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I've had a case of climber's elbow (medial epicondylitis/tendinosis) for the best part of three months now and it's starting to get very annoying!
I've not been climbing, but have been trying to find ways to do upper body training so I don't completely lose condition, whilst also trying elbow physio exercises, stretches and massage. The problem is that any form of resistance exercise seems to keep the elbow sore!
Does anyone have any experience of this? Any thoughts on physio/training combos would be greatly appreciated. Maybe I just need to lay off the training altogether, but I really don't want to do that if at all possible..
I've not been climbing, but have been trying to find ways to do upper body training so I don't completely lose condition, whilst also trying elbow physio exercises, stretches and massage. The problem is that any form of resistance exercise seems to keep the elbow sore!
Does anyone have any experience of this? Any thoughts on physio/training combos would be greatly appreciated. Maybe I just need to lay off the training altogether, but I really don't want to do that if at all possible..
In reply to steve7734:
Well if in fact you have medial epicondylitis then you should stop doing any resistance exercise. They are not good to recover tendons. You should do eccentric exercises with a small weight. Check this exercises http://www.drjuliansaunders.com/resources/feature_articles/dodgy_elbows/
Another thing that you should add to your recover program is a big dose of patience. Recovering tendons takes time and if you push it too soon you will damage it further, increase recovering time. It took me about a year to recover from a medial epicondylitis. However, mine was pretty bad since I decided in the beginning that this pain will go away alone!
Good luck, and go to a physiotherapist, he might help you.
Well if in fact you have medial epicondylitis then you should stop doing any resistance exercise. They are not good to recover tendons. You should do eccentric exercises with a small weight. Check this exercises http://www.drjuliansaunders.com/resources/feature_articles/dodgy_elbows/
Another thing that you should add to your recover program is a big dose of patience. Recovering tendons takes time and if you push it too soon you will damage it further, increase recovering time. It took me about a year to recover from a medial epicondylitis. However, mine was pretty bad since I decided in the beginning that this pain will go away alone!
Good luck, and go to a physiotherapist, he might help you.
In reply to Eciton:
Thanks for your reply. So am I right in thinking that you stopped doing ANY resistance training for your arms at all, for an entire year? Apart from the extensor exercises for physio purposes of course..
Thanks for your reply. So am I right in thinking that you stopped doing ANY resistance training for your arms at all, for an entire year? Apart from the extensor exercises for physio purposes of course..
In reply to steve7734:
No, I am sorry if I was not clear. I was just telling you my experience. You can start doing resistance exercise whenever you feel that your tendon is prepared for. It can take a year, a month, half a year, who knows, it will depend how your elbow will react to physio. I was just telling that mine took a year to be without any pain.
What I meant was that to recover your tendon, resistance exercises are not good (my physiotherapist told me this, I am not making this up), you should do eccentric exercises.
The thing is, recovering from a medial epicondylitis is tricky and a very personal experience. My advice is that you should do exercises to recover you tendon, possibly go to a physiotherapist, but you should not stop climbing completely (unless it is pretty bad pain). Lower your grade to a point that you do not feel pain when climbing, climb slabs. Be patience, it can take a couple of months to see real improvements.
A treatment that help me a lot was doing EPI (Electrolisis Percutanea Intratisular) together with religious eccentric exercises 5 days a week. Check this page (in Spanish! I could not find any in English) http://www.efisioterapia.net/articulos/epicondilitis-o-epicondilosistratami...
This is a new technique, thus it may be difficult to find someone who can apply you that. I also have 3 friends with very good responses to this treatment.
> So am I right in thinking that you stopped doing ANY resistance training for your arms at all, for an entire year?
No, I am sorry if I was not clear. I was just telling you my experience. You can start doing resistance exercise whenever you feel that your tendon is prepared for. It can take a year, a month, half a year, who knows, it will depend how your elbow will react to physio. I was just telling that mine took a year to be without any pain.
What I meant was that to recover your tendon, resistance exercises are not good (my physiotherapist told me this, I am not making this up), you should do eccentric exercises.
The thing is, recovering from a medial epicondylitis is tricky and a very personal experience. My advice is that you should do exercises to recover you tendon, possibly go to a physiotherapist, but you should not stop climbing completely (unless it is pretty bad pain). Lower your grade to a point that you do not feel pain when climbing, climb slabs. Be patience, it can take a couple of months to see real improvements.
