While injury prevention doesn't have the same sexy ring to it as, say, "Blast Your Biceps" or "Quick Ways to Increase Your Bench," it's arguably the most important aspect of your training.
I mean, how the hell much can you bench press with a screwed up shoulder? How can you play pick-up basketball with the guys if you're suffering from anterior knee pain?
Whether it's horrible technique, complete disregard of quality programming, or just plain ol' poor exercise selection, it's a safe bet that a lot of trainees are making unsafe decisions in the weight room.
Mike Boyle, Eric Cressey, Bill Hartman, and Mike Robertson sat down with T-Nation to discuss the finer points of injury prevention and playing it smart.
Testosterone Nation: It seems like a lot of trainees are becoming more aware of actually balancing movement patterns (horizontal pushes vs. horizontal pulls, vertical pushes vs. vertical pulls, etc.) in their programming. If one is aware of the importance of this balance and adheres to it in their training, how important or necessary are isolation movements such as external rotations and the like?
Mike Boyle: I think stabilizer work is always necessary. Current research trends seem to show a difference between training stabilizers and movers. Most of the conventional multi-joint stuff we do works on the larger movers (what are referred to in the literature as "global muscles").The local muscles are small stabilizers and need work of their own. I think the key is that single-joint movements are helpful for rotary muscles, but not for hinges.
It goes back to the joint-by-joint idea. Simple hinge joints (elbow and knee) probably don't need isolation and will be well served by multi-joint exercises. Multi-directional joints like the hip and shoulder may benefit from additional work for the rotators and stabilizers.
Mike Robertson: In this case, your posture needs to dictate your training. For instance, if you're already in a kyphotic or slouched upper body posture, "balanced" training (matching a horizontal push with a horizontal pull) isn't going to fix the problem!
However, if you have optimal posture and alignment, the right muscles are naturally going to be more efficient because you have proper length-tension relationships. If we take that slouched upper body posture into movement, your external rotators simply can't produce the force they're capable of. So until you fix the bad alignment, direct rotator cuff work isn't going to do too much for you.
Long story short, if you're in good alignment, go ahead and add in direct work for the rotator cuff, lower traps, serratus, etc. If you're not, focus on fixing the bigger issues first and foremost.
Eric Cressey: I agree with Mike Boyle that you have to take it joint-by-joint. You won't get true full ROM (range of motion) external rotation on many movements. So it becomes necessary to include some of these movements in your assistance work to not only build strength in crucial stabilizing muscles, but also build and maintain active range of motion.
To be honest, though, it just seems silly to even debate this stuff. It's an extra set or two in your warm-up or at the end of a session once a week. If you have the time and willingness to debate this stuff, I think you'd be better off devoting some time to charity work.
T-Nation: True, but let's debate it anyway. What do you think, Bill?
Bill Hartman: I think there's support for movement pattern balance when you look at ideal strength relationships around the scapula, which are pretty much a one-to-one relationship. The problem that I can see is that this is misinterpreted or misunderstood by saying things like a bench press will balance a row.
If you look at the scapular function in such an exercise selection, they're not all that different, so it's really not "balanced." Then take into account that most horizontal pressing exercises provide proximal (trunk) stabilization (the bench), which means when the stabilizing muscles like the rotator cuff and scapular stabilizers would typically shut down the exercise, the prime movers can keep working.
This creates a case where the stabilizing musculature can't keep up and larger muscles overcome the stabilizers, making them relatively weak. The bottom line then is that if there's an isolated weakness, it needs to be addressed.
This doesn't even take into account the other potential influences like spinal mobility and even hip mobility that can affect shoulder function, though.
T-Nation: We always say that deadlifts are a great exercise when performed correctly. However, most people have absolutely atrocious form. Do you think most trainees can deadlift heavy and well?
Cressey: Over time, yes. Not everyone can pull from the floor right away, though. In fact, I start most beginners with rack pulls and progress them to the floor as their dynamic flexibility improves.
It actually makes it easier to teach as well, as most people struggle the most with the lockout portion of the lift (using the glutes to complete hip extension rather than the lumbar erectors to initiate hyperextension).
