Training Around Injuries

There are four categories of interventions for injuries in training programs:

1) Modify - Modifications to allow training within a similar movement pattern to

avoid pain or immobility.

2) Avoid - Avoiding an injured body part or movement pattern entirely, such as

training around a broken leg or post-surgery shoulder.

3) Technique Refinement - Troubleshooting, preferably via video feedback, to

improve exercise execution and prevent injurious movement patterns.

4) Corrective Work - Providing specific corrective mobilizations and activation

both peri-workout and if possible periodically throughout the client's day to
improve movement quality.

Exercise Modifications

As a rule, almost nobody moves as well as they think or has spent sufficient time
developing fundamental movement patterns. Well prescribed modifications allow
the client to garner a significant training effect while regressing to an exercise with
a lower likelihood of poor execution, pain or injury. Spending time working on
these movements will allow them to develop the instinctive movement quality
necessary to execute more complex lifts correctly in the future, with a greater
potential for improvement.

Common Substitutions

Unilateral lower body lifts for bilateral lifts

Many people lack the movement quality to perform squats and deadlifts well.
Switching a squat variation for a single leg movement like a lunge, step up or
single leg deadlift will decrease shear loading of the spine, allow the development
of better hip mobility and lumbo-pelvic stability and, when executed well, improve
the relative strength potential of the posterior chain (glutes and hamstrings) during
lower body lifts.

It's generally preferable to regress several steps back from the main movement,
rather than make a small change that still allows for technical errors to be made
easily. Most clients will do well going from a squat or deadlift variation to either a
split squat or reverse lunge with the forward leg blocked and a dumbbell held in
the goblet position to prevent a knee-extension and lumbar extension dominant
pattern from re-emerging. If they struggle with a goblet reverse lunge, regress them
to a bodyweight reverse lunge with a strap for assistance until they develop the
necessary movement pattern.

Goblet Reverse Lunge with Blocked Knee

Goblet Split Squat

Reverse Lunge with Assistance

Performance points: in both of these movements, emphasize that the forward leg
must be rooted through the heel, that the forward shin is vertical and does not pitch
forward, that the trailing leg glute is fully contracted, that the spine is neutral, the
chest high and the neck packed. At the bottom of the movement the forward leg is
bent at 90 degrees, the trailing leg knee is bent at roughly 90 degrees and the femur
and spine are roughly vertical (the trailing leg hip can hyperextend by about ten
degrees).

As the client progresses, bring them through a phase of working without a blocked
shin to ensure that they can hold a vertical shin without constraints, then switch the
weight to a barbell in the front squat position, then a barbell in the back squat
position. Finally, put them through a period of goblet squats as substitutions for
squat variations and single leg deadlifts for deadlift variations. From there, you
should be able to move them back to full squatting (start with front squatting) and
deadlifting.

Goblet squats for barbell squat variations, leg presses and hack squats
Goblet squats allow the development of better squatting patterns with low risk of
poor execution. They're particularly helpful when a poor range of motion is an
issue, and can have a significant training effect by simply loading them with a
sufficiently heavy weight. With particularly strong people, consider also adding a
weight vest.

Goblet Squat

Performance points: emphasize that the client's weight is rooted firmly through
their heels, that their chest is high, shoulder blades are pulled tightly together and
down, and that their knees stay forcefully rotated out and over their toes
throughout the movement. At the bottom of the movement the elbows touch inside
the knees and can be used to pry the hips open further. Feet should stay firmly
rooted throughout the movement and not rotate outward as the client drops into the
bottom of the squat position. Clients who significantly lack hip mobility can be
given a goblet squat to a box to help gauge depth and develop better posterior
chain recruitment.

A second variation that is useful here is a plate squat, which will help groove a
deep squat pattern while placing a significant demand on spinal stability (think: ab
training).

Plate Squat

Barbell hip thrust for deadlift variations

When regressing someone from a deadlift, this step should come after the client
has spent some time developing better movement with single leg lifts as many
clients who perform deadlifts poorly are likely to perform hip thrusts poorly as
well if they go straight into them. Once better movement has been developed
through single leg lifts for a while, a phase of barbell hip thrust work can be used
to specifically develop better glute strength and improve posterior chain function
before moving back to full deadlifts.

