Training with Chronic Injuries: A Case Study

by Alex Pisanello and John Petrizzo, DPT, SSC | August 25, 2021

My name is Alex Pisanello and I am a 35-year-old service-connected veteran. Over the course of my time in the military, I served in a variety of combat operations including several deployments and suffered numerous permanent injuries as a result. These injuries include, but are not limited to, a traumatic brain injury, sciatica, lumbosacral radiculopathy, lumbar spine disc prolapse, osteoarthritis in the cervical spine and right acromioclavicular joint, two right hip labrum tears and a left shoulder rotator cuff tear in parallel with a proximal biceps tendon rupture. I had the left rotator cuff and biceps tendon repaired surgically. My rehabilitation protocol was conventional for approximately 10 years after I was honorably discharged from the armed forces. Traditional physical therapy failed to alleviate painful symptoms, restore strength and optimize my ability to function.

My conventional physical therapy was heavily based on the premise of exercise variation. In my opinion, it was similar to CrossFit. I was rarely given the same exercises each session, and the load was not increased. I was given an option to select a weight that worked well for me to perform three sets of twelve to fifteen repetitions. I also primarily performed unilateral exercises such as side lying shoulder external rotation with a light dumbbell, and single-leg glute bridges. Bilateral exercises patterns such as the squat were not prescribed very often.

Over time, I developed an interest in learning how to better manage my orthopedic and neurological injuries which led me to ultimately deciding to pursue physical therapy as a career. Under the auspices of the Vocational Rehabilitation program, the Department of Veterans Affairs awarded me a full scholarship to become a physical therapist. The Vocational Rehabilitation program is awarded to service-connected veterans to afford them the opportunity to gain employment. If a veteran’s service-connected disabilities hinder them from performing an occupation, the Department of Veterans Affairs will no longer fund the veteran’s program. I am currently in the process of being discharged successfully from the Vocational Rehabilitation program, since I am able to sustain a full-time job as a physical therapist. Throughout my physical therapy education, I was gravely concerned I would not be able to perform my occupation due to my service-connected disabilities.

During the course of my physical therapy education, a friend of mine introduced me to Starting Strength. The practical nature of the program made perfect sense to me and I immediately knew I wanted to give barbell training a try. I attempted the Novice Linear Progression on my own a few times. I used the blue book and Rip’s YouTube instructional videos, but without proper guidance, I failed to achieve either gains in strength or relief from chronic pain. That changed in the spring of 2020 when I began a unique rehabilitation protocol under the guidance of Dr. John Petrizzo.

John is a physical therapist and Starting Strength Coach I was introduced to through a mutual friend. Once I started working with John, it became clear that I had to make some adjustments to what I had done in order to successfully manage my injuries while training and obtain the desired results. It is with humble gratitude to Dr. Petrizzo that I successfully completed a modified version of the Novice Linear Progression. I gained strength that exceeded what I possessed as a young man in my early twenties. In addition, my pain is reduced and sometimes absent in much of my daily life, and most importantly I can say that I have adequate strength to function and perform my occupation as a physical therapist.

The mechanism of the injuries I incurred during my military service included various bouts of repetitive microtrauma and macrotrauma that I will not discuss in this article. Details on the mechanism of my injuries is not needed to understand how I utilized the principles of the Starting Strength system for rehabilitation and strength acquisition. The impact of how these injuries affected my quality-of-life, post military, in parallel with the rehabilitation process is necessary to understand their widespread impact.

Prior to engaging in barbell-based rehabilitation my left shoulder and osteoarthritic right shoulder constantly ached. I also experienced sharp pain in both of my shoulders when reaching in all planes. Similarly, my back pain was constant. Sometimes it was so severe I would have to lay down on the ground because I felt paralyzed by the intense muscle spasms I would get. The back pain would also radiate into my calf muscles. My hip pain, in conjunction with arthritis in my neck, made sitting for prolonged periods of time extremely difficult and as a result, I was often forced to stand during classes while I was in graduate school.

Rehabilitation and Training

I purchased a squat rack, barbells, and 200 pounds in plates during the onset of the COVID-19 pandemic. Based on my injury history, and the fact that I was finishing up school in parallel with preparing for my licensing exam, John and I made the decision to train two times per week instead of three to allow for more recovery time between sessions. My caloric intake was around five to six thousand calories a day. I believe my nutrition was good. I consumed nutrient dense foods that contained sufficient ratios of carbohydrates, proteins and fats. I ensured I got 8 hours of rest every night. I very rarely missed a training day. I worked online with John for several months before we got together for in-person sessions.

