The Often Injured Lifter
Whether I like it or not, around these parts I've become known as an "injury guy." People get jacked up doing stupid stuff, and guys like Mike Robertson, Bill Hartman, and myself fix them up by pointing out that said "stuff" is, in fact, stupid.
To that end, a lot of my consulting work is done in the corrective exercise realm — basically handling people who fall into the gray area between physical therapy and healthy training... bridging the gap, so to speak. We know that 80% of Americans will have lower back pain at some point in their lives, and 70% of gym-goers will experience shoulder problems somewhere along the line, but we can't send all of these people to physical therapy.
What do we do with them?
Many times, the people who ask this question are also the ones who question how I can possibly help people with their injuries via online mediums. The truth is that it isn't rocket science or really anything more complex than basic algebra if you understand functional anatomy.
A Real World Example
Rather than get really geeky on you with a textbook outline of what I do, I figured it would be best to highlight a representative example from an online consulting client of mine who was about as jacked up as they come. We'll call him Ben Hurtin.
Here was Ben's self-report in my initial questionnaire:
"In September 2006, I sought the help of another very well known strength trainer. I basically gave him the same info I've given you, however, I was very disappointed in his program. I'm excited about the program you'll be developing for me; you definitely have your work cut out for you.
"My shoulders have hurt on and off for seven years. Now the left shoulder and rear delt area bothers me when pressing. The left front delt hurts when I do heavy close-grip presses. My shoulder pain typically moves from one shoulder to another; however, my left shoulder has hurt consistently for the last two months or so. My left shoulder clicks and grinds occasionally, with no pain.
"My hips have hurt for two years when doing squats, left one at first, now both. Pain subsides after a few sets, but I hurt for three to four days after squat sessions. Lower back has hurt for around two years as well. Hurt it doing deadlifts about a year ago. Squats hurt my lower back until I started stretching.
"My elbows hurt most of the time. I can't do skull crushers at all. Hammer curls and reverse curls hurt my elbow area as well, so I don't do any forearm work. The back side of my entire arm, from wrist to elbow, hurts when I do heavy barbell curls. I haven't done any curls in almost a year. My knees feel great until I try to do interval training on the treadmill.
"I've had cortisone shots in both shoulders, both hips, right elbow, and lower back. None in the last year. I stretch my lower back daily and use a foam roller for my hips daily as well. I do use DMSO on my shoulders and elbows. I felt DMSO was pretty effective. I haven't used any in the last three weeks, however. I haven't benched or done military press in almost a month to give my shoulder a break.
"Problematic exercises: bench press, close-grip press, military press, squats, pull-ups with an overhand grip, skull crushers, hammer curls, reverse curls."
When I asked Ben for his last four weeks of training, here was the response I received:
"I train from 9AM to 10:30AM, Monday through Friday.
Monday: Chest, triceps
Flat bench press, 5 sets of as many reps I could do — typically 3 to 6 reps
Close-grip bench — 4 sets — 10, 8, 6, 5
Triceps pressdowns — 4 sets — 10, 8, 6, 5
Reverse pec dec — 4 sets overhand grip — 12, 10, 9, 8
Reverse pec dec — 4 sets underhand grip — 12, 10, 9, 8
Walk on treadmill or interval training on treadmill — 20 to 30 minutes
Tuesday: Back
Pull-ups — neutral grip — 8 sets of 5 with 50lbs to 70lbs attached
Chest supported T-bar row — 3 sets — 8, 6, 5, 4 (just recently started this one)
Seated cable rows — 3 sets — 8, 6, 5, 4
One-arm cable rows — 3 sets — 8, 6, 5, 4
One-arm dumbbell rows — 2 sets — 6, 5
Walk on treadmill or interval
Wednesday: Shoulders
Seated dumbbell press — military — 5 sets — 10, 9, 8, 7, 6
Seated barbell press — military — 3 sets 6, 5, 4
Seated lateral raises — 4 sets — 7, 6, 5, 4
Seated rear delt raises — 4 sets — 7, 6, 5, 4
Standing cable lateral raises — 3 sets — 7, 6, 6
Standing cable rear delt raises — 3 sets — 7, 6, 6
Barbell shrugs — 5 sets — 15, 12, 10, 9, 8
Walk on treadmill
Thursday: Legs, back
Squats — 5 sets — 8, 7, 6, 5, 4
Squat machine — 4 sets — 6, 5, 4, 3
Leg curls — 4 sets — 10, 9, 8, 8
Standing cable hamstring curls — 3 sets — 10, 9, 8
Pull-ups — 3 sets 10 reps
Seated cable rows — 3 sets 8 to 10 reps
One-arm cable rows — 3 sets 8 to 10 reps
Walk on treadmill
Friday: Chest, triceps, shoulders
Incline dumbbell press — 5 sets — 10, 9, 8, 7, 6
Close-grip bench — 4 sets — 6, 5, 4, 3
Triceps pushdowns — 4 sets — 7, 6, 6, 6
Seated lateral raises — 3 sets — 8, 7, 6
Seated rear delt — 3 sets — 8, 7, 6
Cable lateral raises — 3 sets — 9, 8, 7
Cable rear delt — 3 sets — 9, 8, 7
Walk on treadmill or interval
I try to do abs several days a week at home. I use the ab scissor. I try to do rotator cuff exercises three times a week at home. I've done these for several months. I've stopped these at this point because I don't know if they're helping or hurting."
