Starr protocol for older injuries

[Squatsandgoats]

I strained/pulled a glute pretty badly about 6 months ago (and then made it worse by trying to keep going on my programme) and finally stopped trying to push through when the weight I could handle without being stopped by the pain got lower every workout. Since then I've rested it from heavy training, but tried to stay as active as possible to keep it from seizing up. I've made a few attempts to add load again but its flared up at me when I've done that, but it doesn't actually hurt when I've been resting it. A friend recently told me about how he's used the Starr protocol to deal with a recurring back injury, so I've started to use it, did my first session yesterday, and squatted an empty bar for 3x25, which felt a little awkward, but nothing really felt like I'd reawoken the injury. I woke up this morning and had pain radiating from the area (top of my left glute) and from the local bit of the lower back, and I was pretty immobile. This calmed down after about an hour, with a cold bath and a hot shower, and has more or less subsided enough now that I can get to the gym and go again (which I'm on my way to do now).

Is this a normal response to the programme/should I do anything else as well/instead as this isn't a fresh injury and probably has a reasonable amount of scar tissue from all the times I've reaggravated it?

Thanks in advance

[Will Morris]

I strained/pulled a glute pretty badly about 6 months ago (and then made it worse by trying to keep going on my programme) and finally stopped trying to push through when the weight I could handle without being stopped by the pain got lower every workout. Since then I've rested it from heavy training, but tried to stay as active as possible to keep it from seizing up. I've made a few attempts to add load again but its flared up at me when I've done that, but it doesn't actually hurt when I've been resting it. A friend recently told me about how he's used the Starr protocol to deal with a recurring back injury, so I've started to use it, did my first session yesterday, and squatted an empty bar for 3x25, which felt a little awkward, but nothing really felt like I'd reawoken the injury. I woke up this morning and had pain radiating from the area (top of my left glute) and from the local bit of the lower back, and I was pretty immobile. This calmed down after about an hour, with a cold bath and a hot shower, and has more or less subsided enough now that I can get to the gym and go again (which I'm on my way to do now).

Is this a normal response to the programme/should I do anything else as well/instead as this isn't a fresh injury and probably has a reasonable amount of scar tissue from all the times I've reaggravated it?

Thanks in advance

In advance, just know I ask a lot of questions from posters with regards to their posts. This is a normal occurrence, so don't take it personally.

First question I have is this: what evidence do you have that you strained / pulled your glute? An actual strained glute would present with a very characteristic pattern of signs and symptoms. I would almost bet money that this assessment was made simply because you had pain in your glute area.

Second question is: If it were a strained muscle belly, what does 6 months of relative rest (no persistent loading of the tissue) result in as far as quality of the healed tissue? The follow-up question is this: even if the injured tissue heals with less than optimal functionality with 6 months of relative rest, would we expect continued pain with very little activity 6 months out from a muscle strain?

Third question: when you haven't loaded the tissue or the body for a squat in almost 6 months, what would you expect happens when you perform 75 reps of the exercise?

[Squatsandgoats]

In advance, just know I ask a lot of questions from posters with regards to their posts. This is a normal occurrence, so don't take it personally.

First question I have is this: what evidence do you have that you strained / pulled your glute? An actual strained glute would present with a very characteristic pattern of signs and symptoms. I would almost bet money that this assessment was made simply because you had pain in your glute area.

Second question is: If it were a strained muscle belly, what does 6 months of relative rest (no persistent loading of the tissue) result in as far as quality of the healed tissue? The follow-up question is this: even if the injured tissue heals with less than optimal functionality with 6 months of relative rest, would we expect continued pain with very little activity 6 months out from a muscle strain?

Third question: when you haven't loaded the tissue or the body for a squat in almost 6 months, what would you expect happens when you perform 75 reps of the exercise?

Thanks for responding

1. Only evidence is pain in the region, and a lack of mobility. I don't have a trained eye, so I don't really know what other signs or symptoms to be looking out for. I called it a strain because the type of pain is similar to pains I've been told are due to strains in the past, not because I have any special knowledge of what is going on.

2a. It seems to have healed partially, as I can run and jump more or less pain free, but obviously not totally because of the continued issues under load. I don't know enough for a less qualitative assessment
2b. I don't really know what would be expected tbh, I'm fortunate enough that this is my first exposure to a lingering muscular issue.

3. I see what you're getting at, but I've still been doing plenty of bodyweight squats, to the extent that this isn't a significant amount of volume, and lots of other movement, so the addition of only 20kg (which isn't that far off what I've lost in bodyweight since getting hurt) has made a surprising amount of difference to how it feels.


In addition, observations from today's session were that the bar x 25 and 25kg x 25 were almost entirely pain free,( following a warm up of plenty of bodyweight squats and squats with smaller weights still) 30kg x 25 was fine for the first 20 reps or so, but then started to tug for the last 5.

Sorry if that came across a little terse, I really appreciate the help

[Fulcrum]

I kinda checked out while reading that paragraph, because the first sentence and the thread title says it all.

No. The Starr rehab is used right after the injury occurs (within a day or two or three IIRC).
Not 6 months later.
The idea is to NOT let a bunch of scar tissue develop ... while you "rest" the muscle/injury which is so commonly ill-prescribed.

[Squatsandgoats]

I kinda checked out while reading that paragraph, because the first sentence and the thread title says it all.

No. The Starr rehab is used right after the injury occurs (within a day or two or three IIRC).
Not 6 months later.
The idea is to NOT let a bunch of scar tissue develop ... while you "rest" the muscle/injury which is so commonly ill-prescribed.

So what should be done instead?

[Will Morris]

The best available evidence very strongly supports early, thoughtful loading of injured tissue. Passive healing, as well as the old paradigm of low load stretching and ROM exercises, are strongly indicated in exponentially higher reinjury rates. Heiderscheidt, a prolific researcher on hamstrings and hamstring injuries, reported an 87% reinjury rate with low load stretching and ROM exercises, similar numbers of reinjury rates for passive (time off) healing, but found only a 13% reinjury rate for dynamic loading of hamstring strains.

[Squatsandgoats]

The best available evidence very strongly supports early, thoughtful loading of injured tissue. Passive healing, as well as the old paradigm of low load stretching and ROM exercises, are strongly indicated in exponentially higher reinjury rates. Heiderscheidt, a prolific researcher on hamstrings and hamstring injuries, reported an 87% reinjury rate with low load stretching and ROM exercises, similar numbers of reinjury rates for passive (time off) healing, but found only a 13% reinjury rate for dynamic loading of hamstring strains.

So is this an endorsement of keeping going with the Starr protocol, or does dynamic loading mean something else?

[Will Morris]

In the Heiderscheidt articles, they used things like sprints, agility type drills, etc as their definition of "dynamic loading".

I think you may have missed the most important part of my last post. The most important part was the "evidence strongly supports early, thoughtful loading of injured tissue". In your case, you did not perform early loading of the tissue, and, as such, the Starr protocol is not what would be recommended here. For the record, I don't routinely prescribe the Starr Protocol as I have some very pronounced arguments against it.

In a case that presented in my clinic that was similar to yours, I would have (after a thorough physical exam) them perform a standard novice linear progression. I would not subject them to the extremely high repetition loads of the Starr Protocol. I would be more inclined to focus on strength development, with less emphasis on pain management. For lots of reasons, the idea that it doesn't hurt when you aren't loading it does not support this being the best course of action. In fact, continued rest / avoidance of activity is likely to "increase somatic expression of pain" when subjected to this activity. Kinesiophobia ties in very tightly to the experience of pain. Which, this is another reason I dislike the Starr Protocol, as originally described.