Random Questions about Method

Pain & Rehab Forum [Moderated]
1

Hello sirs,

For starters, I appreciate a lot of what you guys are bringing to the conversation. The field of S&C is a bit of a mixed bag: a lot of the research available isn’t of particularly high quality, due to the nature of studying highly individual, variable populations and not having thoroughly agreed upon intervention protocols for more rigorous studies via RCT and the like. There is decent research available that’s rigorous enough to inject nuance into conversation and to dispel baseless dogma, so I appreciate that being highlighted. That said, I’m also not one to negate the pattern recognition and wisdom/consensus of lifelong coaches, particularly those who are open minded and change their protocols based on emerging research and their own data with large groups of athletes researchers often don’t have access to. All that to say that I’m careful to lean too heavily one way or the other.

What I’m wondering about is the degree to which BBM is swinging the pendulum in regards to conversation about LBP, technique, etc. Watched this podcast recently and had some questions: https://www.youtube.com/watch?v=V43mSQEjZY8

So re: technique has no correlation with injury reduction, it’s simply improper load management. If we take an extreme example: take an athlete who uses solid traditional deadlifting form (posterior chain dominant, minimal lumbar flexion, drives with heels, etc) and then have that athlete lift the same weight at full flexion and drive with their toes and they eventually become “injured” (i.e. feel debilitating pain in their back, sciatic pain down their leg, extreme stiffness for a few days, inability to perform any weight bearing activity for weeks afterward without extreme pain, etc). Doesn’t this constitute an improper load management strategy because they drastically changed which muscle groups and motor pattern dominated the lift? Is that not an extremely roundabout way of saying that good (being a wide range) technique results in more appropriate/consistent/repeatable tissue loading, ergo less likelihood of experiencing pain? If I had to picture this on a scale, we could say that technique neurosis is on the one side, while movement nihilism is on the other. How far is the pendulum toward the nihilism side?

Similarly, if i.e. I squat with most of my weight on my toes and get consistent knee pain that eventually leads to inflammation (swelling at the knee), and technique changes fix these issues, how is technique not correlating with pain/injury at least to some degree? Do we ignore the inherent properties of various tissues and what they are best suited for? Of course this is essential for efficiency, but is the claim that there is no correlation whatsoever between movement efficiency and injury/pain reduction? I have a hard time believing this on an individual level, since it can often be the case that minor tweaks in technique can eliminate pain.

TL;DR: How is avoiding specific tissue overload, leading to pain or injury (a load management issue), for tissues not ideally suited to performance in a given movement, not a technique problem, even if not exclusively a technique problem? I understand this is much more grey and individual than we’ve been led to believe but I want to be sure I’m understanding correctly. Is the claim fundamentally that there is no one technique that’s best for everyone for the purposes of simultaneously optimizing performance and reducing risk of injury, or is it the more extreme claim that technique has no bearing whatsoever on injury and pain?

Secondly, how does this apply to exercise selection? Is the implication that no exercise is potentially more risky than another? For instance, is it not a strange coincidence that numerous veteran strength coaches (such as Mike Boyle and other coaches who work with large groups of sport-specific athletes) found that i.e. eliminating backsquatting in the athlete groups in favour of unilateral squat patterns resulted in a large reduction in back pain and increased performance in their sport-specific athletes (1)? Does this have nothing at all to do with the properties/resilience of the tissues being loaded in each scenario, even on an individual level? Or does it have to do with the fact that it’s much easier to load RFESS and one-leg SLDL to the limit of the leg musculature without getting anywhere near overloading the back (as well as lowering system load and therefore mitigating fatigue)?

