The Injury Prevention Roundtable

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.