Risks of Returning to Training

After a forced layoff, everyone is excited to get back in the gym and “make up for lost time.” But are we at a greater risk of injury when returning after a period of time off? Doctor of Physical Therapy Jason Eure lays out the risks associated with ramping your training back up after a layoff and gives you the steps to reduce risk.

Note from Greg: This article is from Stronger By Science Coach Jason Eure. Jason is our in-house Doctor of Physical Therapy, and he wanted to make sure SBS readers are aware of the risks associated with ramping your training back up after a layoff, and know what steps to take to reduce their risks. As gyms continue to gradually open back up around the country and around the world, this should be invaluable information.

Also, if you’re dealing with injuries, pain, or limitations you’ve been trying to train through or around, you may want to consider hiring Jason for coaching or a consultation.  He understands what lifters need and how lifters think (e.g. he’s not the kind of physical therapist who will tell you to never squat again just because your back is sore), so if you want to keep training while working toward moving and feeling better, Jason’s the guy to talk to.

Now, onto Jason’s article…

A few disclaimers before we get started: 

  • This article was inspired and written during a period in which the vast majority of the world was experiencing significant alterations in their training due to COVID-19 regulations. While we (hopefully) will not experience another mandated change in lifestyle of this magnitude in the near future, this article still applies to the many different scenarios in which you may be returning to the gym after a relative absence OR you are significantly changing your approach to training.
  • Tissue damage is not synonymous with pain. Many individuals have some sort of tissue alteration with no pain or performance decrement whatsoever. To imply that the injury process is straightforward and linearly associated with physical demands is disingenuous at best and not my intention in the slightest. Tissue damage is merely one correlate of pain which I am choosing to examine from the stance of “what we can control.” If you happen to have pain when returning to the weight room, please consult someone who can help guide you through the process. Understand that simply having some type of abnormality on an MRI scan does not mean that you’re unable to return to full capacity. I don’t want to make this a pain science article, but I’d highly recommend checking out the Barbell Medicine forum for anyone interested.

AFTER A FORCED LAYOFF, everyone is excited to get back in the gym, hit the ground running, and “make up for lost time.” But in doing so, are there any inherent risks that this situation poses? Are we at a greater risk of injury when returning after a period of time off?

Post-quarantine readers: While you can absolutely make gains with minimal equipment in a home setting, I’m going to go out on a limb and assume most people reading this article probably didn’t attack their body weight workouts with the same enthusiasm they have in the weight room. Even if you did, heavy external loads can impose some unique physical demands in comparison to a similarly challenging body weight or banded workout.

To address the elephant in the room: Injury prediction and prevention is the holy grail that has been sought after since the invention of sport. It comes to no one’s surprise that a healthy team typically performs better across a season than one plagued with injuries. The incentives are massive to accurately determine who is prone to injury in order to apply early intervention.

There is emerging evidence regarding specific genetic predispositions toward injury propensities. However, genes, the proteins they create, and the environment have complex and poorly understood interactions. We are a long way off from widely accessing and using this type of data for prevention. Historically, sports scientists have attempted to tease out patterns by using more readily observable metrics. Tests and measures have been examined in an attempt to stratify risk using various models of analysis. Unfortunately, the literature isn’t trending well regarding widely used screening methods. In fact, there is a growing sentiment that no single test nor any combination of tests has shown strong enough ability to predict injury in a valid or reliable way. When looking at the powerlifting and bodybuilding communities specifically, prior history of injury is one of the only variables that is strongly predictive on an individual level. This means that I can’t accurately tell you the likelihood you will get injured using easily objectifiable traits.

Prevention is the more interesting question. Several studies have examined the topic in the sporting world with results that will sound like music to your ears. In a review by Lauersen et al., strength training was shown to reduce sports injuries up to 68% and cut “overuse” injuries by almost 50%. The same group later demonstrated a dose-response relationship between volume and injury risk, with a 10% increase in the number of training repetitions resulting in a 4.3% reduction in risk. Not only that, but strength also seems to play a moderating role. Relatively stronger individuals appear to be at reduced risk and tolerate greater workloads without adverse events.