Re: Low back pain.
The problem I have with the “2-4 injuries in 1000h of training” idea is that it tells you precisely nothing about the severity of the pain or injury. Having a sore shoulder or upper back after a training session is categorically different from someone with a history of back pain with neuropathy who can’t get out of bed for 3 days following yet another back tweak, especially when said person only experiences said pain during a particular lift. The long term effects of scenario 2 can often be a great deal more debilitating and disruptive in the long run. I do understand how difficult a topic this is, but is the thrust of what you present on this topic more to do with the inherent mechanisms of pain, or what to do about it? I.e. Yes, pain is neurological in nature and not always indicative of tissue damage. But I think I recall Mike (in the podcast) talking about ruling out actual injury before going down the psychological route – is that the approach BBM takes? I assume you don’t ignore the fact that i.e. Olympic lifters have higher rates of symptomatic pars fractures than, say, soccer players? If such an injury is present, is it not prudent to attempt to allow for adequate repair of the actual damage so as to prevent potential future issues? In an adolescent athlete in this scenario that would mean bracing followed by strength training (for example), so as to prevent needless and potentially symptomatic spondylolisthesis in the future (I’m aware of the stats on this topic as well as the incongruence between imaging and symptoms, but it doesn’t change the fact that there is still a link in some scenarios).

Sorry for the rambling! I do have questions about myself but I want to make sure I understand the principles.

(1)https://www.strengthcoach.com/public/Unilateral-Training-and-the-Bilateral-Deficit.cfm

2

To address your tl;dr, you will not find any of us quoted as saying that there is “no bearing whatsoever” on pain or injury risk, because we do not make claims with that level of confidence unless we have strong enough evidence to justify it. It would be great if more people held those who made strong claims about technique being critically important for pain/injury risk to the same standard.

As far as the rest of the post, it is quite lengthy and detailed; I would suggest perusing the prior discussions of this topic on the forum and, if you’d like, attempting to distill your fundamental question down further. If you have objections to the claims/arguments, you are also free to provide supporting evidence for discussion.

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

https://forum.barbellmedicine.com/forums/pain-and-rehab-q-a-with-dr-derek-miles-and-dr-michael-ray/49483-question-about-the-form-injury-relationship

3

Thanks for the response and for the references. Been doing more reading and watching videos as I had only encountered the articles and seminar questions previously.

To begin with, I apologize if I came across as strawmanning your perspective. What I’m mostly trying to get at is separating the “Changing the conversation/debunking” part of the conversation with the “What do you actually believe” portion; not to say the two are completely different, but there is markedly more emphasis on skepticism in the aforementioned.

Perusing the links and discussions, there does seem to be a consensus (at least between mods and other practitioners on here) that technique does contribute somewhat to injury/pain risk, but is more appropriately framed by considering it as a matter of load management, efficiency and exposure rather than an objective right or wrong “technique”, resulting in a spectrum more than a dichotomy. So load management referring to volume/intensity of load on particular structures, efficiency referring to which strategies are better for lifting higher loads (rather than “best”), and exposure being what the various structures have been exposed to previously (obviously implying adaptation). Am I understanding roughly correctly?

As a practical example: someone squatting forward onto their toes displaces load from the posterior chain to the knees, and this consistently induces knee pain. Getting them to change their foot positioning and drive with their midfoot/heels better loads their posterior chain and results in the usual knee pain being absent. In this case, more efficient technique not only allows the individual to use more weight due to load being distributed more evenly/“appropriately”, but also reduces load on structures less optimally suited for load (i.e. patellar tendon vs glutes, as a crude example). In this case and most it seems to be a combination of factors, but the correlation with pain and “technique” comes from managing all 3 dimensions adequately.

(PS: I am aware that self-organization is a component here).

Regarding fatigue: I can’t find the reference now but I thought I recall you or Jordan mentioning fatigue does somewhat increase risk of pain or injury broadly speaking – is this essentially the same idea, that fatigue means structures normally adapted to load shift load onto areas less adapted? This would seem to jive with research on core endurance:

Part 2 (if you have time):
I’m trying to integrate this with the idea of movement variability. If movement variability is a good thing, and events like strongman/highland games have higher injury rates due to a combination of high velocity/high load/less than adequate preparation (due to the unpredictability of events resulting in insufficient exposure in some athletes), can movement variability be seen on a spectrum of sorts as well? Too much and you’re in “unpredictable force and load” territory and too little and you’re in “no resilience” territory?

