Simple & Sinister in a Rehabilitation Setting

In December 2013, I was a fit and spry 32 years old. I had decided to volunteer with our local high school and youth wrestling programs. I wrestled for many years and thought I might have a nugget or two of wisdom to pass along to the younger generation. At the third practice I attended, I found I may have not been as resilient as I thought.

How My Injury Occurred

We were doing routine takedown drills and I was deep on a single leg. The kid sprawled hard. My left arm was trapped behind his knee and between his legs. As my left elbow reached hyperextension, I felt the snap. If any of you have ever experienced a complete tendon tear, you know the feeling I am describing. It feels like ripping apart two pieces of Velcro at high velocity.

The kid jumped back, looking at me standing there with my left arm dangling by my side. “You okay, Doc?” he asked. My left biceps tendon had completely ruptured at the elbow. I slowly sat on the floor and told him to find a new partner. Then, the worst part came. You sit there realizing you have to go home and explain this to your wife. As a person who makes a living with his arms, I am a chiropractor; I could imagine how this conversation was going to play out.

Kettlebell training for rehabilitationSimple & Sinister and My Rehabilitation Plan

After I got past my lovely wife, I called a friend, an orthopedic surgeon, and we scheduled surgery for later in the week. My second call was to my good friend and mentor, Kelly Starrett. He had a Marc Pro sent to me to control the swelling and promote proper healing of the tendon and reduce disuse atrophy.

We then formulated a plan to get me back in action. As anyone who has been through this knows, the first ten days after surgery are spent in a cast. The cast covers your arm from knuckles to armpit and locks you at ninety-degrees of elbow flexion. As a self-employed chiropractor, I did not have the luxury of time off. I could have written a book describing one arm chiropractic by the end of those ten days!

As our rehabilitation plan consisted mostly of holds, grip work, and rewiring shoulder stability and mobility, I picked up my copy of Simple & Sinister and gave it another read. I have always seen an injury as your body demanding you return to the basics. There is something you were ignoring in your training, and when your options for exercise and activity are limited you can learn a lot about yourself. I thought hard about how to make the necessary modifications given my current situation and went to work.

My Rehabilitation Progressions

With my left hand I took the lightest kettlebell I own, 12kg, and just laid there on the ground in the position of the Turkish get-up before the press (remember, I’m in a cast). With my right arm, I did floor presses with a pause at the top. I was not able to roll to my left elbow.

Anyone who has had surgery will tell you there is almost a loss of connection between your brain and the limb. I would switch between holding the kettlebell bottom down and bottom up with both hands. I realized I needed as much time under tension as I could handle. I crush gripped the kettlebell to help reengage my nervous system with the injured limb. This is where the value of the bottom-up kettlebell work was revealed.

Bottom-up work forced me to engage the latissimus and reconnect my shoulder to my rib cage. I followed it up with the 100 swings, 10 sets of 10, with a 24kg kettlebell. I did all the swings with my right hand. This was not ideal, but I wanted to maintain some conditioning. Jumping rope and running outside were not an option. If you are familiar with Iowa winters, you know what I mean.

I also own several Captains of Crush grippers by Ironmind. I took the #1 and used the grease-the-groove technique we are all so familiar with. Several times a day, I squeezed that gripper as hard as I could for two or three repetitions.

At day ten, I had my appointment to have my cast removed. The surgeon could not believe how well I had healed. I truly believe the ten days I spent doing as much as I could with the cast on were pivotal in my overall recovery. I believe too many people are scared to do much during this phase.

Kettlebells for rehabilitation
I credit my Simple & Sinister training for my amazing rehabilitation.

Out of the Cast and Into the Brace

The next phase of my rehabilitation involved a cumbersome brace from wrist to shoulder that limited my flexion and extension at the elbow. But, importantly, I was able to roll onto my left elbow and begin to transmit force through my shoulder girdle. Many people forget the importance of the arm without the kettlebell. It needs to be in perfect position to handle the load of your body. So this brace also allowed me, ever so slightly, to begin to move the left arm under load.

This phase of rehab became extremely tedious. You are allowed to open the brace 10 degrees in each direction every couple weeks until you have full range of motion. As I opened the brace, I would do more and more with the left hand, slowly working to a full floor press. In the world of rehab, there are hundreds of different exercises given for “scapular stability” and “rotator cuff strengthening.” News flash, the brain works in patterns, not muscles. Yet, most rehab fails to work the motor patterns.

Following this simple progression, I was able to work mid-range flexion and overhead positions (flexion with external rotation) when I was holding the kettlebell in my left hand. When I had the kettlebell in my right hand, I was able to work on loading that shoulder in extension and internal rotation.

The big one is rewiring your trunk stability. As I opened the brace more and more, it was so difficult to roll properly with my left hand holding the kettlebell. It was even difficult without any weight! I could bore you with more details, but I think as the reader you can see where this is going. At my last appointment with my surgeon the first week of February, I was able to do a full Simple & Sinister routine using a 12 or 16kg kettlebell with my left hand for the get-up depending on how I felt.

Rehabilitation Is About Remembering the Basics of Movement

The get-ups were extremely valuable in my recovery, but I did not forget about the swings. As I could straighten my arm to an acceptable degree, I began doing two-hand swings. While we all know the swing is an elegant hip hinge exercise, we forget how important it is for practicing packing the shoulder in a dynamic environment and relearning to transition between stiffness and relaxation.