A treatment that help me a lot was doing EPI (Electrolisis Percutanea Intratisular) together with religious eccentric exercises 5 days a week. Check this page (in Spanish! I could not find any in English) http://www.efisioterapia.net/articulos/epicondilitis-o-epicondilosistratami...
This is a new technique, thus it may be difficult to find someone who can apply you that. I also have 3 friends with very good responses to this treatment.
In reply to Eciton:
OK thanks again! Think I need to stop procrastinating (read 'self help'), spend some money and see a physio..
OK thanks again! Think I need to stop procrastinating (read 'self help'), spend some money and see a physio..
In reply to steve7734:
I tried everything, in the end I think time is the biggest healer, that and being very careful what you climb indoors (I rarely get a problem outside). Avoid sustained and very overhanging climbs, especially leads.
I would however say the brachioradialis stretch definitely helps me and I think my elbow problems are down to an imbalance in the muscles pulling the tendons too much of the time and over stressing the point they join to the bones (which I guess is why the stretch helps me)
I tried everything, in the end I think time is the biggest healer, that and being very careful what you climb indoors (I rarely get a problem outside). Avoid sustained and very overhanging climbs, especially leads.
I would however say the brachioradialis stretch definitely helps me and I think my elbow problems are down to an imbalance in the muscles pulling the tendons too much of the time and over stressing the point they join to the bones (which I guess is why the stretch helps me)
Post edited at 16:29
In reply to steve7734:
Never heard of climbers elbow is it different to golfers elbow and tennis elbow? This helped me: http://www.ukclimbing.com/articles/page.php?id=3614
It took a couple of months but the trouble is I'm note sure if complete rest would have had the same affect.
Never heard of climbers elbow is it different to golfers elbow and tennis elbow? This helped me: http://www.ukclimbing.com/articles/page.php?id=3614
It took a couple of months but the trouble is I'm note sure if complete rest would have had the same affect.
In reply to Eciton:
http://www.clinicasohail.com/en/technology/epi.html It does seem to be a treatment developed in Spain. There are a few small-scale studies that suggest it is effective. I wonder if anyone in the UK does it?
> (In reply to steve7734)
> A treatment that help me a lot was doing EPI (Electrolisis Percutanea Intratisular) together with religious eccentric exercises 5 days a week. Check this page (in Spanish! I could not find any in English)
> A treatment that help me a lot was doing EPI (Electrolisis Percutanea Intratisular) together with religious eccentric exercises 5 days a week. Check this page (in Spanish! I could not find any in English)
http://www.clinicasohail.com/en/technology/epi.html It does seem to be a treatment developed in Spain. There are a few small-scale studies that suggest it is effective. I wonder if anyone in the UK does it?
In reply to GridNorth:
It's the same as golfer's elbow, yes. Definitely not the same as tennis elbow, which is on the lateral (outer) side of the elbow. I tried the Bart van Deenen exercise and all it did was make my wrist slightly sore.
It's the same as golfer's elbow, yes. Definitely not the same as tennis elbow, which is on the lateral (outer) side of the elbow. I tried the Bart van Deenen exercise and all it did was make my wrist slightly sore.
In reply to Mark Harding:
I'm sure EPI it has some kind of benefit but a google certainly doesn't come up with anything for it in Scotland (where I am), or indeed the UK.
How someone is supposed to go back to bouldering or pushing their grades after this, without it recurring, is beyond me...
I'm sure EPI it has some kind of benefit but a google certainly doesn't come up with anything for it in Scotland (where I am), or indeed the UK.
How someone is supposed to go back to bouldering or pushing their grades after this, without it recurring, is beyond me...
In reply to steve7734:
It does get to feel like that doesn't it? I've been suffering for years and although I've tried most of the non-invasive strategies I've not been really disciplined and carried them out for months on end (if need be).
There are some interesting "off-piste" ideas on Tom Randall's site and Dave Macleod's blog. Most other sites seem to repeat the mantra of eccentrics.The reverse Tyler twist with a Thera-bar has a lot of supporters too.I'm currrently putting together a programme which I've promised myself I will follow religiously.We will see ...
> (In reply to Mark Harding)
> How someone is supposed to go back to bouldering or pushing their grades after this, without it recurring, is beyond me...