To be honest, though, I think that the better question is: "Do most trainers know how to coach the deadlift well?"
T-Nation: True. What do you think, Mike?
Boyle: As a former powerlifter it pains me to say it, but very few people are able to deadlift both heavy and well. I know many who read this site have an affinity for the three powerlifts, but I think in the performance world most coaches have all but abandoned the conventional deadlift. It still comes back to the risk/benefit idea, though.
Robertson: The average trainee? Is there such a thing? The "average" client I work with can deadlift heavy and well because I'm working with them in a one-on-one setting. I'm constantly reinforcing good mobility, proper posture, and flawless technique.
However, this "average" client of mine is vastly different from the casual gym goer who reads about deadlifts in a muscle rag. I'd argue that most of these people have no business doing deadlifts for multiple reasons:
1. They don't have adequate mobility to assume a good starting position.
2. Most have no concept of "neutral spine."
3. They use absolutely horrendous technique from start to finish.
4. The majority also use excessive loading too soon.
I love deadlifts, but there are a lot of people out there doing more harm than good by performing them.
Hartman: If you're self-taught in the deadlift, it may be a good idea to get some instruction from a qualified coach. So I guess my answer would be that no, most can't deadlift well from what I've seen.
In fact, you can throw about any lift from the floor into this category. Many just don't grasp the need for sufficient mobility, trunk strength, and scapular strength to take a barbell safely from the floor.
The deadlift also seems to be the one exercise where technique goes out the window in an effort to pull more weight to satisfy the ego. That said, deadlifts certainly have their place.
T-Nation: Okay, let's talk deloading. When it comes to training, just how important is it? Any general rules of thumb in terms of volume, frequency, and the like?
Robertson: The greater the training and chronological age of the athlete, the greater the need for deloading. Each and every time they train they impose greater demands on their bodies, therefore necessitating more recovery.
I've also found that I need to cut back more so than others when it comes to unload weeks. For instance, in my Modified 5x5 Squat Routine article, I discussed how when I cut back my volume/intensity on my unload weeks, I saw even greater gains on my loading weeks. After all, we're not trying to set PR's on unload weeks, right?
The "it depends" answer works well here, but I think this is a very individual thing and something each trainee should learn to understand for himself.
Cressey: In a nutshell:
1. Beginners really don't need to worry about deloading. Changing exercises alone comprises enough of a deload because fiber recruitment and overall volume drop when you impose a new challenge.
2. Intermediates do well with maintaining intensity, but dropping volume.
3. Advanced lifters generally need to drop intensity and volume.
Along the injury prevention lines, a valuable approach with the deload is the "prehab week." Basically, I just substitute a higher volume of corrective training exercises to replace the ordinary assistance work in the program. For instance, we might do an extra two to three sets of seated rows and drop the close-grip bench presses altogether.
Hartman: From a performance standpoint, the greater the amount of fatigue that you can induce, the more important deloading becomes. Fatigue has to be able to dissipate or progress stagnates. Nothing new there, but a lot of guys don't consider that the structural tissues need time to adapt to progressive loading.
How many guys set a gym PR and then try to go for more weight? Sure you may have the muscular strength, but I'd hazard to guess that most don't consider whether they have the connective tissue strength to handle such loading.
For dynamic athletes, it's even more important because in a single week they may be lifting explosively, running, and performing jumping exercises. That's a tremendous stress to your connective tissues, where most injuries are from cumulative trauma.
T-Nation: Good point, Bill. What say you, Mike?
Boyle: This is an area where Jason Ferrugia has really opened my eyes in the last month. I think Jason has really looked at things from the performance side and come to some great conclusions. The reality is his thoughts on CNS fatigue are going to cause me to rewrite a lot of workouts.
This again illustrates the disconnect between powerlifting and performance. Powerlifters don't have to worry about the volume of sprinting, Olympic lifting, plyometrics, and conditioning work impacting their pursuit of strength. Other athletes do.
I think when many of us follow a conjugate template we're frying the nervous system. Jason pointed this out to me a few weeks ago. As much as I wanted to argue, he was right. In our periodization scheme, it's not unusual for us to do five to six CNS intensive exercises in a week between squatting, Olympic lifting, plyometrics, and speed work.