Ben also took the following supplements:
Multivitamin, B-complex, Ester C, fish oil, Vitamin E, Beta Carotene, NAC, ALA, R-ALA, ZMA, Chromium Picolinate, Acetyl-L Carnitine, Glucosamine & Chondroitin, D-Ribose, Taurine, Creatine, Glutamine, Orotic Acid, Citrulline Malate, Beta Alanine, BCAA's , and protein powder.
Quite a hefty supplement bill for a guy who's so banged up that he can hardly train!
The first thing you'll notice is that Ben never actually discussed a pathology. It's not like he knows he has a torn labrum or herniated disc. Pretty much all the pain comes about when he lifts, meaning that it's largely self-imposed and self-aggravated.
Most doctors will simply tell Ben that if an exercise gives him pain, he shouldn't do it (incidentally, this is also the extent of the wisdom of the "hamster wheel supervisors" at Curves). I agree that he shouldn't be in pain, but just avoiding the problem isn't going to fix anything. Ben needs to eliminate the cause of the problem and work to correct it. Mr. Hurtin is a classic "gray area" guy.
Program Dissection
Let's dissect our banged-up weekend warrior's program in greater detail.
1. When I asked Ben for his program, all he sent me was a list of resistance training exercises, sets, and reps. This is a good start, obviously, but where's the dynamic flexibility warm-up? When is he doing soft-tissue work in the form of foam rolling and lacrosse ball?
Lifting is a large piece of the puzzle, but certainly not the entire puzzle. Ben needs to realize that in order to move big weights he's going to have to attend to the length and quality of his tissues — even if that isn't as sexy as an extra four sets of bench presses.
2. There's absolutely no structural balance in this program. Here are the glaring weaknesses I see on this front:
• Far more shoulder internal rotation than external rotation
• Far more scapular elevation than depression exercises
• No single-leg exercises
• No hip dominant exercises
Just incorporating some lunge variations, deadlifts, external rotations, and rows done correctlywould go a long way in fixing his problems.
3. In my humble but hopelessly blatant opinion, leg curls are crap from a functional anatomy perspective; the hamstrings never work independently of the glutes. To quote my good friend and colleague Carl Valle, "You can't have Popeye hamstrings and an Olive Oyl ass."
4. Interval training is just randomly thrown in there whenever Ben feels like it. Believe it or not, fluctuation of training stress is more important than you might think when it comes to fixing imbalances. If your whole system is beaten up all the time — so much that it can't even recover from acute stress — how can you expect it to fix chronic problems at the same time? Ben never mentioned how he deloads.
Note: For those interested in how to better integrate interval sessions, check out this article.
5. There's a ton of overlap in this program. Does Ben really need to do both dumbbell and barbell military presses? And, with his history of shoulder problems, does Ben need to be doing military presses at all? Hell, does he even need a full "shoulder day" on Wednesday when he's already pressing twice a week?
