Question about the Form/Injury relationship

Pain & Rehab Forum [Moderated]
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Doctors,

I’ve been binging on your articles, forum comments, podcasts, and (a bit) on the research you’ve cited, as far as cause of injury is concerned.

Very simply put; poor load management is correlated with injury (plenty of evidence). What “bad” form is, seems impossible to define (where do we draw the line between “good” and “bad” form with respect to, for instance, spinal flexion? Does that line move depending on the individual in question? Etc), and therefore how it (“bad” form) correlates with injury, seems equally impossible to determine. Anecdotal evidence, however, of what is colloquially considered “bad” form, suggests that there’s no correlation, as a lot of people who lift with “bad” form are totally fine, while others who obsess over “perfect” form are hurting/“injured” constantly.

I’m completely on board. But I’m wondering about this:

Surely, form is A factor in how much load gets applied to a particular region of the body, just like the exercise in question, and the weight, and so on, are factors in that? I mean, moving one way loads body region X more/less than moving another way does.

I understand that blaming “bad” form is missing the underlying stuff – no type of movement (obviously ignoring the super extreme stuff) is bad IN ITSELF. A certain variation of a deadlift (let’s say rounded back) isn’t bad IN ITSELF. That deadlift with a certain weight, for a specific individual, may just mean too great a load on some part of their body, such that they sustain an injury.

So the root cause is still (or seems to be) load, and not form, since that individual might’ve been fine doing it with a wooden stick.

… But, that individual might’ve been fine deadlifting the same weight that injured them, with a different (in this case, I guess “better”) form, right? Since the load on the injured region would’ve been different.

So, isn’t form still a matter of >0 relevance as it pertains to injury risk reduction (NOT prevention)? I know that You do attempt to hammer in proper technique with clients; is it ONLY about efficiency, or do you also do it in order to reduce the risk of injury?

It just seems as if, since load is a factor in injury risk, that form is still a relevant part of the topic (of injury).

Of course there’s no one-size-fits-all form (Pavlova)… again, I get what you are trying to communicate with respect to this subject. But still, for instance, if a client perceives a lot of internal load in body region X from deadlifting with a particular form, isn’t asking them to “try keep your back like this” a logical next step to see if the subjective internal load decreases IE “form check for injury risk reduction”?

Maybe you’re adamant about the proper angle of approach being “load” instead of “form” because it’s just a much more precise view of reality, or maybe I’m missing something that makes my question nonsensical?

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This has been discussed a bunch around here, so I’d start here:

https://forum.barbellmedicine.com/forums/pain-and-rehab-q-a-with-dr-derek-miles-and-dr-michael-ray/25530-influence-of-exercise-technique-on-risk-of-injury

https://forum.barbellmedicine.com/forums/unmoderated-forums/pain-science-rehab-discussion-forum/22785-strength-training-and-injury-risk-reduction

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This has been discussed a bunch around here, so I’d start here:

https://forum.barbellmedicine.com/fo…risk-of-injury

https://forum.barbellmedicine.com/fo…risk-reduction

Thanks for the reply,

I have read those, and many more. And I’m in agreement with it all (not that I have a choice, the evidence is what it is).

But the question/point I’m making is that if we begin with the premise that poor load management is, to a large degree, responsible for injury, doesn’t technique still kind of play a part?

I mean, the way in which one moves, determines which body region/structure is loaded and how much. As Matthew Rupiper PT said:

“For a moment, throw out the idea of good form vs. bad form. Put in its place the term “load.” With resistance training, running, cycling, you name it, the technique used simply applies “loads” differently.
A back squat with low bar, flexed trunk and restricted anterior knee migration will “load” the lumbopelvic-hip region. A front squat with upright trunk will load the knee more. A conventional deadlift will “load” the lumbar erectors more than a hex bar deadlift. So what people sometimes call “bad technique” is merely placing more loads on a body region or structure.”

I gave the example in the op of someone maybe being able to deadlift a wooden stick with one form, and be fine, but if they attempted a larger weight with that same “form”, they’d experience an internal load in some body region, maybe a 10/10 RPE or something, and consequently get injured, WHILE perhaps being able to deadlift that same weight that injured them, but with different form, and hence experience less internal load, and not get injured.