We really need to look at the amount of CNS intensive work we're doing and try to balance it. From a frequency standpoint, I'm going to move from a situation where I work each strength pattern twice a week to once a week.
Jason also had some great points about upper body versus lower body. My previous feeling was that upper body might benefit from less frequency more than lower body. The thing I wasn't accounting for was the cumulative CNS fatigue of all the non-strength lower body work we do.
T-Nation: It seems that for more and more strength trainers, elbow extension exercises such as skull crushers are being replaced with heavier compound movements such as board presses, floor presses, etc. But are we saving the elbows at the expense of the shoulders?
Hartman: Considering the fact that I'll use limited range pressing to spare the shoulders, I'd have to provide a conditional no.
The limited range can reduce the demands on the rotator cuff to stabilize the shoulder, so it canhave a sparing effect. However, in the cases of extreme loading, if the loads used exceed your ability to effectively stabilize the shoulder joint, then you're talking about potential wear 'n tear.
T-Nation: Eric, are we saving the elbows but jacking up our shoulders?
Cressey: I think so. As I mentioned in my 13 Tips for Mighty Elbows and Wrists article, it's likely a matter of the muscles crossing a joint becoming too strong for the joint itself. This is even more readily apparent in guys with smaller joints. I'd much rather have the load distributed among the scapulae, shoulders, elbows, and wrists than just place it right on the elbows.
Boyle: I don't think this is the case. Historically, most good lifters have favored multi-joint assistance work over single-joint assistance. I wouldn't say this was true in every case, though. I don't remember reading about too many great bench pressers who were big single-joint assistance guys. Most recommend exercises like close-grip bench press or dips to improve the bench press.
I think most shoulder problems relate more strongly to the volume and intensity of pushing versus pulling than to an elbow-oriented assistance strategy versus a shoulder-oriented assistance strategy.
T-Nation: Next topic: knees. Anterior knee pain is a common finding in running, jumping, and strength athletes. What deficits do you find and how do you typically address the training and progression of an athlete/lifter with such a problem?
Cressey: Most commonly, we see poor ankle and hip mobility; poor glute medius and maximus function; and loads of soft tissue restrictions in the hip flexors, quads, calves, and peroneals.
Soft-tissue work like ART (Active Release Techniques), foam rolling, massage, and Graston are a good start for the soft tissue work, and you complement them with mobility training for the ankles and hips and activation work for the glutes. We've had a ton of great feedback on our Magnificent Mobility DVD from people who've dealt with chronic anterior knee pain.
Lastly, it's important to make sure that work in the gym is done correctly, not just differently. People shouldn't be breaking with the knees first when they squat, and the knees shouldn't cave inward when they lunge. The hips need to come through completely to fire the glutes at lockout on deadlifts, squats, pull-throughs, etc.
Boyle: I think there are a number of keys. Stability at the hip and mobility at the ankle are both important. Many athletes with anterior knee pain have difficulty controlling adduction and internal rotation at the hip and also have decreased mobility at the ankle.
Very often the knee is just the hinge caught between a bad joint above and a bad joint below. I think single-leg exercises where the athlete or client is on one foot is the key to developing hip control. We refer to these exercises as "single-leg, unsupported" as the free foot isn't in contact with the ground.
In other words, for anterior knee pain I'd prefer a one-leg squat to any split squat variations. With anterior knee pain clients, I break my full ROM rule in favor of pain-free ROM. I've coined the term Progressive Range of Motion Exercise in this case. Instead of trying to increase load, we try to increase pain-free, controllable ROM.
Robertson: Here you go, getting me started on knees again! I'll do my best to keep it brief:
1. No glutes. Most trainees that have anterior knee pain have terrible glute function. This includes both the glute max and glute medius. Basically, these portions of the glutes are responsible for all three planes of movement. When they shut off, we're left with poor hip extension, poor external rotation, and poor hip abduction.