If we take a high-level powerlifter moving serious weight around (like yourself or Jordan), there doesn’t seem to be nearly the amount of individual movement variability with heavy weights as there is with lighter weights, I assume due to the combination of anatomy and physics. In the beginner athlete, GPP and “movement learning” within specific programs seem to supply a great deal of the movement variability. Where do higher level lifters get movement variability from? Is this part of why they benefit more from exercise variation? I think of this graph when I think of variability for participation as it pertains to novice vs elite level powerlifting (again assuming individual variation):
https://www.barbellmedicine.com/wp-c…10/derek-4.png

Apologies for the length, I thought I could distill it down but it’s difficult to do given all the caveats and qualifiers.

Edit: Apologies, I should have posted this in the training forum.

4

Hi, I’ve read through your posts and am still not exactly sure what you are asking? Are you worried you are going to get injured training with a barbell because your form isn’t perfect? Everyone’s form is a little different and injuries are very rare. I would recommend you just train. Start with a manageable low weight and follow a Barbell Medicine template. As long as you avoid really extreme ego lifting, you will be fine.

I suppose I could be wrong, but I have never seen any evidence that being a bit on your toes while squatting has any negative effect on your knees. Squatting is not bad for your knees. Being on your toes feels awkward and will limit the amount of weight you can move, but it won’t cause an injury.

Barbell training is a multiple years long (hopefully lifetime) pursuit. Getting really strong takes a long time and a lot of dedication. I see a lot of people worrying too much about the perfect optimization of their training. You will make great progress, make a few mistakes in your programming, and sometimes life will cause you to take a few steps backwards. I would recommend avoiding overthinking the minutia and just dive in slow and steady. and have fun!

5

This is true, but the symptoms of the over 90% of “injuries” documented during RT resolve in under two weeks. We agree that how you define injury matters, which include some metric of severity and consequence in most, but not all studies.

Just wanted to clarify this.

6

Perusing the links and discussions, there does seem to be a consensus (at least between mods and other practitioners on here) that technique does contribute somewhat to injury/pain risk, but is more appropriately framed by considering it as a matter of load management, efficiency and exposure rather than an objective right or wrong “technique”, resulting in a spectrum more than a dichotomy. So load management referring to volume/intensity of load on particular structures, efficiency referring to which strategies are betterfor lifting higher loads (rather than “best”), and exposure being what the various structures have been exposed to previously (obviously implying adaptation). Am I understanding roughly correctly?

Roughly, sure. This is a reasonable take, although the aspect of “efficiency” and which strategies are “better” is a more complicated topic. The load management and exposure piece hold primary importance, in our view.

As a practical example: someone squatting forward onto their toes displaces load from the posterior chain to the knees, and this consistently induces knee pain. Getting them to change their foot positioning and drive with their midfoot/heels better loads their posterior chain and results in the usual knee pain being absent. In this case, more efficient technique not only allows the individual to use more weight due to load being distributed more evenly/“appropriately”, but also reduces load on structures less optimally suited for load (i.e. patellar tendon vs glutes, as a crude example). In this case and most it seems to be a combination of factors, but the correlation with pain and “technique” comes from managing all 3 dimensions adequately.

  1. When you claim that the patellar tendon is less “suited for load” than the glutes, what specifically does this mean, and what is it based on?

  2. We should keep separate the discussion of sports performance - in which there is no debate regarding the relevance of mechanics and technical execution - and pain. In your example, I would not dispute that bringing a lifter into better balance will likely result in improved performance, and I cue this sort of thing all the time for that purpose. When it comes to pain, the question/idea that we are continuously battling is whether that forward position is inherently “bad”, “dangerous”, injurious, likely to induce pain, or should be avoided. To these questions, we would argue no. It is absolutely possible to train and adapt to tolerate substantial amounts of load through the patellar tendon without pain - and indeed this is necessary for certain athletes or individuals with certain goals.

can movement variability be seen on a spectrum of sorts as well? Too much and you’re in “unpredictable force and load” territory and too little and you’re in “no resilience” territory

Probably, yes.

7

Thank you. I’m not sure how I missed that but that adds a great deal of clarity.