You said that “The point here is that movement, in general, is safe. Load matters to the extent you have / have not been prepared for it.”, and I understand that!

The deadlift technique in my example wasn’t itself the issue, the load was (one weight->injury, other weight->no injury, same form). However, if someone experienced a very heavy load somewhere when doing a lift with a certain form, wouldn’t the natural thing to do be to try to “correct” their technique, so that they could lift that same weight without the substantial subjective internal load? I know that you deem technique important as a matter of efficiency, but doesn’t it also present a range of possibilities to reduce load and therefore injury risk? IE “correcting technique for the purposes of reducing injury risk”… now of course, if the individual has assumed the most comfortable lifting form for their body, then no… but if not?

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We are trying to get away from dichotomizing normal human movements into “good” and “bad”, but rather into those that one is adapted to versus those that are novel, which then translates into their respective tolerance for loading. Exposing yourself to novel situations/stimuli you are poorly prepared for likely results in some non-zero increase in the risk of pain and/or injury (which, it could be argued, is part of life) – but that doesn’t mean that a novel movement where you experience pain is an inherently “bad” movement to be avoided. Such unnecessary dichotomies increase the general perception of threat around movement (and particularly resistance exercise) and reinforce avoidance behaviors, which all have well-established implications for the experience of pain.

This ties into our efforts to combat movement perfectionism, biomechanical reductionism, and the obsession with minimalism/simplicity in the context of training. Viewing the body as a rigid machine and training 1) to only perform a select few movements under high loads with poor fatigue management, 2) in the context of perfectionist tendencies, 3) while trying to minimize any and all movement variation, is a recipe for poor load management and acute injury or chronic overuse issues – and this is not to mention the implications of early vs. delayed specialization for long-term adaptation and performance outcomes. Many of these are things we have had to change our minds about over time as we learned more, and they’re also issues that our coaching and rehab teams deal with every day.

I would also recommend challenging some of your biases about movement with the movement variability literature as well, for example starting here: Is movement variability important for sports biomechanists? - PubMed

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Both load and technique will always play a role. The way I typically frame this is it is not a matter of “are you strong enough” but rather “are you strong enough to do what you are trying to do.” The second part of that sentence alludes to your example of the wooden stick. The overall demand for lifting the stick is relatively low so the amount of variability with which the task can be accomplished can be relatively high. I can stand on one leg and bend over, twist from hips, etc, likely with little consequence. As the overall demand of the task increases, the tolerance for variability decreases, but this is still not to say that technique is paramount. I would actually argue the opposite in some cases that having some variability built into the system would make it more resilient. If an individual is more susceptible to injury when their form is not absolutely “perfect” (however we may deem that), that is an individual who likely is going to struggle to progress with weight.

There aren’t absolutes with any of this and yes, technique does matter. It is more likely the technique from which the individual has adapted more than the societal ideal of what is “perfect” technique. I don’t think anyone at BBM would say that technique does not matter as if you look there are extended videos and resources on technique. Just as the statement above is “are you strong enough to do what you are trying to do,” it can also be said “technique doesn’t matter as much as most people would think that it does.” The second part of the sentence in both instances is the imperative part. If we look at other sports, there is a high variability in running form over the course of a race, not every cut in basketball is perfect, no one expects every tackle in football to resemble form tackling drills. That doesn’t mean runners do not benefit from technique work or form tackling drills should not be a part of practice design. It means we all absolutely should work on technique and strive for form to be more towards an ideal, but not at the expense of that being the limiting step for progress.

In the beginning stages of learning a novel task, technique is always more highly variable. This is part of the learning curve, and over time things become more dialed in. The issue is the expectation set forth that if technique is perfect, something bad is going to happen. It is more important to see technique as part of the process instead of the rate limiting step. We’re all going to have bad reps from time to time, and that is okay.