I began my first modified NLP workout weighing 158 pounds on 06/01/2020 with the following:

• Front Squat 95 x 5 x 3
• Press 45 x 5 x 3
• Sumo Deadlift 115 x 5 x 1

My second workout was three days later consisting of:

• Front Squat 100 x 5 x 3
• Bench Press 45 x 5 x 3
• Sumo Deadlift 120 x 5 x 1

I started with the front squat and a modified sumo deadlift because, through trial and error, John and I determined that at that time my hips could not tolerate the amount of flexion required for the squat and my lower back could not tolerate the starting position of the conventional deadlift. I added 5 pounds to the bar every workout on every aforementioned barbell exercise unless form broke down under load. If my form was not in accordance with the model, John would typically have me repeat the same load the following workout. I transitioned to a high-bar back squat after I front squatted 115 x 5 x 3. I transitioned to a conventional deadlift after I pulled 225 x 5 x 1 with a sumo deadlift. To my surprise I was able to perform 115x5x3 high bar back squat and 225x5x1 conventional deadlift without any major problems. There was a significant amount of feedback, coaching and instruction on all the lifts to rectify a multitude of errors while I was training. John also provided me with all the resources in order to purchase all the necessary gear to train properly.

I set up my first platform coaching session with John in the fall of 2020 and made the hour-long trip to his clinic where he treats patients. To our surprise, I was unable to set my back correctly in a deadlift at 275 lb resulting in a very inefficient pull. I thought my linear progression had stalled because I could not pull 275 for a set of 5. It was instructive for me to see the difference that in-person coaching can make when compared to online. Despite that I had made good progress working with John remotely, in my opinion, there is no substitute for in-person instruction when it comes to the barbell lifts.

I continued getting platform coaching and online coaching from John as needed. John taught me the power clean so I could add it into the program. Unfortunately, my anthropometry limits my ability to perform the lift, as I have long forearms and relatively short upper arms, so it did not fit well into my program. In place of the power clean, John taught me the power snatch and I was able to include that in my program without much difficulty. Around this time, I also began incorporating chin-ups into my linear progression.

The lifts began to stall in December of 2021. As I progressed, I switched to the low bar back squat, began incorporating back-off sets, and transitioned to using 5 sets of 3 for several of the lifts. The Advanced Novice Phase ended on 03/01/21 nearly 10 months after I began my modified Novice Linear Progression. I weighed 185 pounds and had gained a considerable amount of strength. My training session on 03/01/21 included the following:

• Squat 320 x 3 x 1, 285 x 3 x 4
• BP 272.5 x 3 x 5
• Chins BW+7.5 x 5 x 3

I want to add that the previous workout on 02/26/21 included the following:

• Light Squat 235 x 5 x 2
• OHP 185 x 3, 155 x 3 x 4
• DL 350 x 5 x 1

I transitioned to an intermediate program, similar to the Texas Method, where I alternated between volume days and intensity days which began on 03/08/21. I performed it consistently until 05/06/21. My training session on 05/06/21 included:

• Squat 350 x 1, 330 x 4 x 1
• OHP 202.5x1, 190 x 4 x 1
• DL 395 x 1, 375 x 4 x 1

John modified my program to prevent functional overreaching or overtraining. I am still currently training under John’s instruction to current date under slightly more complicated programming. Throughout the course of my training, I experienced back tweaks, hip tweaks, and I am currently working on a shoulder tweak. Injury is nearly an absolute guarantee in life regardless of whether or not you train. Proper training can help an individual manage injuries when they arise, and being stronger has certainly helped me successfully manage my injuries and pain. I preach this advice to all of my patients.

I have a little over a year of coaching experience using the Starting Strength method in a physical therapy clinic. I am currently taking the Starting Strength Coach Prep Course under the mentorship of Nick D’Agostino. I have a strong desire to expand upon my current credentials and education and engage in becoming a Starting Strength Coach. Apart from the numerous invaluable benefits I have personally experienced since engaging in this endeavor, I have been seeing outstanding results in the progress and success of the patients I treat as a physical therapist. I believe that achieving mastery in the performance and instruction of the basic barbell lifts already has and will continue to significantly contribute to my development of becoming an autonomous, exemplary health care practitioner.