8

Definitely agree. And I understand the desire to move the conversation away from elusive “perfect technique” in terms of injury risk, when strategies like RPE, adequate recovery, movement-based warmup and proper programming are the front lines of “defense”. I still find it hard to put in simple terms, but watching some additional videos on other topics has (I think) given me a better understanding of “what we believe” vs “changing the conversation” (and that you’re not “movement nihilists”).

  1. When you claim that the patellar tendon is less “suited for load” than the glutes, what specifically does this mean, and what is it based on?

Fair point. Will clarify next.

  1. We should keep separate the discussion of sports performance - in which there is no debate regarding the relevance of mechanics and technical execution - and pain.

Good point, and I agree.

In your example, I would not dispute that bringing a lifter into better balance will likely result in improved performance, and I cue this sort of thing all the time for that purpose. When it comes to pain, the question/idea that we are continuously battling is whether that forward position is inherently “bad”, “dangerous”, injurious, likely to induce pain, or should be avoided. To these questions, we would argue no. It is absolutely possible to train and adapt to tolerate substantial amounts of load through the patellar tendon without pain - and indeed this is necessary for certain athletes or individuals with certain goals.

Right, and I think there is some room for distinction between “practical” and “technical” there. But I suppose when it comes to pain, is it safer to simply treat it as individual/iterative rather than general? It’s difficult to make generalizations about pain, but for some people, some of the time, certain strategies may be suboptimal and/or may lead more quickly to overuse based on programming and load. In my case, there are very obvious squat strategies that consistently lead to pain that worsens and others that don’t, and similarly for strategies with i.e. bench press.

9

But I suppose when it comes to pain, is it safer to simply treat it as individual/iterative rather than general? It’s difficult to make generalizations about pain, but for some people, some of the time, certain strategies may be suboptimal and/or may lead more quickly to overuse based on programming and load.

We certainly do not treat it (or recommend treating it) as general. Regarding whether it should be treated as individual/iterative: to a point, yes.

The only challenge here: we work with people ALL THE TIME who come in either for performance coaching, or for rehab purposes, who tell us about their training history and how there are certain movements or programming strategies that they absolutely cannot tolerate. Things like “every time I’ve ever done high bar squats I get knee pain” (often paired with a narrative about how forward knee travel results in “shear” on the joints, and other associated nonsense), or “every time I do conventional deadlifts I get back pain, so I need to sumo”, etc. etc. We often find that their prior attempts to train these movements involved poor programming/loading decisions, or were occurring in the context of other issues like poor sleep, high life stress, etc. We can typically get them to tolerate these movements just fine using a different programming strategy.

So yes, there are tons of individual variations in people’s tolerance and response to a given movement or training strategy. Training should be adjusted based on this tolerance and response, and always in the context of the individual’s goals. For example, if the goal involves a specific competitive task, you must find a way to train the competitive movements regardless, and we would continue to experiment and trial strategies as long as needed to figure that out. On the other hand, if an individual is training simply for their own enjoyment or for health goals, we would spend far less time doing this – although we would still discourage the idea of a particular movement or activity being “bad”, “dangerous”, or otherwise intolerable under all circumstances.

10

Thanks for the response.

That’s quite interesting, and I may well be one of those people. Anecdotally I’ve found that to be the case with me, in hindsight. I never used to be able to shoulder press but I seem to be able to do so just fine now for reasons I’m unsure of. I’m not sure if increased movement variability is a factor. When I was younger I had rather painful joints that I suspect were related to diet; I had my CRP checked twice when I was about 21 and it was at about 8.1 but more recently it’s around 1; never thought to address joint pain with dietary modification but it seems to have worked for generalized joint pain. I know CRP is somewhat related to pain sensitivity in the literature but that’s still a very loose hypothesis as it relates to shoulder pain during pressing (and I suspect it has more to do with movement variability).

PS: Are there any exercises you guys don’t ever program due to needless load, or is it mostly because they’re useless? I.e. situps have been universally decried as useless and a risk for injury due to repetitive end-range flexion (as have high-volume or high-weight upright rows), but it may well be better to view it as a relatively useless application of load.

11

Not really, as exercise selection primarily relates to individual goals.