Barbell Hip Thrust

Performance points: The primary risk with these is hyperextension of the lumbar
spine, which is a common compensation for poor glute strength and/or excessively
tight hip flexors. Ensure that the client maintains a neutral spine by tightly
squeezing the shoulder blades together and down and firmly bracing the lats and
abs with a big "belly breathe" of air. Cue them to squeeze their glutes (make sure
they know what glutes are) forcefully at the top of the lift and to get their hips as
high as possible without arching their back. The knees should rotate outward
slightly at the top of the lift, as fully contracted glutes will externally rotate the
hips.

Pushup variations for bench press

Switching from bench press to pushups frees the scapulae (shoulder blades) to
move freely and can prevent shoulder impingement issues. In clients with
excessively tight pecs relative to their upper back this can reduce the loading on
the chest and somewhat improve shoulder function. Loading can be progressed by
using band resistance (a good travel option), rings or a weight vest.

Pushup

Banded Pushup

Ring Pushup

Performance points: Neutral spine, braced abs, neutral neck (many people allow
their head to fall forward), braced glutes and abs, elbows stay tucked in and
scapulae don't elevate.

Horizontal pulling and external rotations and weighted carries for overhead
pressing
There are multiple reasons why overhead pressing may not work for an individual,
including poor scapulae function, hooked acromions on the scapulae, poor thoracic
mobility and poor soft tissue quality/mobility around the shoulder. Often, a
combination of all of those will make overhead pressing problematic. When this
happens, overhead pressing can be replaced with horizontal pulls like single arm
dumbbell rows or chest supported rows and external rotations like band or cable
rotations and face pulls. These two patterns are often undeveloped and
emphasizing them while providing specific corrective work can help improve
shoulder function and eventually get the client back to overhead pressing if
desired. For additional shoulder development (not always needed) heavy weighted
carries along with deltoid specific movements like lean-away lateral dumbbell
raises can be added.

Chest Supported Row

Band Pull Apart

Single Arm Dumbbell Row

Banded No Money

Face Pull

Dumbbell External Rotation

Farmers Walk

Lean Away Lateral Dumbbell Raise

Performance points: Chest supported row and single arm dumbbell row: Neutral
spine, neutral neck, no spinal rotation, chest high, lift finishes with strongly
retracted and depressed shoulder blade, elbow is roughly in line with back of rib
cage at finish of lift.

Performance points: External rotations: Head of humerus is packed back with

retracted shoulder blades and not pitched forward in capsule. Chest is high, spine is
neutral, head is held back in neutral and not pitched forward. On face pulls, the
hands are supinated.

Performance points: Farmer's walks (weighted carries): Spine is neutral, neck is

packed, chest is high, shoulder blades are squeezed strongly together and down and
abs are braced.

Performance points: Lean away lateral dumbbell raise: Shoulder does not elevate at
beginning of movement, head and spine are neutral.
Banded no moneys, light dumbbells or face pulls for barbell cuban rotations
Using even an unloaded bar is often too much weight for most people doing a
cuban rotation. Either reduce the load by switching to light dumbbells or switch the
movement out with face pulls or banded no moneys (external rotations). If the
client is having shoulder pain, just go straight to banded no moneys.

Avoiding an Injured Bodypart

In the event of an acute injury like a broken bone or surgery it can be necessary to
avoid a body part entirely and switch to predominantly or exclusively upper or
lower body training.

Programs for this can switch entirely to upper or lower training or include some
unilateral training for the non-injured side. Continuing to train the non-injured
body part will allow that limb to maintain most of its strength and function and will
have a neurological carryover to the opposite limb, helping that limb maintain its
strength despite not being trained. The downside to this is the potential
development of imbalances, twists and compensations from exclusively training
one side of the body which will be inherently stronger than the other side once full
body training is recommenced. Using exclusively upper or lower body training and
ignoring the non-injured side will lead to more atrophy and strength loss on that
side and reduced strength on the injured side, but allows more equal development
of both sides of the body once full training is recommenced and limits the risk of
ingraining compensatory patterns.