> How someone is supposed to go back to bouldering or pushing their grades after this, without it recurring, is beyond me...
It does get to feel like that doesn't it? I've been suffering for years and although I've tried most of the non-invasive strategies I've not been really disciplined and carried them out for months on end (if need be).
There are some interesting "off-piste" ideas on Tom Randall's site and Dave Macleod's blog. Most other sites seem to repeat the mantra of eccentrics.The reverse Tyler twist with a Thera-bar has a lot of supporters too.I'm currrently putting together a programme which I've promised myself I will follow religiously.We will see ...
In reply to Eciton:
that article looks very interesting mario, do you have some connection with the authors ? any chance of a summary in english. i m off to google EPI treatment. lots of evidence that eccentric contractions work when done religiously. there was a good video on ukc that used a bit of broom handle and small weights. anybody got a link for that ?
that article looks very interesting mario, do you have some connection with the authors ? any chance of a summary in english. i m off to google EPI treatment. lots of evidence that eccentric contractions work when done religiously. there was a good video on ukc that used a bit of broom handle and small weights. anybody got a link for that ?
In reply to steve7734:
http://www.efisioterapia.net/en/articles/treatment-of-patellar-tendinopathy...
<voice of homer simpson...>
doh
http://www.efisioterapia.net/en/articles/treatment-of-patellar-tendinopathy...
<voice of homer simpson...>
doh
In reply to steve7734:
I've been suffering with this for about 9 months. I tried having a lay-off of around 3 months, seen physio and doing the excentric exercises with no improvement.
I had to move house rapidly which meant carrying lots of heavy stuff for about 3 days no stop and it actually improved over those 3 days.
Since then I've just been climbing pretty much as normal. I spend a lot of time warming up, and stretching my forearms out and after a while I can climb without really noticing (They are still sore but have been slowly improving over the last few months). I started off very low grade (for myself) and stuck mostly to slabby problems for a few months. I have slowly increased my grade and been doing more power oriented problems. I'm now climbing better than I have for a few years. So, the upshot is it's still there but it's not holding me back as long as I manage it to the point where I'm enjoying climbing as much as ever.
I've been suffering with this for about 9 months. I tried having a lay-off of around 3 months, seen physio and doing the excentric exercises with no improvement.
I had to move house rapidly which meant carrying lots of heavy stuff for about 3 days no stop and it actually improved over those 3 days.
Since then I've just been climbing pretty much as normal. I spend a lot of time warming up, and stretching my forearms out and after a while I can climb without really noticing (They are still sore but have been slowly improving over the last few months). I started off very low grade (for myself) and stuck mostly to slabby problems for a few months. I have slowly increased my grade and been doing more power oriented problems. I'm now climbing better than I have for a few years. So, the upshot is it's still there but it's not holding me back as long as I manage it to the point where I'm enjoying climbing as much as ever.
In reply to steve7734:
I suffered a bout of this some years ago and found that after a few days or a week or so of rest I could climb again, albeit very carefully. I found that the problem only really showed itself when I straightened my elbow completely, so I used a velcro elbow support to strap my elbow such that it was difficult for it to straighten (tape works well too but taking it off hairy arms isn't recommended!); at the very least I would be very aware of when I was trying to straighten it and could usually avoid doing so.
I found it was painful during careful warm-up but got less so during a session, and as the weeks progressed the pain would be reduced and would last a shorter time, until maybe 3 months or so later I could carefully climb again without the strapping.
I suffered a bout of this some years ago and found that after a few days or a week or so of rest I could climb again, albeit very carefully. I found that the problem only really showed itself when I straightened my elbow completely, so I used a velcro elbow support to strap my elbow such that it was difficult for it to straighten (tape works well too but taking it off hairy arms isn't recommended!); at the very least I would be very aware of when I was trying to straighten it and could usually avoid doing so.
I found it was painful during careful warm-up but got less so during a session, and as the weeks progressed the pain would be reduced and would last a shorter time, until maybe 3 months or so later I could carefully climb again without the strapping.
In reply to kedvenc72:
That's interesting, my experience has been similar. I took a total lay-off for about a year and there was absolutely no improvement. Then as I started to do some light gym work and easy climbs things started to improve. The big problem was that it was so easy to go past a certain threshold level and the pain sarted to increase.In my experience you do have to think "gradual" and "long-term"... and that's not always as easy as it sounds.
