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Corrective Exercise Solutions to Weight Training Injuries


As more and more people add weightlifting to their exercise regimens, injuries related to the activity are becoming more common. A 2010 study (Kerr, Collins & Comstock) published in The American Journal of Sports Medicine found that weightlifting-related injuries increased by more than 48% between 1990 and 2007, resulting in nearly one million emergency rooms visits during that time. These figures don’t even take into consideration the prevalence of exercise-related dysfunctions of the core that contribute to the low back pain and hip and shoulder impingement injuries – many of which can be directly traced back to poor stabilization of the trunk, spine, and pelvis during weight training and related exercise – that flood chiropractic, medical, and physical therapy offices each year.

While some experts suggest that many of these injuries could be avoided if people were simply taught proper weightlifting form, the sobering reality is that many injuries related to weightlifting are the direct result of the very exercises and stabilization patterns that the fitness industry teaches and encourages.

Fortunately, it doesn’t have to be that way.

With a corrective exercise approach to weightlifting, fitness professionals can teach clients how to optimally breathe, stabilize, and move throughout each exercise. This, in turn, will help clients experience fewer injuries and enjoy better function and success in reaching their health and fitness goals.

This article will discuss the role of trunk, spine, and pelvis stability during weight training. We’ll also look at a dysfunctional postural and stabilization pattern that is common to many weightlifting-related injuries, which will help you better assess your personal training clients. Finally, we’ll review valuable training and cuing strategies you can use to improve your clients’ stabilization and movement patterns during weight training sessions and mitigate their risk of potential weight training injuries.

Understanding the Role of the Core in Weight Training

To truly appreciate how correct breathing and core stabilization can improve your clients’ weight training outcomes while decreasing risk, it is important to first understand the related functional anatomy. The lower six thoracic rings, lumbar spine, and pelvis are referred to collectively as the “abdominal canister” (Lee, 2011). This area can be expanded to include the entire thorax (thoracic spine and rib cage), lumbar spine and pelvis, and is referred to as the thoraco-pelvic canister (TPC) (Osar, 2012). The deep musculature – comprised of the three diaphragms (muscles of the thoracic inlet, the respiratory diaphragm, and the pelvic floor diaphragm), the psoas and quadratus lumborum (posterior walls), and the transversus abdominis (anterolateral walls) – is responsible for segmental control of the TPC. The superficial abdominal muscles and thoraco-lumbar erector spinae (attaching around the thoraco-pelvic region) provide the higher levels of support and movement that are necessary during weight training and day-to-day activities. Working together, the deep and superficial muscle systems, along with the myofascial chains connecting the extremities with the trunk, make the TPC a critical hub for stability, control, and the development of proper movement patterns during activities of daily living and exercise.

The TPC is often central to many of the injuries that occur both as a direct result of specific weightlifting incidents and as an indirect, cumulative result of habituated patterns that develop from repetitive loading and/or incorrect cueing (Elphinston, 2008). For example, fitness professionals often cue their clients to squeeze the shoulder blades “down and back” and “lift the chest” during upper extremity pushing and pulling patterns. Over time, this cue leads to overactivation of the scapular depressors and retractors, contributing to the downward rotation syndrome of the scapula. Additionally, by overactivating the scapular depressors and retractors, as well as the the thoracolumbar erectors to lift the sternum, the posterior aspect of the thorax becomes functionally locked, which inhibits the diaphragm, transversus abdominis, psoas, and other deep trunk stabilizers.

This strategy also disrupts one of the primary stabilization strategies of the core and makes the nervous system compensate by overusing the accessory muscles (scalenes, sternocleidomastoid, and pectoralis minor) for breathing and the trunk stabilizers (oblique abdominals and superficial erector spinae) for trunk stability, which can lead to many common postural and movement dysfunctions, including:

As noted, the inability to optimally stabilize the trunk affects the entire kinetic chain by inhibiting many of the deep muscles responsible for respiration and stabilization. Muscle weakness or inhibition of these muscles then manifests as alignment and movement-related issues in the trunk, shoulders, and/or pelvis (Umphred, 2007).