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I often Wondered why Major League Baseball teams tried to change a pitcher’s mechanics when they grew up throwing a certain way, developed that way, and had the movement pattern adapted to. It always seems as soon as they “corrected the mechanics” to take stress off of the (insert body part here), that the pitcher blew out his elbow/shoulder…and now that makes sense as the body was not ready for the load with the new movement pattern. It’s interesting that now in MLB you see greater variety in pitching than 15 years ago…but makes one wonder how many careers were shortened chasing “proper pitching mechanics”.

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This is an excellent discussion. I agree with Derek and Austin and will only add a few points here:

  1. January Monthly Review theme is this topic.
  2. Much of this conversation around technique is contextually related to injury which often is hinged to the pain experience (doesn’t have to be but tends to be the case) and thus wanting to avoid a negative outcome.
  3. When it comes to pain and learning we can think at a macro level (society) down to a micro level (individual experience) said differently, it would appear we can narrow frame this discussion to two ways of learning about pain: 1) indirect learning (language and observation) and 2) direct learning (personal engagement resulting in pain experience - we know flaws with this discussion such as pain doesn’t always and in every situation equal tissue damage equals protect/avoid).
  4. Our narratives around pain and technique/movement/activity typically are based on linear propositions of cause and effect or “if-then” statements, for example: “Don’t lift that way or else…”, ‘If you are not careful with your back, you will end up in a wheelchair", to directives such as “Lift with you Legs not your back” based on a better safe than sorry approach. Paradoxically it would appear these narratives lead to the idea that we can’t trust our backs and need to protect them which likely has led to us to altering how we move and engage with our environment (more on this next month). These by definition are verbal rules being outlined to minimize what is often viewed as a negative consequence of living (pain). Unfortunately as Austin discussed above, this automatically paints the discussion in black and white terms, good vs bad, injurious vs non-injurious, right vs wrong. Now rules may have applicability in life. For example, Erica and I recently had baby Lucy and we may preemptively warn her about playing with fire as it may lead to a burn (tissue damage) that may lead to a painful experience unnecessarily. This rule has usage as it informs her and provides indirect learning without a potentially negative experience.

However, these rules can be unnecessary in the context of movement and pain, as well as self-limiting, and even potentially perpetuating of a pain experience:
According to Vlaeyen 2019,

“Rules allow one to behave without having to directly experience the contingencies. Nevertheless, rules can have negative effects when they are erroneous (e.g., ‘If you are not careful with your back, you will end up in a wheelchair’). Following rules may also make individuals less sensitive to actual changes in contexts or contingencies, a phenomenon called the “rule-based insensitivity effect.”

In other words, erroneous rules can have negative effects on beliefs and learned behavioral responses.

Beeckman 2019 states, “Research suggests that rigidly relying on verbal information may play a central role in several types of psychopathology and may underpin impaired functioning in people with chronic pain as well. Indeed, when people persist in doing things based on beliefs about the right thing to do or how it should be, this pattern of thinking often has unwanted consequences (eg, see the literature on substance abuse, self-harm, delusions, or depression."

I will expand on this topic more in January BMR but this is one aspect of our counter argument to the dichotomy being created around movement and pain.

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Thank you, @Austin_Baraki ,

emphasis mine

I completely understand. As I previously said:

“I understand that blaming “bad” form is missing the underlying stuff – no type of movement (obviously ignoring the super extreme stuff) is bad IN ITSELF. A certain variation of a deadlift (let’s say rounded back) isn’t bad IN ITSELF. That deadlift with a certain weight, for a specific individual, may just mean too great a load on some part of their body, such that they sustain an injury.”

Thank you, @Derek_Miles ! This is essentially the entire point upon which my question is built.

Thank you, @Michael_Ray !

I totally get the idea that You are all communicating. The dichotomy of “good” and “bad” movements, is false. No movement is bad IN ITSELF. Derek can stand on one leg, twist from the hips, pick up a light stick, and be fine. The movement isn’t “bad”. ### IT’S JUST A MOVEMENT … a movement that may have a high injury risk for Derek, however, were he to do it to pick up a 500lb bar, whereas the injury risk from him picking up a 500lb bar with both feet on the ground, would be considerably lower.