> (In reply to steve7734)
>
> I've been suffering with this for about 9 months. I tried having a lay-off of around 3 months
>
> I've been suffering with this for about 9 months. I tried having a lay-off of around 3 months
That's interesting, my experience has been similar. I took a total lay-off for about a year and there was absolutely no improvement. Then as I started to do some light gym work and easy climbs things started to improve. The big problem was that it was so easy to go past a certain threshold level and the pain sarted to increase.In my experience you do have to think "gradual" and "long-term"... and that's not always as easy as it sounds.
In reply to steve7734:
I suffered this the summer before last when the weather was crap and I hardly did any climbing. It lasted for a good 6 months or so.
I found the Powerball helpful, but I think it really got better when I did loads of regular low intensity climbing (laps at the wall). It became clear that I get it when I don't climb, basically, and if I climb a lot it's fine. This summer it was fine and now I'm indoor bouldering a lot (which I assumed would bring it back with a vengence) and it's still good.
So resting did me harm, and loads of laps did me good. Quite unpredictable things it seems.
I suffered this the summer before last when the weather was crap and I hardly did any climbing. It lasted for a good 6 months or so.
I found the Powerball helpful, but I think it really got better when I did loads of regular low intensity climbing (laps at the wall). It became clear that I get it when I don't climb, basically, and if I climb a lot it's fine. This summer it was fine and now I'm indoor bouldering a lot (which I assumed would bring it back with a vengence) and it's still good.
So resting did me harm, and loads of laps did me good. Quite unpredictable things it seems.
In reply to steve7734:
The concentric exercises helped me, but Tom Randall's blog basically cured me! I can't link to it on my phone, but if you google his blog, he demonstrates how to do the stretch. Apparently doesn't work for every case, but it's a magic bullet if it does
The concentric exercises helped me, but Tom Randall's blog basically cured me! I can't link to it on my phone, but if you google his blog, he demonstrates how to do the stretch. Apparently doesn't work for every case, but it's a magic bullet if it does
In reply to Kemics:
There is a small article in DPM magazine (pg. 50-51) about it with a flexbar exercise.
http://mydigitalpublication.com/publication/?i=187833 (just flip through all the commercials).
There is a small article in DPM magazine (pg. 50-51) about it with a flexbar exercise.
http://mydigitalpublication.com/publication/?i=187833 (just flip through all the commercials).
Post edited at 05:21
In reply to Kemics:
thanks for this.
http://tomrandallclimbing.wordpress.com/2012/11/23/golfers-elbow-a-possible...
thanks for this.
http://tomrandallclimbing.wordpress.com/2012/11/23/golfers-elbow-a-possible...
In reply to Kemics:
and thanks Tom.
and thanks Tom.
In reply to steve7734:
I had something similar and at last I am better - this might help a bit assuming we have the same injury: http://www.ukclimbing.com/forums/t.php?n=565845
In short, based on my experience:
1. I'd stop everything for 2-3 weeks to allow swelling etc to go down
2. Assuming there is not much pain, I'd then start getting back into really light exercise and focusing on strengthening antagonistic muscles. For me pushups keeping elbows close to body really helped and the weight on rope exercise (like reverse curls). Do very few to begin with and gradually build up.
3. Examine your climbing habits and technique - consider mixings things up a bit if you do lots of bouldering or overhangs. Don't hang on for dear life when you slip and climb really easy routes for a while.
4. Stop pull ups etc
5. Climb a lot less frequently for a while and build back up gradually.
6. Don't stretch before climbing/exercise - stretch after. Do lots of mobility exercises beforehand instead.
Since mine improved I made it a habit to do pushups. I do a set of 10-15 right after every other route/problem I do.
Hope this helps - obviously if in doubt, see a doctor. Depends how severe it is etc.. My experience with resting was as above, long rests didn't help - even if you do heal to an extend after a long rest you will only get injured again if you start climbing without addressing the root cause (climbing habits/technique, muscles imbalancesetc)
I had something similar and at last I am better - this might help a bit assuming we have the same injury: http://www.ukclimbing.com/forums/t.php?n=565845
In short, based on my experience:
1. I'd stop everything for 2-3 weeks to allow swelling etc to go down
2. Assuming there is not much pain, I'd then start getting back into really light exercise and focusing on strengthening antagonistic muscles. For me pushups keeping elbows close to body really helped and the weight on rope exercise (like reverse curls). Do very few to begin with and gradually build up.