Before you can devise a strategy to improve function, you must be able to recognize and assess for the signs of dysfunctional TPC stabilization. The two most common stabilization dysfunctions related to weightlifting injuries are the loss of optimal TPC alignment and the loss of three-dimensional breathing. The remainder of this article will discuss these issues along with a corrective exercise strategy aimed at improving these functions as a means of reducing the incidence of weightlifting-related injuries.

Assessing Thoraco-pelvic Canister Stability

Let’s consider the alignment of a female client who presents with hip tightness and low back pain that worsens during weight training. Both her personal trainer and physical therapist had previously told her that she was in an anterior tilt and had a tight psoas, which was causing her low back pain. To address these issues, they had her work on stretching her hip flexors as well as strengthening her core and gluteals. Additionally, she was cued to “tuck her pelvis under” and “pull her shoulder blades down and back.” The health care practitioners were basing their assessment of this client on her static posture and commonly recognized postural dysfunction (the upper and lower crossed syndromes) and the individual’s overall complaints rather than taking an objective look at her presenting issues.

In Image 1A you will notice that the curve of her spine is actually at the thoracolumbar junction rather than at her lumbar spine (indicated by the arrow). During the modified Thomas test (a common test used to indicate shortness of the hip flexors), she demonstrated over-lengthened hip flexors, shown in Image 1B. During the rib cage mobility and breathing assessment, she demonstrated overall rigidity of the thorax and was primarily using a chest and upper airway breathing strategy. On manual muscle testing, she tested weak in her psoas, quadratus lumborum, and transversus abdominis. Unfortunately for this client, her physical therapist and personal trainer based their assessment on her static posture, commonly recognized postural dysfunctions (the upper and lower crossed syndromes), as well as on the individual’s overall complaints rather than taking an objective look at her presenting issues.

client presenting with hip tightness and low back pain
Image 1A Image 1B

client presenting with low back pain

Image 2

Lumbar instability is another common finding in clients that present with an altered TPC stabilization strategy. This is easy to spot on postural evaluation with the client seated in a comfortable posture. Note the amount of thoracic erector tone (top, left-facing arrow) in this client (Image 2). Also note the lumbar instability (bottom, right-facing arrow) that results because he is over-gripping through his thoracic erector spinae. Similar to the previous client, he has been cued to “lift his chest” and “squeeze his glutes” during his weight training and yoga practice, which has resulted in a posterior pelvic tilt, lumbar spine flexion (the unstable segment), and thoraco-lumbar hyperextension posture.

These findings are consistent with a large majority of clients who complain of low back pain and/or tight hips and have been labeled as having a weak core. These clients do not have core weakness. Rather, they have a dysfunctional core and need to be taught an improved breathing and core stabilization strategy that they can use throughout their day and especially when weightlifting. The overall alignment and stabilization strategy of these clients must be improved before additional external loads (i.e. resistance) are applied or they are encouraged to do more bracing (gripping of the superficial muscles) of their core. The most efficient way to re-pattern these compensatory bracing or gripping type strategies is to optimize their respiratory patterns and teach them how to breathe while activating their deep muscle system.

Developing Thoraco-pelvic Canister Stability

The following progression provides specific guidelines for establishing optimal alignment, efficient breath mechanics, and a coordinated TPC stabilization strategy. These can be regularly included as part of clients' functional warm-ups and incorporated into their weight training programs.

Alignment

Proper alignment of the TPC occurs when the spine and pelvis are in neutral alignment and the lower ribs face relatively towards the feet. This alignment enables optimal utilization of the muscles of the thoracic inlet, diaphragm, pelvic floor, and the other components of the deep muscle system. While the superficial muscles definitely contribute, it is primarily the deep stabilization system that is responsible for maintaining this alignment. This is why alignment, breathing, and coordination are so synergistic – each component relies on and improves the functions of the rest. Optimal breathing strategies improve the mobility and alignment while proper utilization of the deep muscle system assists in maintaining control of the trunk and spine. This strategy, in turn, enables efficient loading of the trunk, spine, pelvis, and extremities.