If I had a military trainee who needed to prepare for a military physical fitness test (which has historically included max sit ups for time), I would certainly be programming them sit ups, although the dosage would be individualized based on their level of fitness, tolerance, training response, and ultimate goals. While sit-ups may have been “decried” for those reasons, it is hardly universal; that reasoning is completely made up and unsupported.

12

That makes sense.

I wonder if the nature of the ROM of situps combined with the load (often going to failure and then some) is why numerous military divisions cut situps out of PT tests, including the US Army, the USMC and the Canadian Forces as far as I’m aware. There doesn’t seem to be hard data pertaining to situps specifically. Training for it certainly makes sense if it’s something that will be tested, however.

It can be somewhat difficult to merge observation and research data as patterns are rather complex. Regardless of injury risk, it seems a step in the right direction as they’re mostly a useless exercise (or at least I haven’t heard a compelling case for them in most contexts). If one is going to spend time doing core work, stability based endurance exercises seem to be more applicable to general weightlifting.

Speaking of which, I’m not sure if I’ve encountered yours or Jordan’s thoughts on the association between core endurance and LBP (if you have time):

13

You seem to be continuing to think about this issue in a similar way.

I work in a military setting. The overwhelming majority of folks I work around do not regularly train in general, much less train with specificity towards the goal task of a PT test. Historically, lots of young, otherwise healthy folks could get by for the typical run/push-up/sit-up by either doing nothing, or doing a few practice sets 1-2 weeks before the test. Throw these folks into a timed, semi-competitive setting for max reps and it is trivially easy to exceed an individual’s tolerance/capacity. The same applies for running, push ups, and essentially any other physical pursuit. If you have not prepared to do what you are trying to do, and/or are not doing the thing that you have prepared for, you are likely at an increased risk for pain/injury compared to those who are better prepared for the task demands.

Now, the other aspect of this issue is that the timed max sit-ups is arguably a stupid test with little relevance for their occupational demands (an argument which I would agree with). So I am in favor of the elimination of this particular test for reasons independent of any injury risk.

I can find cross-sectional studies finding associations between any number of things and back pain. The better/more pertinent question is whether specifically targeting core endurance improves LBP outcomes.

We do not have evidence that specific modalities of exercise (such as “core”-focused exercises) provide unique benefit compared to general/non-specific exercise for LBP outcomes. Mike Ray has written a fair amount about this.

14

I appreciate your patience, it does take some time to dramatically reframe ideas. I was not unfamiliar with DST, movement variability, etc but they are still somewhat new concepts for me and trying to shift a biomedical approach to one accounting for complexity takes some time. I appreciate your time on this.

I work in a military setting. The overwhelming majority of folks I work around do not regularly train in general, much less train with specificity towards the goal task of a PT test. Historically, lots of young, otherwise healthy folks could get by for the typical run/push-up/sit-up by either doing nothing, or doing a few practice sets 1-2 weeks before the test. Throw these folks into a timed, semi-competitive setting for max reps and it is trivially easy to exceed an individual’s tolerance/capacity. The same applies for running, push ups, and essentially any other physical pursuit. If you have not prepared to do what you are trying to do, and/or are not doing the thing that you have prepared for, you are likely at an increased risk for pain/injury compared to those who are better prepared for the task demands.

That was my experience in the infantry, oddly, and PT was usually run by someone by virtue of their rank, not whether they had the first clue about what they were doing. The train-past-fatigue Crossfit-esque mentality that was present certainly didn’t help so load management certainly makes sense.

I thought I recall you or Jordan mentioning fatigue relating to injury – I imagine significant fatigue during heavy loads being a risk falls into the “load management” category?

Now, the other aspect of this issue is that the timed max sit-ups is arguably a stupid test with little relevance for their occupational demands (an argument which I would agree with). So I am in favor of the elimination of this particular test for reasons independent of any injury risk.

I recall a study on JTF2 or CSCOR candidates (here in Canada) showing that leg strength correlated more with course success than did max situps/pushups, V02 max (I think), etc, so I’m glad qualifications and training are finally heading in an evidence-based direction, because the dropout rate I personally witnessed even on basic courses was monstrously ineffecient and likely quite expensive.