3. Examine your climbing habits and technique - consider mixings things up a bit if you do lots of bouldering or overhangs. Don't hang on for dear life when you slip and climb really easy routes for a while.
4. Stop pull ups etc
5. Climb a lot less frequently for a while and build back up gradually.
6. Don't stretch before climbing/exercise - stretch after. Do lots of mobility exercises beforehand instead.
Since mine improved I made it a habit to do pushups. I do a set of 10-15 right after every other route/problem I do.
Hope this helps - obviously if in doubt, see a doctor. Depends how severe it is etc.. My experience with resting was as above, long rests didn't help - even if you do heal to an extend after a long rest you will only get injured again if you start climbing without addressing the root cause (climbing habits/technique, muscles imbalancesetc)
Post edited at 09:21
In reply to steve7734:
> I'm sure EPI it has some kind of benefit but a google certainly doesn't come up with anything for it in Scotland (where I am), or indeed the UK.
I do not live in UK, so cannot help you find someone that does EPI.> How someone is supposed to go back to bouldering or pushing their grades after this, without it recurring, is beyond me...
I understand you very well! I have no pain for a couple of months now, I have not started bouldering because I am still afraid, my sport climbing is still not at the same level as before, but I am improving at a good pace without any pain. On the other side my trad climbing is better than before. But I have to say that I am starting to see myself returning to the previous form without pain in my elbow (including bouldering). Fingers crossed! In reply to mike123:
> that article looks very interesting mario, do you have some connection with the authors ?
No, sorry I have now idea who they are.In reply to mike123:
I have tried this at early stages of desperation, and I have to say that my elbow got worse with this stretch! This stretch is very aggressive, so be sure your tendon can handle it.
I have tried this at early stages of desperation, and I have to say that my elbow got worse with this stretch! This stretch is very aggressive, so be sure your tendon can handle it.
In reply to Mark Harding:
That is the thing, stopping will not help you for curing an tendon. Dave Macleod has shared an interesting link of an article where tendons don't like rest and change (onlineclimbingcoach.blogspot.pt/2013/12/the-difficult-question-of-sports.html)
> That's interesting, my experience has been similar. I took a total lay-off for about a year and there was absolutely no improvement. Then as I started to do some light gym work and easy climbs things started to improve. The big problem was that it was so easy to go past a certain threshold level and the pain sarted to increase.In my experience you do have to think "gradual" and "long-term"... and that's not always as easy as it sounds.
That is the thing, stopping will not help you for curing an tendon. Dave Macleod has shared an interesting link of an article where tendons don't like rest and change (onlineclimbingcoach.blogspot.pt/2013/12/the-difficult-question-of-sports.html)
In reply to steve7734:
In my experience there is a lot of miscommunication regarding what exactly is 'climbers elbow', 'golfers elbow' and 'tennis elbow' (with the exception of the latter, which is well understood due to the greater popularity of tennis).
To avoid giving things names, I seperate elbow pain into three zones:
1- below joint on inside of forearm
2- below joint on outside of forearm (commonly called tennis elbow)
3- above joint on inside of elbow (brachialis tendon i.e more to do with bicep than forearm)
All are essentially related to inflammation of the tendons which attach the muscle to the bone.
Most climbers suffer more from 1 and 3. I personally am sensitive to 3, on occasion in the past it has been very acute.
Steps I have followed to help alleviate/avoid symptoms:
- when it starts to hurt, stop climbing
- if it hurts consistently, stop climbing for several weeks
- stretch the bit that hurts (try different stretches to find the one that works the best) during and after every climbing session
- warm up (I really can't emphasise this enough)
- doing press-ups has also worked for me in the past, the theory is is 'balances' your arms. Not sure how scientific that is though.
Hope this helps, good luck.
In my experience there is a lot of miscommunication regarding what exactly is 'climbers elbow', 'golfers elbow' and 'tennis elbow' (with the exception of the latter, which is well understood due to the greater popularity of tennis).
To avoid giving things names, I seperate elbow pain into three zones:
1- below joint on inside of forearm
2- below joint on outside of forearm (commonly called tennis elbow)
3- above joint on inside of elbow (brachialis tendon i.e more to do with bicep than forearm)
All are essentially related to inflammation of the tendons which attach the muscle to the bone.