To achieve an optimal position in clients with thoraco-lumbar hyperextension, the easiest position to begin with is supine with the legs supported on a stability ball or edge of a chair where hips and knees are approximately in table top position (90° knee and 90° hip flexion). While breathing will often decrease much of the global trunk hypertonicity, some clients will require myofascial release (foam rolling or manual therapy) of the thoracolumbar region, hips, and/or anterior thorax to help them achieve a more optimal alignment.

Note the proper alignment of the TPC shown in Images 3a and 3b – the client is able to maintain the alignment of the lower thorax with the pelvis as her arms are raised (Image 3a). It is common for clients to lose optimal alignment of the TPC when they primarily use a posterior bracing strategy or are cued to “lift the chest.”  This results in hyperextension of the thoracolumbar junction, flaring of the lower, anterior ribs, inhibition of the deep muscle system, and subsequent compromised stability of the trunk, spine, and pelvis (Image 3b).

proper TPC alignment
Image 3A Image 3B

Breathing

Once the client achieves proper alignment, she places her hands inside her anterior superior iliac spine (ASIS) and focuses on breathing into her fingers. The client should be able to feel the abdominal wall push out into her fingers. The client then places her hands into her lateral abdominal wall beneath the lowest rib and above the lateral aspect of her iliac crest. Again, she should feel her breath push the abdominal wall into her fingers. A great cue to use to facilitate this three-dimensional activation of the diaphragm is to have the client visualize “breathing down and back” as if filling up a balloon within her entire abdomen. To develop endurance of her diaphragm and assistant respiratory muscles, she should work up to 5 sets of 10 deep breaths or 3 minutes of continuous breathing in this manner. She should not rush her breaths and should fully expire at the end of each breathing cycle. A good cadence is a 5-second inspiration and 5- to 7-second expiration with a one second pause between each inspiration/expiration. Look for signs of dysfunctional breathing patterns, including elevation of the shoulders and hyperextension of the spine during inspiration, flexion of the spine during the expiratory phase as well as overactivity in the accessory muscles of respiration including the scalenes, sternocleidomastoid, and pectoralis minor.

Coordination

Once the client is able to develop a more optimal strategy, she is taught to coordinate three-dimensional breathing with a three-dimensional activation strategy. To reduce the harmful effects lifting weights can place on the joints and soft tissues, clients should develop a proper intra-abdominal stabilization strategy while coordinating this function with activation of the deep muscle system. Why is this function so important even when all our clients already do “core” training? Because most clients can develop a good breathing strategy and sometimes even demonstrate a good stabilization strategy during weightlifting. Where most clients struggle – especially the ones with back and neck pain – is in coordinating breathing while maintaining stability (Osar, 2012). Many clients either breathe or stabilize; there is the lack of coordination between these activities during loading activities, and this disconnect is a common cause of chronic postural and movement syndromes.

The client begins by placing her hands inside her ASIS, takes a deep breath in, and then breathes out. She then activates her deep abdominal wall and continues to breathe while maintaining this activation. She then moves her hands to her lateral abdominal wall and repeats the process. She maintains this activation for 1 to 3 breath cycles working up to the point where she can perform this strategy for up to 60 seconds or while carrying on a conversation. This is the three-dimensional breathing and activation strategy that will ensure she maintains optimal stabilization of her trunk, spine, and pelvis during her weight training activities. Watch for faulty patterns of coordination such as losing the activation during the expiratory phase, altered TPC alignment, and overactivation of the oblique abdominals which functionally locks the client’s thorax and will often pull the pelvis into a posterior pelvic tilt and the lumbar spine into flexion.

