps it worsens with heavier loads and is now becoming extremely bothersome at work and while in bed at night. Nevertheless, the majority of folks will improve faster with gradual exposure to movement.
We might start with the following conservative two-day setup, given the severity of symptoms. Recall that the initial weight selected for the first few sessions can be extremely light, in order to find an entry point without “overshooting” and causing a significant flare-up of symptoms.
Day 1
- Treadmill (or outdoor) walk x 15 min
- Single-leg Romanian deadlift (dumbbell or kettlebell): 2 sets of 8–10 reps per leg, controlled tempo
- Kettlebell windmill: 2 sets of 6–8 reps
- “Bodybuilding”-style accessory work: leg curls, cable rows, etc.
Day 2
- Treadmill (or outdoor) walk x 15 min
- Jefferson curl (starting as light as 2.5–5 lbs if needed): 2 sets of 8–10 reps, controlled tempo
- Posterior medial tap (video): 2 sets of 8 reps
- “Bodybuilding”-style accessory work: leg extensions, lat pulldowns, etc.
The program would be adjusted and loads progressed based on the person’s symptom trajectory as described above. Over time, the exercise selection could evolve to gradually reintroduce some sumo or conventional deadlifts at higher rep ranges with a slow, controlled tempo, or other movements involving the low back like safety squat bar “good mornings”. It is often wise to keep some of the rehab exercises in the training program longer-term, based on the person’s preferences.
Finally, what about a lifter experiencing a similar pain in the shoulder or elbow region? A starting point might look like the following. Recall that the initial weight selected for the first few sessions can be extremely light, in order to find an entry point without “overshooting” and causing a significant flare-up of symptoms.
Day 1
- Dumbbell bench press: 2 sets of 10–12 reps, controlled tempo
- Lat pulldown: 2 sets of 10–12 reps, controlled tempo
- Lying triceps extensions: 2 sets of 8–10 reps, controlled tempo
- “Bodybuilding”-style accessory work: biceps curls, cable press downs, etc.
Day 2
- High incline dumbbell bench press (or DB overhead press): 2 sets of 8–10 reps, controlled tempo
- Machine row, or dumbbell row: 2 sets of 10–12 reps, controlled tempo
- Ab wheel rollout: 2 sets of 8–10 reps, controlled tempo
- “Bodybuilding”-style accessory work: cable curls, cable press downs, etc.
This program could gradually evolve to reintroduce controlled-tempo barbell presses and bench press variations, followed by a normalization of tempo and a decrease in the rep ranges, and finally an introduction of more explosive movements in the last phase of training.
Summary
It should be noted that there is nothing special about any of the sample starting programs provided here. Equally (or perhaps even more) effective programs could use different exercise selection, rep ranges, volume, or frequency. These are simply examples that can be modified, customized, or adapted to an individual person’s situation and preferences. Accordingly, our low back pain and knee pain rehab templates offer lots of options to tailor the program to the user’s needs.
In summary, our approach to rehab involves setting appropriate expectations, reducing external loading to find an entry point, increasing movement variation, and a flexible approach to progression that accounts for symptom fluctuations over time. Hopefully this article provides clarity and actionable strategies to manage your own aches and pains, but if you still find yourself in need of individualized guidance, our rehab team is available and eager to help.
Thanks to Tom Campitelli, Charlie Dickson, and Quentin Wiley for their contributions to this article.