Most climbers suffer more from 1 and 3. I personally am sensitive to 3, on occasion in the past it has been very acute.
Steps I have followed to help alleviate/avoid symptoms:
- when it starts to hurt, stop climbing
- if it hurts consistently, stop climbing for several weeks
- stretch the bit that hurts (try different stretches to find the one that works the best) during and after every climbing session
- warm up (I really can't emphasise this enough)
- doing press-ups has also worked for me in the past, the theory is is 'balances' your arms. Not sure how scientific that is though.
Hope this helps, good luck.
One thing about this, there's no shortage of tips. Thanks muchly to all. I think the reason it's so tricky to deal with is that even though climber's elbow is so common, everyone reacts differently to any given remedy.
Simos, Alun, I've stopped climbing for nearly 3 months now! Not stretching when cold seems to be a common theme though. I'll try push-ups at the wall too, but already do them regularly at the gym
Simos, Alun, I've stopped climbing for nearly 3 months now! Not stretching when cold seems to be a common theme though. I'll try push-ups at the wall too, but already do them regularly at the gym
In reply to steve7734:
I couldn't agree more with this - it seems that everyone who has overcome it has done so with their own combination of methods (sometimes completely contradicting what somebody else did).
Best of luck and I hope you manage to solve it!
> I think the reason it's so tricky to deal with is that even though climber's elbow is so common, everyone reacts differently to any given remedy.
I couldn't agree more with this - it seems that everyone who has overcome it has done so with their own combination of methods (sometimes completely contradicting what somebody else did).
Best of luck and I hope you manage to solve it!
In reply to Alun:
Yep you're certainly right there.I decided to resurrect this thred when I realised there wasn't a link to what may possibly be the most comprehensive on-line discussion on the problem.http://www.colinmcnulty.com/blog/2008/05/31/the-cure-for-golfers-elbow-medi...
> (In reply to steve7734)
> [...]
>
> I couldn't agree more with this - it seems that everyone who has overcome it has done so with their own combination of methods (sometimes completely contradicting what somebody else did).
> [...]
>
> I couldn't agree more with this - it seems that everyone who has overcome it has done so with their own combination of methods (sometimes completely contradicting what somebody else did).
Yep you're certainly right there.I decided to resurrect this thred when I realised there wasn't a link to what may possibly be the most comprehensive on-line discussion on the problem.http://www.colinmcnulty.com/blog/2008/05/31/the-cure-for-golfers-elbow-medi...
In reply to Mark Harding:
Wow, this guy's tried everything! I've got one eye on my elbow and the other on my wallet though, so repeated trips for ultrasound would be a last resort. I did see a sports physio on 16th December and he gave the elbow a beasting - acupuncture followed by a really vigorous massage. It felt very sore for a couple of days, and since then I've been doing regular flexor exercises interspersed with self-massage every 5-6 days.
I've also found a way to keep doing weights - by using a curl machine but resting the handles on my wrists! No strain on the flexors, but still hits the biceps. So far so good.
Wow, this guy's tried everything! I've got one eye on my elbow and the other on my wallet though, so repeated trips for ultrasound would be a last resort. I did see a sports physio on 16th December and he gave the elbow a beasting - acupuncture followed by a really vigorous massage. It felt very sore for a couple of days, and since then I've been doing regular flexor exercises interspersed with self-massage every 5-6 days.
I've also found a way to keep doing weights - by using a curl machine but resting the handles on my wrists! No strain on the flexors, but still hits the biceps. So far so good.
Post edited at 14:16
In reply to steve7734:
You are right, hope you manage to sort it out soon. One thing I would say is that for me at least, stopping completely a sport to get over an injury never helped for some reason - laying off for a couple of weeks initially and then getting back into it seems to have worked for most my injuries. The key I found is aim to do as little as needed in order to not feel pain - I then build up from there. If I do feel pain then it's much easier to isolate what movement caused it.
You are right, hope you manage to sort it out soon. One thing I would say is that for me at least, stopping completely a sport to get over an injury never helped for some reason - laying off for a couple of weeks initially and then getting back into it seems to have worked for most my injuries. The key I found is aim to do as little as needed in order to not feel pain - I then build up from there. If I do feel pain then it's much easier to isolate what movement caused it.
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