Even with a broken arm or post-surgery shoulder, lower body training can be
continued with things like hip belt lifts, glute ham raises, banded good mornings,
hip extensions, safety squat bars and barbell hip thrusts. Emphasizing these lifts for
a phase can actually improve hip strength and function while de-loading the spine
for a period, which in the long run will improve strength and movement patterns in
conventional lower body lifts like barbell squats and deadlifts.

Hip Belt Squats

Glute Ham Raises

Banded Good Mornings

Hip Extensions

Safety Bar Squats

Barbell Hip Thrusts

For injured or deformed hands, hand hooks can be used.

Hand Hook Pullup

See sample programs for injury programs.

Technique Troubleshooting

Most people baseline at defective, injurious movement patterns. Without guidance

the movement they instinctively execute in an exercise will either eventually hurt
them or produce poor results. Often, it's not a matter of changing out the exercise
but of refining technique in order to perform it correctly.

Common Issues

Squirrel Pullups
These are a common pattern in which during the pullup the shoulder blades are
pulled down (depressed) predominantly by the action of the pec minor and major
rather than by the muscles in the upper back. It predisposes the trainee to shoulder
dysfunction and poor posture. See linked article for full description. For clients,
emphasize that a pull-up should be finished with the bar pulled to the sternum, the
neck neutral, elbows just behind the ribcage and shoulder blades squeezed
maximally down and together. If the client cannot finish the lift with solid
retraction and depression (shoulder blades down and together) and a high sternum,
add assistance from a band or break the set into clusters (i.e. two closely spaced
sets of five reps each with about fifteen seconds of rest in between, rather than one
straight set of ten).

Anterior load shift on squats, lunges and deadlifts

Most people possess a dysfunctional pattern in which the quads are significantly
stronger than the hips (glutes and hamstrings) relatively speaking. This predisposes
the client to an instinctive movement in which a lower body lift is executed as
much as possible with knee extension, rather than hip extension or at least an equal
contribution between the two. A knee extension dominant pattern often includes an
unstable lumbar spine with excessive force being contributed by the lumbar
muscles as the spine flexes and extends.

In any lift, much can be ascertained by watching the feet. If the lifter shifts weight
onto the balls of their feet, their heels come off the ground or they rotate their heels
around the axis created by the balls of their feet they are shifting into anterior
loading. Also watch for the movement at the knee and hip. If the knees straighten
before the hips, the lifter is relying on quad-driven knee extension and avoiding the
use of his under-active hips. The closer the lifter is to a vertical shin the less likely
they are to rely on a quad and lower back dominant pattern.

In squats, watch which joint moves first. A good squat is initiated with a hip break;
the lifter pushes her hips back as the descent begins. A quad dominant lifter will
initiate the lift by popping the knees forward, shifting the load onto her quads and
away from the hips. Watch the knee as the lifter drives out of the bottom of the
squat. If they pop forward, the lifter is again shifting force production to the quads
in order to avoid hip activation. This is often accompanied by the knees
straightening faster than the chest rises. Ideally, the hips and chest rise at the same
rate out of the bottom of the squat.

With lunges, watch the forward foot for heel rise or the absence of a vertical shin.
Recall the 90/90 cues for split squats and lunges in the exercise substitution
section. A quad dominant lifter will put weight through the ball of the foot rather
than the heel and pitch the knee forward over the toes in order to get better force
production out of the quads (at the expense of glute and hamstring contribution).
Secondly, watch the trailing leg. In a lunge the primary source of force production
should come from the glute and hamstring on the forward leg. Some quad
dominant lifters with particularly tight quads and hamstrings will attempt to lever
themselves out of the bottom of the squat by pulling the trailing knee under them
and using a combination of hip flexion and knee extension on the trailing leg to
drive them back upward. Insist that the trailing leg glute stay fully contracted,
producing a slight stretch in the hip flexors, and that the trailing leg femur is close
to vertical or slightly extended behind the lifter.