The problem remains that these papers are all examining injury risk while engaging in sport, not risk while participating in the proposed antidote. While the frequency of powerlifting injuries is low (recently estimated between 1-4.4 injuries per 1000 training hours) the prevalence is actually quite high. A survey of Swedish, sub-elite powerlifters indicated that 87% had experienced an injury within the past 12 months and the SBS study resulted in a similarly large 74% experiencing injury within a year of observation.

To my knowledge, no prospective studies have examined training variables in a way that could determine causality on a group or an individual basis. In my field of physical therapy, even the common heuristic “too much too soon” has come under fire. Initial evidence was promising that we could quantify the rate of change in volume and use the data to guide training in order to limit injuries in team sports. There was optimism that we could then co-opt this metric (the acute to chronic workload ratio) and use it to the same effect in the weight room. This theory does not seem to be panning out. Recent challenges outline significant mathematical concerns of the proposed ratio and the totality of evidence in its favor has been questioned. Dalen-Lorentsen et al. claim “the extent and quality of the evidence (regarding the acute to chronic workload ratio) is currently insufficient to inform any consensus process.” Other more contentious criticisms state that the ratio should be invalidated completely due to “major methodological flaws.” So as things sit currently, this isn’t a foundation I’m willing to build on.

This all means that I can’t tell you how likely you are to be injured and I can’t offer any guaranteed, bullet-proofing solutions to ensure you will stay healthy once you get back to the iron.

However, instead of ending with a big shoulder shrug, I want to at least provide some actionable pieces of information. If you are young, healthy, and have been able to exercise with little to no major obstacles in your training career, you probably have very little to worry about from a perspective of modifiable variables. The simplest advice I can give is “don’t be dumb.” Take advantage of the many resources at your disposal regarding programming (like this great, practical video from Dr. Mike Zourdos), and go do what you enjoy.

The advice below is mostly aimed at those who have experienced pain or injuries in the past.

To note: These are all temporary suggestions. Conditioning your body to handle higher levels of stress, in all manners and ranges, should be a long-term priority.

1) Don’t outkick your coverage

While it appears the acute to chronic workload ratio is fatally flawed, it can still be useful in a broad sense. The idea that we shouldn’t drastically change our training volume is hardly a radical one. There tends to be a sentiment that more is always better and we act as if we’re all under a time-constraint to get as big and as strong as possible. Instead of caving to the pressure of imagined timelines, we should recognize progress is a beautiful thing.

There is some evidence showing that even trained individuals can improve muscle strength and size with as little as one working set per session. While this is not a blanket endorsement of such a low-volume approach, it does demonstrate that results can be obtained with substantially less volume than you’d expect.

We’re better served under-estimating current capabilities rather than pushing the outer limits of what’s tolerable. Start laughably light in terms of intensity and volume. Long term gains are not going to be thrown away by one or two training cycles performed below your maximum recoverable threshold. Gradually increase both volume and intensity over time and begin individualizing volume by generally accounting for prior performances. This basic guideline is a great option to hold yourself accountable and prevent that inner voice from telling you to test the waters.

2) Learn how to auto-regulate your training

Percentage-based programming is probably not the best way to organize your training at this point. You have likely experienced some level of detraining during the separation. Even if you have been exercising during your time away, the big movements should be considered skills that require specific neuromuscular coordination. As such, your prior 1RM estimates are possibly far removed from your current state and don’t allow you to plan effectively.

I do not recommend immediately re-testing your maxes. Doing so is an unnecessary risk and your progress will almost assuredly outpace your programming anyway. Using something like the Epley formula to estimate maxes more frequently is a decent option, but this is not without its own difficulties. Even in normal circumstances, there are large variations in the number of reps that can be completed at a given %1RM. At best, this leaves you with a rough approximation of your current state.