With that said, I was merely curious as to whether there is any place for “correcting”(changing/tweaking) technique with the purpose of reducing injury risk. Like, if a client lifts a weight with a specific technique, and they can feel a high internal load in body region X, isn’t it reasonable to tell them to “try this instead”, to see if the subjective load decreases, and with it the injury risk? I understand the intention in being extremely careful with how those technique recommendations are framed, as to not perpetuate the false “good form”/“bad form”- dichotomy, fear of movement, and so on. And I understand that efficiency is dependent on technique, which is a definitive reason to endorse various technical aspects of a lift, anyway.

Yes, a movement is just a movement. But it seems like form is still relevant wrt injury risk, IN THE WAY that I described. I’m just not sure if I’ve missed something here.

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I view these as two fundamentally different movements rather than as a case for technique. Derek is prepared for a deadlift with both feet on the ground via training; it is also perfectly possible to train a single-leg deadlift as well.

This is entirely up to a coach’s judgment on a case-by-case basis, IMO. We are always balancing risks and benefits, and we want to find ways to help people break down individual barriers in order to train productively and sustainably for the rest of their lives.

However, we may have situations like this: https://forum.barbellmedicine.com/fo…apular-winging where someone is unnecessarily hypervigilant to a particular body region, and feeding into that is unlikely to help.

Similarly, we deal with people all the time who avoid movements like high bar or front squats because they perceive this sort of “internal load” that you describe on the knees … seemingly without putting together that this very stress is what’s needed for adaptation. They may also incorrectly interpret such sensations as evidence of impending injury risk due to things they’ve been told / beliefs about the movements in question. An example can be seen in this thread: https://forum.barbellmedicine.com/fo…press-template , where reassurance was provided, but ultimately a form of compromise was offered in order to keep the person training.

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Absolutely. I was hyperbolizing :slight_smile:

Similarly, we deal with people all the time who avoid movements like high bar or front squats because they perceive this sort of “internal load” that you describe on the knees … seemingly without putting together that this very stress is what’s needed for adaptation.

I borrowed that term from You guys, after listening to podcast #39. I thought I had it right lol. Yes, of course it has to be felt, I was thinking more along the lines of a very high vs a much lower subjective load when “fixing” technique on a lift, with the same weight. Dr Ray seemed adamant about the subjective load being very significant, as it’s the easiest thing to “measure”, outside of weights, obviously.

I think I get your stance on this matter. I wasn’t looking to challenge anything, not that I could - I don’t s*** about this stuff. It just seemed logically inevitable that there’d be a technical factor in injury risk reduction… although not in the folk wisdom sense (mobility work + stretching + perfect technique + blabla). It feels like it’s hit home.

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I understood, we just don’t usually apply the term “internal load” to specific body parts.

No sweat. I am open to being challenged.

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Duly noted.

No sweat. I am open to being challenged.

Oh, I’m not challenging that… were you not, you’d still be calling SStrength general. Just meant that I have no agenda, I’m just seeking some truth, trying to get some expert input to my questions :slight_smile:

Thank you for your help!

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My thoughts are that you can choose. If you want to change load/loading and keep form the same then do so. If you want to move differently and progress loading with this different form then do so. Load can definitely be applied more or less to different areas with different technique. Just don’t describe one way as being “correct”, “better”, and the other way as being “wrong”, “dangerous,” “bad”.

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Piggybacking/hijacking this discussion slightly, is there any additional nuance to these ideas when the external load is not controllable? I’m working in construction right now as a laborer and don’t really have control over what I get asked to lift, how many times or where to put it. As such, would I gain risk reduction by my attempting to be as efficient as possible to reduce the internal load experienced from these situations or by thinking about it am I potentially noceboing myself and actually increasing risk?

Additionally, since strength is specific, does working in this way mean that doing more strong man style work that involves moving odd objects in more irregular patterns would have a better carry-over and therefore potentially more injury risk reduction? For example, lifting sandbags seems more specific to lifting bags of concrete than lifting a barbell does.