On deadlifts, look for similar patterns as the squat. A quad dominant lifter shifting
to knee extension and lower back stress will pop the knees forward at the bottom of
the lift, allow the bar to drift out in front of them and straight then knees faster than
the hips and chest rise. Cue your clients to push for vertical shins and a chest that
rises at the same rate as the hips out of the bottom of the lift. The bar should be
firmly against the body throughout the lift. If they're hitting their knees on the bar,
they're not getting their hips far enough back.

Knee valgus (knock knees)

This is problematic in all lifters but especially so with females due to their greater
Q angles at the hips. This pattern results from excessive shortness and tension in
the adductors and internal hip rotators (as well as the external rotators in deep hip
flexion) and weakness in the glute medius and max, to put it somewhat simply. In
some cases, the lifter is compensating for a lack of glute-driven hip extension by
adducting and internally rotating the hips in order to use the adductor magnus
muscles to drive hip extension.

This simply comes down to knee collapse in a lower body movement. Watch that
the knees do not collapse inward on lunges, squats and even deadlifts and that the
lifter is activating the hips in order to keep the knees out over the toes and power
the movement with glute-driven hip extension.

Spinal position on overhead press

Many lifters lack sufficient mobility in their shoulders and thoracic spine to get
their arms cleanly overhead and will compensate with a lack of thoracic extension
and glenohumeral range of motion by hyperextending their lumbar spine. Don't let
that happen. If the lifter cannot press overhead without lumbar compensation,
regress the movement as illustrated in section one and focus on the necessary
correctives to improve thoracic extension and shoulder function.

Scapulae positioning on bench presses

An effective bench press is a full body lift, with a tight arch (not lumbar
hyperextension) and a strong upper body base comprised of tightly braced lats and
shoulder blades that are squeezed tightly together and down. From this position the
natural movement produced will keep the elbows tucked in at the bottom of the
movement and the bar will be lowered to roughly the lower pecs. Poor technique is
often marked by elevated and protracted scapulae (shoulder blades pulled towards
the ears and spread apart), elbows flared wide at the bottom of the lift and a bar
that lowers towards the neck or upper pecs.

Overhead squat as an assessment tool

If you need to quickly ascertain a client's movement patterns, an overhead squat is
typically the most effective single tool. Have the client overhead squat a
broomstick with their feet pointed straight forward and roughly shoulder width
apart. Get a side view from 90 degrees and a view of the front of the lifter, looking
straight on. This will show you almost every compensatory pattern listed above in
a single movement.

Corrective Work

Corrective stretches, mobilizations and activations must be used to optimize a

clients posture and movement patterns. These can be used before a workout during
their warmup, during a workout as an active rest interval or post workout for
intensive corrective stretches. For cases of significant postural imbalances they
should also be included as an additional daily drill performed outside of workouts
(such as first thing in the morning) to speed progress. This will only be an effective
strategy with a high-compliance client.

Remember to think in terms of the fewest number of correctives with the greatest
impact, rather than shotgunning a bunch of things at once that are all likely to be
performed poorly and for insufficient time. In particular, many lifters will do well
focusing on nothing but long duration super couch, deep squat and pigeon stretches
as their correctives following their soft tissue work and prior to a short, quick
activation session. With clients with tight hips, those three movements are good to
include in a round of post-workout cool down stretching or as an early morning
routine.

Super Couch Stretch

Super Couch Stretch without Bench

What it does: Lengthens the superficial front line of fascia, particularly the rectus
femurs (quad/hip flexor).

Indications: Anterior pelvic tilt, knee-dominant lower body movement patterns,

limited hip extension range of motion.

Deep Squat Wall Stretch

What it does: Lengthens the internal hip rotators and adductors. Improves deep
squat patterns.

Indications: Knee valgus either in static posture or during lower body lifts, poor
squat depth.

Lat and Triceps Stretch

What it does: Lengthens and improves soft tissue quality in the lats and triceps.