Enter auto-regulation (AR). AR is a form of periodization that caters programming to an individual’s capacity on a daily basis. The most practical and accessible variant is probably the repetitions-in-reserve (RIR) rating scale. Put simply, a lifter will subjectively estimate the numbers of reps they have before failure, in real-time, during the set.

Implementing this scale to tailor workload allows us to match our level of effort to what we’re capable of on any given day. Lifters are generally accurate within 1 repetition once they reach 3-5 reps from failure. While returning from a break, we’ll want to spend most of our time in this range. You’ll be far enough from failure to comply with advice point one and this will also allow for the performance of “hard sets” which are not anchored to an inaccurate 1RM estimate.

I would recommend starting with a moderate rep range (5-8 reps) and adjusting weight until you reach a given RIR (~3) within that range.

(Feel free to read more on auto-regulation to build confidence in this area).

3) Consider the range and velocities used in training

According to data provided by Kalkhoven and Cook, the common denominators for acute muscle and tendon injuries appear to be range of motion and speed. Muscle damage is correlated to strain (change in length), and evidence suggests the damage is more severe during faster elongation velocities. When tendons are stretched, they become compressed against surrounding structures. As I’ve painstakingly outlined previously, the combination of compression and tensile loading is considered “especially damaging to the tendon” and the magnitude of stress experienced by tendons significantly increases as movement velocity increases.

This should not scare you away from ever performing full range movements or faster lifts. Tissue “damage” is an important stimulus for positive physiological and mechanical adaptations (aka gains). Only when damage exceeds our ability to remodel and recover do we experience the negative consequence of “injury.”

Detraining leads to altered tissue properties which leaves them less able to cope with stressors. Knowing this, it follows that using slow-tempo variations and avoiding end-range postures would help mitigate damage during the reintroduction period. This translates to constraining the range of motion using movements like box squats, Anderson squats, pin presses, etc and opting for 3-1-X (eccentric-isometric-concentric) type tempos during the initial phases of training.

Eventually transition back to more complete ranges of motion and faster movement speeds as your body adapts to handle greater loads.

4) Don’t ignore the elephant in the room

As of this time, no specific studies have prospectively determined if sleep quality or quantity independently affect injury risk in lifters. However, limited cross sectional data suggest there is a positive association between “good sleep” (whatever that means) and lower injury rates. There also exists more than enough evidence in other populations that it’s at least a factor worth considering (For example, see: here, here, here). This is not a sexy topic. You’ve heard and ignored the advice to “get more sleep” since childhood. Sleep is the lowest hanging fruit of “recovery” and “prevention” that likely exists. If injury is a realistic concern of yours, do not neglect this part of the equation.

Wrapping Up

The key takeaway here is that injuries are complex. They are nearly impossible to predict on an individual level and there remains a lot of uncertainty surrounding methods to limit their occurrence. While some view this pessimistically, the evidence should be liberating. There is no real indication of determinism when it comes to weight-room injuries and there exists way more bandwidth in what can be viewed as acceptable and safe. However, this is not a get out of jail free card. If you have experienced injuries that have hindered your training in the past, or you are simply worried about handling the stresses associated with lifting after a long break, follow the TL;DR version below.

  • Under-estimate yourself early on. Start much lighter and with lower volume than you’re capable of. Do not scratch the itch of chasing PRs until you’ve completed at least one or two training cycles to allow for appropriate adaptations to occur.
  • Auto-regulate your training. Using the RIR-based method is probably the most accessible and most accurate combination readers will have at their disposal. Use moderate reps (5-8) with a moderate approximation to failure (3-5 RIR) to address size and strength without overloading the system.
  • If you’re particularly vulnerable, try to avoid end-range loading and use slow tempos (primarily during the eccentric portion of the lifts). 
  • Get enough sleep. For the millionth time.

While I can’t definitively say your injury rate will be lower while following the advice outlined above, there is minimal downside to this approach. You will be controlling the risk factors you can, while still providing enough stimulus to return to your former glory (and beyond).

I’m glad everyone is able to get back to training. Enjoy the process and don’t get bogged down with fear of injury. 

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