2. Terrible mobility at the hips and ankles. The knee is largely "slave" to what's going on at the hips and ankles. If you have terrible mobility in these areas, you're probably going to have knee pain at some point. Eric and I covered a ton of hip mobility drills in our Magnificent Mobility DVD, and I covered some ankle mobility drills in my 18 Tips for Bulletproof Knees article.
3. The progression depends on the lifter, but I'll typically start off with a ton of glute activation and single-leg work to improve the recruitment patterns, then progress from there. This is what I've found to work well:
Single-Leg Work -> Posterior Chain Dominant Bilateral -> Knee Dominant Bilateral
Hartman: There was actually a prospective study in 2000 that looked at over 280 male and female athletes over a two year period. The most significant findings in those that developed anterior knee pain was short quadriceps, decreased explosive strength (measured by vertical jump), shortened reflexive response time for the vastus medialis, and a hypermobile patella.
Short calves were also a significant finding, but it was felt it wasn't a primary contributor. Based on experience, I'd definitely agree with the short quads and calves finding in most cases. Other range of motion deficits you'll typically find is a loss of hip internal rotation and hip weakness.
In addition to ART, addressing the range of motion, and isolated strength deficits, I've been using a five-day-per-week double-leg squat progression that uses a progressive increase in range of motion and increasing eccentric speeds based on patient/athlete tolerance. The final stages are done with a single-leg squat progressing to a single-leg drop squat.
T-Nation: Okay, okay, enough of this running crap. I understand that some coaches have more than a few problems with the box squat. One argument I've heard is: "How do you justify placing the spinal column between two immoveable objects?" Thoughts?
Boyle: I don't do box squats for this exact reason. No one would place their hand between a piece of wood and hundreds of pounds of iron; why would they place their spine in such a position? It makes no sense to me with the massive amount of back pain in this country that people still do stuff like this.
Robertson: This is a tough call. As with all exercises, try to minimize the risks involved. Obviously staying tight, keeping the core braced, and barely touching on the box are all musts when we talk about box squatting. Good cues and coaching are an absolute necessity.
However, the box squat is the most viable option in a team setting, especially when the coach-to-athlete ratio isn't great. For example, I have twenty kids who come in for basketball. When I let them free squat last year, it just wasn't pretty for all the usual reasons: too much weight, terrible depth, etc.
So this year I vowed to only use the box squat, and I've seen great results. The technique is 200% better, depth is constantly reinforced, and I can teach virtually anykid to squat in two minutes or less. Trust me, I have some kids who just aren't all that athletic and even they can learn to box squat in no time.
T-Nation: What do you think, Eric?
Cressey: Last time I checked, the floor is just as immovable an object as the box, so if you really think about it, the only difference is the point at which the compressive forces are applied.
I actually had this discussion with Stuart McGill. Most important to this discussion is the fact that that our spine handles compressive forces very well. Where we get into trouble is with shearing forces – what happens when guys rock on the box and allow lumbar flexion to occur. 12,000 to 15,000N of compressive forces are tolerable, yet you'll injure the spine at 1,800 to 2,800N in shear.
Lumbar flexion can occur with any kind of squatting if your flexibility is poor. The box is a great teaching tool, especially if it keeps guys with terrible flexibility out of dangerous range of motion. The recruitment of the large erector spinae group to maintain the arch helps to buttress against shearing forces, too.
So, once again, it's a matter not of what you do, but how you do it. Any exercise can injure you if you perform it incorrectly.
If you want to really scrutinize any classic powerlifting movement, you'd be better off going after hyperextensions and full ROM reverse hypers. The former involves too much range of motion in an area that needs stability (high spine power correlates with back pain, while high hip power with high spine endurance correlates with health and performance).
The latter involves tons of shear stress – and in a manner that isn't particularly well buttressed (lower body shearing forward on the upper body means that the discs often have to take the burden).
Hartman: I wonder how many lifters would quit using the box squat if Louie Simmons came out and said, "Ya know fellas, I was completely wrong about that whole box squat thing."
I'll frequently use the box as a teaching tool and to limit range of motion, but I'd rarely, if ever, use it much like a powerlifter would with a loaded pause on the box. I sure as hell wouldn't use that type of box squat with a young trainee just learning, as there's too much risk in losing technique and exposing the spine for injury.