Indications: Poor overhead range of motion, internally rotated humeri (palms

facing backward) kyphosis.

Hamstring Mob with Lacrosse Ball

What it does: Improves tissue quality and length in the hamstrings. Can be rolled
into adductor magnus as well.

Indications: Poor hip flexion range of motion.

Scalene and Upper Trap Lacrosse Ball Mobs

What it does: Improves tissue quality and length in the scalenes and upper traps.

Indications: Forward head posture, tension headaches, hiked shoulders (elevated

scapulae).

Pec Mob with Lacrosse Ball

What it does: Improves tissue quality and length in the pec major and minor.

Indications: Internally rotated humeri, protracted scapulae (shoulders pitched

forward), kyphosis, poor overhead range of motion.

Pec Minor Broomstick Mobs

What it does: Lengthens pec minor.

Indications: Poor overhead range of motion, protracted scapulae.

Pigeon Stretch

What it does: Lengthens external hip rotators (piriformis et al)

Indications: Poor hip mobility, poor squat depth (feet turn outward at bottom of
squat), lower back tension.

Deep Neck Flexor Activation / Suboccipital Stretch

What it does: Strengthens and activates deep neck flexors, lengthens suboccipital
muscles.

Indications: Forward head posture, excessive cervical curve (high cervical), tension
headaches.

Considerations for Online Distance Coaching

Many online clients are self conscious and/or don't understand the importance
of technique videos and coach feedback. As a result, very few will actually
send in videos.
- Establish better individual rapport to increase client trust and comfort and
emphasize importance of videos. Private emails, etc.
- Control the perception of technique videos with occasional group emails
mentioning the progress being made by clients who actually submitted them,
congratulating them on their efforts and encouraging everyone else to do the same.
- Circumvent and send detailed instruction on movement execution
(probably limited effectiveness in clients with poor proprioception) and/or
immediately regress client to less technically demanding movement with detailed
instructions on movement execution and video.

Many clients are working out in crappy gyms or at home with Fisher Price
plastic dumbbells.
- Movement matters more than method.
- Almost any movement pattern can be developed and progressed with little
more equipment than a collection of bands. Horizontal pulling is the most difficult.
A set of gymnast rings, a TRX or any other version of a rope with a handle on it
works best for that.
- Regress the client to bodyweight movements using band resistance for
progression.
- Banded goblet squats, pushups, overhead presses, triceps extensions,
good mornings, deadlifts.

Many client technique videos are poor quality and even with good ones there
are subtleties within movements which are difficult to ascertain through video.
- When in doubt, regress the movement.
- You're not a physical therapist. If the cause is not easily identified, refer out
to a PT.
- Be very explicit in requirements for technique videos.

Seek to understand the actual motivation behind the client's problem with this
movement
In some cases the difficulty and "discomfort" the client has with a movement is
either psychosomatic or subconsciously contrived. They are seeking an excuse to
maintain status quo, effectively playing a variation of the "If it wasn't for you"
game explained in Games People Play by Eric Berne.

Stating that front squats are causing pain provides a psychologically comfortable
excuse to opt out of doing them. "I'd be doing so much better in this program if it
weren't for those darn front squats causing my back/knees/left upper incisor to hurt
but I have to skip them."

This can be part of the reason clients seem unwilling to provide technique videos
or engage in dialogue to find a solution that allows them to do front squats (or
whatever exercise is the problem). They (subconsciously) need a reason to avoid
doing things that are hard and uncomfortable. The decision to fail and adhere to
their status quo must hinge on a rationalization that makes the failure acceptable
and justifiable. Mysterious pain or difficulty can be that reason. It's a solution.

In this case you can play the motivational interviewing game in order to draw the
client towards deciding to do the movement with conscious effort towards proper
execution and sufficient effort. Do not allow the client to control the frame of the
interaction. In somewhat the same process, an easier method is to talk with the
client and regress them down into a movement that provides a similar training
effect within the movement pattern but is not psychologically uncomfortable for
them.