The swing is also crucial for patterning your breathing and creating a stiff torso; both of those things are extremely important in developing a strong platform for your shoulder to work correctly. These also added time under tension for my grip, and I also began adding in some jump rope work and several different carries (waiter’s walks, bottoms up, front rack, etc.).

Creating a stable spine and shoulder and moving was another skill I found helpful in recovery. There were several soft tissue and joint mobilization techniques I used, as well as the Marc Pro device, which are beyond the scope of this article. You are more than welcome to research Kelly’s work or attend one of our courses for more information.

Kelly Starrett helped me design my rehabilitation program.
Kelly Starrett helped me design my rehabilitation program.

Successful Rehabilitation Requires the Right Approach

The surgeon could not believe where I was from a recovery perspective at my last appointment. I was by no means totally healed, but I was cleared to start doing other things.

Anyone who has experienced a complete tendon rupture knows the recovery process is really twelve to eighteen months. Although I have introduced other activities to my routine, get-ups and swings remain a staple. I did not mention this earlier, but this was my fourth surgery (both shoulders, both elbows).

Revisiting the basics of human movement is exceedingly important to me for long-term health. I am at thirteen months post-surgery and constantly return to the get-up when I feel something is not right with one arm or the other. I can usually trace it back to not bracing properly before the initial roll. There is a pearl of wisdom there and many of you may have missed it. If your spine is not stable and your trunk is not stiff and engaged, your shoulder will not work properly. There may be some joint restriction, but if you do not work on spine stability first, you will not get to the bottom of it.

Spinal stability is essential for good movement.
Spine stability is essential for good movement.

I will finish with a caveat. I am a healthcare professional with many good friends in the fields of strength and conditioning and rehabilitation. I also have many years of experience in weight training and injury care and prevention. If you have torn your distal biceps tendon, seek advice from physicians and physical therapists who understand basic weight training. If your doctor does not deadlift or gives you a funny look when you say “Turkish get-up,” find a new doctor. Had I not myself understood how to use the principles of tension, grease-the-groove, and motor patterns and movements, I would not have been as far along at discharge.

If you are at a loss for a good doctor, contact organizations like StrongFirst or Functional Movement Screen or one of the staff members at MobilityWOD. We may be able to put you in touch with providers in your area who understand the lifter. There is a gap between healthcare providers and the strength and conditioning communities that needs to be narrowed.

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Travis Jewett
SFG I, SFL
Dr. Travis Jewett is a Chiropractor, MobilityWOD Team Member, and CrossFit Level I Trainer.

He travels and teaches the CrossFit Mobility Certification as part of the seminar staff. He has been involved in weight training, powerlifting, teaching, and coaching for 22 years. He works with a wide range of people at his clinic in northwest Iowa.

Currently on hiatus from competing, he always goes back to picking up his kettlebells. He can be reached at travis@mobilitywod.com

12 thoughts on “Simple & Sinister in a Rehabilitation Setting

  • I’m am currently 2 weeks post surgery with the same injury. I have been working primarily with the unaffected side. Do you know of any practitioners in the middle TN/southern Nashville area? My PT is totally against any for of resistance to the injured side.

  • Excellent article Travis. I am a big fan of both Pavel and Kelly.
    I had a motorbike accident and dislocated right shoulder and broke my right humerus along with the right femur. Several surgeries later I was left weak, imbalanced and with anterior tilted shoulder scap.
    I have become a big fan of TGUs too.

  • Thanks for the article. I’m 2 weeks post surgery for the same injury. Of course my Dr. and PT are telling me to do nothing. Do you have anyone that you’d recommend in the middle Tennessee south Nashville area? Thanks.

  • A year ago I had an unlucky skydive and landed on my butt, heavily bruising the tailbone (nothing serious, but I was unable to sit for a week and had pain for a month). So I ditched my gym membership, and for 3 weeks did nothing but medical procedures and yoga (choosing poses that relieved the painful feelings and “opened” my lower back). After that, I decided to give Simple&Sinister a go, and with the program could recover most of my strength without any discomfort — and also got rid of all the symptoms. I was doing it until I hit the Simple goal, and then switched to Rite of Passage.
    Since then, I’m in love with Simple&Sinister. It is both fun and effective, but I also value how much good it does to my body without putting it in serious danger.

    • Anastasia

      I am enjoying hearing these stories of others using the same idea. It is such an elegant idea. Improve your ability to hinge at the hip and create some power, under some load take your body through all its shapes and motor patterns. Patience and consistency. That is the piece most people ignore when trying to rehab and recover.

    • You know it. Pavel has been one of the biggest influences on my thinking and career along with Kelly Starrett and Dan John and Geoff Neupert. There are others but I think that is a pretty good group to pay attention to.

  • Very insightful and informative, thanks! I haven’t had this injury, but I just hit 40 and want to do everything I can to stay healthy and out of the surgeon’s office. This post is a great resource.

  • Doc Travis, awesome article!

    I am working w/ a slightly torn rot. cuff as well and fear I am ALMOST in that same boat w/ my bicep as it has atrophied….. I have adjusted training quite dramatically but still have some fear in me so it makes my training quite reserved……

    This article is a Great help, thank you!

    BTW, I also fear the wife! ha ha

    Z

    • Thank you for the kind words Zach. Big fan of your work, reading your book right now! There’s something about old wrestlers, we know one another just by looking at each other! Stay safe, speed is the enemy with your shoulder!

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