Once the client is able to coordinate three-dimensional breathing with activation of the deep stabilization system, she must develop this function in the upright position. She begins in the seated position, activates her lateral abdominal wall, and should be able to palpate the contraction in her fingers just below the 12th rib and above the lateral aspect of the iliac crest similar to when she was lying (Image 4). She maintains this activation and is cued to continue breathing “down and back.” This same strategy is taken into her fundamental movement patterns. You can monitor that she maintains alignment of her TPC (thorax over the pelvis) and coordinated breathing and activation as she goes through her patterns (for example, a split squat, as shown in Image 5). To help improve and encourage more optimal TPC alignment while decreasing the likelihood of thoraco-lumbar hyperextension, utilize cues such as “keep your spine long” rather than “lift your chest.”

Image 4 Image 5

Maintaining Control of the Thoraco-pelvic Canister during Weightlifting

Once three-dimensional breathing and core stabilization have improved, the goal then shifts to improving the individual’s ability to get the most out of their weightlifting program while maintaining integrity of the spine, thorax, and pelvis and not overloading any single region of the kinetic chain. During all basic weightlifting patterns, including squatting and lunging as well as pushing and pulling patterns, the client should be able to maintain their TPC alignment while continuing to breathe three-dimensionally. They should be able to maintain this alignment and optimal stability during weight training and to release this high level of tension when they are done with their exercise pattern. In other words, while lying on a table or mat after their weight training session, they should not be stiff through their trunk and spine or lose range of motion of their extremities. If your client is significantly stiffer after their workout or has lost extremity range of motion, then their training session has likely created instability through their system, which has stiffened in response. Over time, this leads to compromised habitual movement patterns and contributes to over-compression syndromes, which are common causes of indirect weight training injuries.

To see both ideal and compensatory strategies of thoraco-pelvic canister stability during common pushing and pulling weightlifting patterns, watch the video below:

Conclusion

Weight training provides many benefits for our clients, including enhanced overall health, increased muscle mass and strength, improved circulation, and an improved sense of confidence and well-being. While injuries can occur as part of a weight-training program, maintaining proper alignment and function of the thoraco-pelvic canister is an effective strategy for reducing this likelihood. And while there are no guarantees, instructing clients how to correctly align, stabilize, and move through their spine, rib cage, and pelvis during lifting can dramatically reduce their chances of injury, improve performance, and move them closer to accomplishing their functional goals.

References

  1. Brody, J. (2010, December 13). Before You Lift a Weight, Get Some Advice. New York Times. Retrieved from http://www.nytimes.com/2010/12/14/health/14brody.html?pagewanted=all
  2. Bryant, C., & Green, D. (2003). ACE Personal Trainer Manual (3rd ed.). San Diego, CA: American Council on Exercise.
  3. Elphinston, J. (2008). Stability, Sport, and Performance Movement. Lotus Publishing: Chinchester UK.
  4. Hoffman, J. (n.d.). Resistance Training and Injury Prevention. American College of Sports Medicine. Retrieved from www.acsm.org/docs/current-comments/rtandip.pdf
  5. Kerr, Z.Y., Collins, C.L., & Comstock, R.D. (2010, April). Epidemiology of Weight Training-Related Injuries Presenting to United States Emergency Departments, 1990 to 2007. The American Journal of Sports Medicine, 38(4).
  6. Kolar, Pavel. (2009). Dynamic Neuromuscular Stabilization: A Developmental Kinesiology Approach. Course Handouts. Chicago, IL.
  7. Lee, Diane. (2011). The Pelvic Girdle (4th ed.). New York, NY: Churchill Livingston.
  8. Osar, Evan. (2012). Corrective Exercise Solutions to Common Movement Dysfunction of the Hip and Shoulder. Chinchester, UK: Lotus Publishing.
  9. Radebold, A, Cholewicki, J, Panjabi, M, & Patel, T. (2000). Muscle Response Pattern to Sudden Trunk Loading in Healthy Patients with Chronic Low Back Pain. Spine, 25(8): 47-54.
  10. Umphred, D. (2007). Neurological Rehabilitation (5th ed.). St. Louis, MO: Mosby Elsevier.