6. The program makes no mention of it, but it's fair to assume that it isn't just a function of what Ben is doing, but howhe's doing it. There are very few exercises that are genuinely bad, but there are an infinite number of exercises that can be made dangerous with incorrect technique.
I outlined some common bench press blunders in Shoulder Savers: Part I. The response to these simple videos was so good that Mike Robertson and I decided to devote two DVDs of our Building the Efficient Athlete set purely to detailed troubleshooting technique on over thirty common resistance training exercises.
7. Ben is doing plenty of bench presses, but no push-ups. Don't get me wrong, as I love the bench press. It's just that you need to complement open-chain upper body work (e.g. benches) with closed-chain upper body work (e.g. push-ups).
In the former scenario, the scapulae are fixed, and in the latter, the scapulae are free to move. Even just working some push-up variations in during the warm-up period or on off-days can dramatically improve shoulder health.
8. Ben is doing five exercises on machines in this program. As far as I'm concerned, when you're banged up, this number should be zero. Incidentally, it should also be zero when you're healthy, drunk, incarcerated, pregnant, or in a vegetative state after being kicked in the head by a mule.
9. Ben has a training age of seven years, yet he's lifting with the volume that would typify a program from a newbie who just picked up his first muscle magazine. The longer you've trained, the less you can do; it's just that simple. Advanced lifters recruit more muscle fibers than novice and untrained lifters, so every rep "counts" more toward accumulated fatigue and the overall training effect.
10. The idea of training five days "on" and two days "off" is just plain silly, in my opinion. I prefer a Monday, Tuesday, Thursday, Saturday set-up whenever possible, with a Monday, Tuesday, Thursday, Friday approach in second place. Very few people can get away with five days of lifting per week, and even fewer can do them consecutively.
As I mentioned, this is just the tip of the iceberg. And I'm sure you're thinking, "One specific programming example isn't necessarily applicable to what I'm doing." I agree completely, and that's why I've compiled this ten-point list of how to approach corrective exercise while still maintaining a solid training effect.
The Rules
Rule #1: Fit the program to the lifter, not vice versa. The best way to correct dysfunction is to prevent it. If you're blindly following cookie-cutter programs, stop.
Rule #2: Learn to program for yourself. Establish a small group of people who will give you honest feedback on your programming ideas, and then use your intuition when it comes to modifying things on the fly.
If you're strapped for time, pay someone else to write your programs and provide them with a ton of information about you.
Rule #3: Some exercises just aren't worth it. Don't bother with them; there are better options available to you.
Rule #4: You can never have too much information. Ask a lot of questions and consider every angle — and know when to refer out to a professional more qualified than you to handle the problem in question.
Rule #5: Think "correct" before you think "different." If an exercise causes pain, stop performing it. Evaluate technique before moving on, though. If performing the exercise correctly alleviates pain, keep it. Chances are that correctly performing the exercise will actually help correct the imbalance. An athlete will be more receptive to "do it this way instead" than he will to "don't do this."
Rule #6: Make the athlete feel like an athlete — not a patient — both physically and psychologically. Tell them what they can do.
Rule #7: Before you go changing what's going on in the gym, figure out what you can do to improve what's going on outside of it. Think posture, repetitive motions, sheer lack of movement, sleeping posture, footwear, and even poor diet.
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Awesome vs. Atrocious
Rule #8: Soft-tissue work serves a valuable role in preventing and correcting imbalances, without making any programming modifications. Foam rolling and lacrosse ball work is cheap and effective. Just do it.
Rule #9: Implement mobility and activation work in your warm-up. It only takes 5-10 minutes, which is a lot less time than it takes to recover from an injury. You'll be amazed at what shakes free when you enhance stability through full ranges of motion.
Rule #10: As a last step, modify the training plan — and only on a small-scale, if possible. This is the most "sacred" aspect of an athlete's preparation, so you should butcher it as little as possible. The more you screw with things, the more the athlete is going to feel like a patient.
Closing Thoughts
It might sound like a terrible thing to say, but I hope that you do encounter some sort of musculoskeletal injury or condition at some point in your training career. It'll make you realize how much you appreciate being able to train, and you'll learn a lot about what you were doing wrong in the process.
As hackneyed as the phrase may seem, whatever doesn't kill you makes you stronger.
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