I can find cross-sectional studies finding associations between any number of things and back pain. The better/more pertinent question is whether specifically targeting core endurance improves LBP outcomes.

We do not have evidence that specific modalities of exercise (such as “core”-focused exercises) provide unique benefit compared to general/non-specific exercise for LBP outcomes. Mike Ray has written a fair amount about this.

In this case I thought it would relate to fatigue since the sample pool was all athletes, but then there was no separation of athletes based on any fitness metrics that would reliably control for general fitness. There is evidence “core” work relieves LBP more quickly in the short term but is no more effective in the long term, is that correct?

Thanks again, this is coming together in a more cohesive frame.

15

Yes, that is how we view it. “Load” as a broader concept than just external (“absolute”) load, but inclusive of internal load as well.

Compared to what?

Sure thing.

16

If you’ll indulge me:

I’m trying to make sense of the fairly large discrepancy between cross-sectional studies and the RT’s you’re referring to. I’m aware of the issues with retrospective studies like recall bias and the resulting data being generally of low quality, but the BMJ systematic review (https://bjsm.bmj.com/content/51/4/211.full) cites a study that recorded much longer periods of symptoms:

In the study by Raske and Norlin, the athletes self-reported that 25% of their injuries were chronic, 20% were acute muscle injuries and the rest were not defined. The authors did not report any difference between weightlifters and powerlifters. Raske and Norlin also reported that 93% of the shoulder injuries, 85% of injuries to the low back and 80% of the knee injuries resulted in symptoms that lasted for more than 4 weeks.

Now the obvious are the definition of injury, the severity of symptoms, and to what degree they affected training, but I don’t have access to the full study. I read another similar analysis that indicated chronic/recurring injury being somewhat common (adjusted OR 1.54: https://www.strongerbyscience.com/po…es-background/), as well as a cross-sectional study indicating some injuries (I think it was around 40-50%) having symptoms lasting more than a few months, although I frustratingly can’t find it now. I don’t know if that caused significant alterations to training but in the realm of “this constantly hurts and sucks” as it pertains to longevity, it does leave me somewhat ambivalent.

Now I also don’t know if this is an issue of specificity (many powerlifters seem to only train a handful of exercises), or purely load, but even load and intensity seemed to not be as predictive as thought in some of the literature. Do you have a rundown of the RT’s anywhere? Or did I just miss it in an obvious place? This is probably more relevant to my thread on deadlifting, but my current conclusion is mainly that powerlifting elicits more injuries due to load management (obviously) as a result of training volume/intensity but also “system load”.

Anecdotally, a lot of powerlifters do seem to be beat up by the time they’re in their 50’s. But on the other hand, likely a personal bias from sport-specific training, the goal of powerlifting training is the movements done in powerlifting; we rarely had athletes in pain or injured in the gym, but then the point of the gym in their case (hockey players, fighters, etc) was to build capacity for their sport in which they were obviously injured at one point or another.

17

Anecdotally, a lot of powerlifters do seem to be beat up by the time they’re in their 50’s.

As I mentioned in an earlier thread, what is your sample population for this anecdote? I wouldn’t think of older youtube personalities as a cautionary examples for myself. Guys who used performance enhancing drugs to get their lifts into astronomical numbers might be dealing with nagging injuries now, but I’m in my 50’s and have never been stronger. Just came in 2nd (in the open class) at meet last weekend against guys half my age. The entire point of RPE training is to get stronger with a healthy amount of stress. Age isn’t a factor in a good training program.

18

I tried to reply there but it’s moderated and my posts weren’t approved.

Yeah that’s a good point. A variable that seems to pollute the data is PED use, definitely, and it’s difficult to get a good handle on injury rates in non-competitive or casually competitive lifters. Couple that with self-selection in various sports and the many variables surrounding proper programming, RPE use, etc and it’s difficult to draw conclusions. It does seem to be safe to say that powerlifting the way BBM advocates is likely pretty safe in the long run, especially the way some would practice it via adding variations, higher rep phases, etc.