T-Nation: Oh boy, I just heard a can of worms being opened! Let's open up another, shall we? The Olympic lifts: Are they valuable power exercises for the majority of trainees? How long does it truly take to get proficient enough at these lifts to actually make gains?
Boyle: I think in a performance setting, Olympic lifts are extremely valuable, possibly invaluable. So I guess my question is, "Who are the majority of your trainees?" If your clientele are athletes, take the time to teach them to Olympic lift. If they're not, don't bother.
I think it takes six to twelve weeks to become proficient enough so the lifts are more beneficial than dangerous. I often envision that I'll train an athlete for years, so I'm willing to invest the time to teach Olympic lifts. I think it depends on the amount of contact time you anticipate.
Robertson: Although I don't use my USA Weightlifting certification all that much, I love the Olympic lifts because of their balance of speed, strength, and athleticism. Watch a great Olympic lifter like Pyrras Dimas or Pocket Hercules and you gain a new respect for their balanced physical development.
However, for the majority of trainees, I don't like using them. Why? First off, they're difficult to teach and it does take a while for someone to get proficient at them. Even if someone only learns the lifts from the hang position, it can be very tough to teach someone who's not athletic to learn to be explosive with a barbell in their hands.
Next, most lifters don't have the mobility that a good Olympic lifter does. Olympic lifters have amazing mobility throughout the body, but especially in the right places (ankles, hips, and T-spine).
Finally, great Olympic lifters are great not just due to their training, but genetics play a small role, too!
In my opinion, you can get a great carryover from various medicine ball, bodyweight, and dumbbell variations, with much less coaching and "teaching" time. I'd love to have four years to teach all my kids how to Olympic lift, but that's just not feasible in my current situation.
Hartman: As much as I like them, I can't remember the last time I taught the full weightlifting movements. I do use pulls occasionally. I just don't think they're essential in developing an athlete. As far as your typical athlete is concerned, you can develop all the necessary qualities with other forms of jumps, throws, and reactive squats.
I've heard the arguments about the value of the Olympic lifts for training triple extension, but I don't think many athletes ever get there. (By the way, Dimas didn't get there either.) Just watch videos of your athletes if you don't believe me. On the other hand, try a standing long jump without triple extension.
If you do choose to do them, learn from a qualified coach. If you wish to preserve your shoulders, starting from the hang may give you a better opportunity to set your shoulder girdle. And always drop your weights from the shoulder or overhead. Catching the barbell on the way down wreaks havoc on your AC joint.
Cressey: Let me preface my response by saying that I love watching Olympic lifting; it's a great sport. In fact, it's such a great sport that we have an Olympic lifting team at our facility. They practice Olympic lifts three to four times per week to get proficient in their chosen sport, as it takes time to get really technically proficient and move impressive weights. Can you see where I'm going with this?
Everyone likes to cite the research on Olympic lifts being superior exercises in terms of power output, but nobody ever seems to mention that these tests were done on trained lifters – and it takes quite a bit of time and regular practice to become a proficient Olympic lifter that generates that much power.
On the other hand, I can teach various jump training exercises (e.g., countermovement jumps, bounce drop jumps, jump squats) in ten seconds and a box squat and speed deadlift over the course of a few sessions. Which is a more efficient means to an end, especially when I might only have an athlete for two months, or sporadically throughout the year due to the competitive season?
As Bill said, this doesn't even take into account the wrist and AC joint problems lifters often encounter with cleans, and it obviously doesn't bring to light all those who can't snatch (and sometimes clean) because they don't tolerate overhead work well.
Lastly, I've seen quite a few people with anterior hip pain and hyperextension-based lumbar spine problems because they rush the second pull and never complete hip extension before turning the bar over. This isn't a problem with the aforementioned exercises, as complete hip extension occurs at lockout.
Like I said, Olympic lifts are great exercises, and that's why they deserve to be a sport of their own.
T-Nation: Well, you guys certainly gave us a lot to think about! Thanks for taking the time to sit down with us.